What is the best course of action for a female patient in her 40s with severe abdominal pain, history of mini gastric bypass, addiction, and depression, who is currently on buprenorphine (opioid partial agonist), presenting with tachycardia and slight hypotension?

Immediate Resuscitation and Surgical Emergency Evaluation

This patient requires immediate aggressive fluid resuscitation, urgent surgical consultation, and CT imaging to rule out life-threatening post-bariatric surgery complications, while continuing her buprenorphine and preparing for substantially higher opioid requirements if surgery is needed. 1, 2

Critical First Actions

Hemodynamic stabilization takes absolute priority:

• Establish large-bore IV access and initiate aggressive crystalloid resuscitation targeting normalization of heart rate and blood pressure 1, 2
• The tachycardia and hypotension suggest hypovolemia, sepsis, or intra-abdominal catastrophe—all potentially fatal without immediate intervention 1

Obtain urgent CT abdomen/pelvis with IV contrast to evaluate for:

• Internal hernia (most common cause of severe abdominal pain post-gastric bypass) 3
• Bowel obstruction, perforation, or ischemia 3
• Anastomotic leak or stricture 3
• Intra-abdominal abscess 3

Activate surgical consultation immediately given her history of mini gastric bypass—these patients can deteriorate rapidly with internal hernias or bowel complications that require emergent operative intervention 3

Buprenorphine Management Strategy

Continue her current buprenorphine dose without interruption to prevent withdrawal, which would worsen her clinical presentation and complicate assessment 1, 2

If she requires emergency surgery:

• Verify her exact buprenorphine dose with her prescriber or treatment program 1, 2
• Continue buprenorphine throughout the perioperative period 4
• Add scheduled short-acting full opioid agonists (morphine, hydromorphone, or oxycodone) at 1.5-2 times higher than standard doses due to cross-tolerance and buprenorphine's high μ-receptor affinity 1, 2
• Administer opioid analgesics every 3-4 hours on a scheduled basis, never as-needed 1, 2

For immediate pain control while awaiting imaging:

• Administer scheduled IV ketorolac 15-30 mg (if no contraindications) and IV acetaminophen 1000 mg 4
• Add IV morphine 4-6 mg or hydromorphone 1-2 mg every 3-4 hours scheduled, recognizing these doses may need to be doubled due to buprenorphine competition at opioid receptors 1, 2
• Consider IV ketamine 0.1-0.3 mg/kg as an adjunct for severe pain 4

Critical Diagnostic Considerations

Post-bariatric surgery complications that present with severe abdominal pain and hemodynamic instability include:

• Internal hernia with bowel strangulation (surgical emergency) 3
• Marginal ulcer perforation 3
• Anastomotic leak 3
• Small bowel obstruction 3

The combination of severe pain, tachycardia, and hypotension in a post-gastric bypass patient should be considered a surgical emergency until proven otherwise 3

Common Pitfalls to Avoid

Do not withhold or reduce buprenorphine thinking it will improve opioid analgesia—this precipitates withdrawal and worsens pain perception without improving analgesic efficacy 1, 2

Do not use mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as these will precipitate acute withdrawal syndrome 1, 2

Do not attribute her pain to drug-seeking behavior due to her addiction history—this represents dangerous bias that delays diagnosis of life-threatening surgical pathology 1, 2, 3

Do not use as-needed opioid dosing—write continuous scheduled orders to prevent pain recurrence between doses, which increases patient-provider tension and worsens outcomes 1, 2

If Surgery Is Required

Multimodal analgesia is essential:

• Continue buprenorphine at her maintenance dose 4
• Maximize scheduled NSAIDs and acetaminophen 4
• Add gabapentin 300-600 mg preoperatively and continue postoperatively 4
• Consider regional anesthesia techniques if anatomically feasible 4
• Use patient-controlled analgesia (PCA) with morphine or hydromorphone at higher basal and bolus rates than standard 4, 1

Explicitly reassure the patient that her maintenance therapy will continue uninterrupted and that her pain will be aggressively treated—this reduces anxiety that worsens pain perception 1, 2

Notify her buprenorphine prescriber about hospitalization and any controlled substances prescribed, as additional opioids will appear on routine urine drug screening 1, 2

Monitoring Requirements

• Monitor level of consciousness and respiratory rate every 1-2 hours when using higher-dose opioids 1, 2
• Have naloxone immediately available, though recognize that reversing buprenorphine requires higher naloxone doses and prolonged monitoring due to buprenorphine's 36-48 hour duration of action 5
• Monitor for signs of evolving peritonitis or sepsis requiring escalation of care 3