The concept of multimodal pain management has become one of the important approaches to the treatment of a multifaceted issue of postoperative pain and recovery in the patients with cardiac surgery. The postoperative pain after a cardiac surgery, including coronary artery bypass grafting (CABG) and valve repair, is usually mild to severe, which prevents early mobility and functional recovery, and which is linked to the risk of a higher number of an immediate and delayed-term complications, including chronic pain, delirium, and long hospitalization. Historically, opioid analgesics have been the backbone of analgesic therapy of cardiac surgery postoperative pain, yet opioid-based therapy is fraught with undesirable side effects including respiratory depression, nausea, vomiting, constipation and enhanced propensity to delirium, particularly among elderly patients. In a bid to address the shortcomings of single agent opioid therapy, the theory of multimodal analgesia has been popularized, in which combinations of various classes of analgesic and focal modalities are used to address more than one pain pathway. This practice is now suggested as a best practice recommendation of the strategy to achieve better pain management after cardiac surgery with the aim to reduce opioids use and the side effects. Multimodal regimens can be comprised of drugs like non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, nerve blockers in the region, and other adjuvant drugs, with each having a different mechanism of action. Nevertheless, the best mix of medications and methods is not established yet, and the clinical practice is highly varied, and no solid and consensus-based protocols have been developed so far despite the guideline recommendations. Recent systematic reviews and meta-analyses have already started to shed some light on the possible benefits of multimodal pain management after cardiac surgery. Some studies have shown that multimodal regimens are more beneficial than opioid-based interventions, resulting in reduced patient-reported pain scale and use of opioids, as well as secondary benefits like a decrease in time to extubation and length of stay in the intensive care unit (ICU). Furthermore, there is some evidence indicating that some combinations, e.g., paravertebral nerve blocks with the presence of flurbiprofen, or even the use of acetaminophen as the adjuvant may result in cognitive improvement and decrease the number of postoperative complications, e.g., delirium and postoperative cognitive dysfunction[ 7]. Although the results are promising, substantial methodological heterogeneity, a high risk of bias, and the use of poorly standardized pain assessment of the studies do not allow the generalization of the findings. Moreover, the new information points to the fact that some of the interventions, including regional blocks, can be associated with their own risks, and can be selected and monitored carefully. Since nearly one-third of the adult population suffers chronic pain even a year after surgery, the pursuit of the best multimodal protocols is not only scholarly but essential to a better immediate and long-term outcomes of cardiac surgical patients.,[8]. With these unsolved questions, a strong necessity in producing quality and large mass trials exist so as to clearly establish the most effective combinations of multimodal analgesics in mitigating post operative pain and enabling quick recovery after a cardiac surgery. This evidence will be the basis of standardized, evidence-based pain management interventions, which are applicable to this high-risk group.

The research was undertaken at Pacific Institute of medical sciences, Umarda, Udaipur (Rajasthan) between April 2023 and March 2025. 1. Study Design This was a prospective and observational study which sought to compare the effectiveness of the multimodal pain management in the reduction of postoperative pain and faster healing of patients undergoing cardiac surgery. The research was a two-year study, in which the data was gathered on patients who were undergoing elective cardiac surgeries including coronary artery bypass grafting (CABG). 2. Study Population A total of 100 patients aged 45-75 years who were to undergo elective cardiac surgery in the Pacific Institute of Medical Sciences, Udaipur were included in the study. The patients were chosen with the help of preset inclusion and exclusion criteria, which guaranteed them a homogeneous sample to assess the results of multimodal pain treatment. •Inclusion Criteria: Patients aged 45-75 years of age who underwent elective cardiac surgery and gave informed consent. •Exclusion Criteria: Patients with severe comorbidities and recovery, substance abuse history, and patients incapable of giving consent to the study. 3. Randomization and Group Allocation. Two groups of patients were randomly allocated: Group 1 (Multimodal Pain Management - MM-PM): The patients that were treated with a combination of analgesics, which are opioids, NSAIDs, and local anesthetics. Group 2 (Normal Pain Postoperative): Patients that were provided with standard postoperative pain management, which was mainly opioid-based. Every group comprised 50 patients with comparable baseline attributes to control bias in treatment effects. 4. Data Collection The process of data collection was carried out with the participation of a group of trained medical workers. Each patient was gathered on the following data points: •Preoperative Evaluation: Demographic information (age, gender, BMI), comorbidities, and pain levels at the baseline with the help of Visual Analog Scale (VAS). •Postoperative Monitoring: 24, and 72 hours of pain levels, opioid use, time to extubation, ICU length of stay, hospital length of stay, postoperative complications (e.g., nausea and vomiting) and patient satisfaction scores. 5. Outcome Measures The primary outcomes were: •The evaluation of postoperative pain on the Visual Analog Scale (VAS) at 24, 48, and 72 hours. •Accumulated morphine equivalents of opioid through the initial 72 hours of the surgical procedure. The secondary outcomes were: Time to extubation, length of stay in the ICU, length of stay in the hospital, and postoperative complications (nausea and vomiting). Patient satisfaction, measured on a Likert scale on discharge. 6. Statistical Analysis Online free available software was used to provide statistical analysis. Demographic and clinical data were summarized using a descriptive statistic (mean, standard deviation). Independent t-test of continuous variables and chi-square tests of categorical variables were used to analyze the differences between the two groups in the postoperative pain scores, consumption of opioids, and recovery parameters. The statistically significant p-value was taken to be less than 0.05.

Table 1: Demographic Details of Patients Demographic Characteristic Value Total Patients 100 Age 62 ± 8 years Gender 55 males (55%) 45 females (45%) Body Mass Index (BMI) 28.3 ± 3.2 kg/m² Comorbidities 40% Hypertension 30% Diabetes 20% Smoking history Surgical Procedure Coronary Artery Bypass Grafting (CABG) Table 1 presents the demographic details of the 100 patients included in the study. The mean age of the participants was 62 ± 8 years, with a gender distribution of 55 males (55%) and 45 females (45%). The average body mass index (BMI) of the patients was 28.3 ± 3.2 kg/m², indicating a slightly overweight population. In terms of comorbidities, 40% of patients had hypertension, 30% had diabetes, and 20% had a history of smoking. All patients underwent coronary artery bypass grafting (CABG) as part of their cardiac surgery. Table 2: Postoperative Pain Scores Time Point Multimodal Pain Management (MM-PM) Standard Pain Management Statistical Significance 24 Hours 3.1 ± 1.2 5.8 ± 1.6 p<0.001 72 Hours 1.5 ± 0.9 3.9 ± 1.4 p<0.001 Table 2 presents the postoperative pain scores at 24 and 72 hours. Patients in the multimodal pain management (MM-PM) group reported significantly lower pain scores at both time points. The MM-PM group had an average score of 3.1 at 24 hours, compared to 5.8 in the standard group. At 72 hours, MM-PM patients continued to report lower pain, with a score of 1.5 compared to 3.9 for the standard group, demonstrating superior pain control with MM-PM. Table 3: Opioid Consumption (Morphine Equivalents) Group Cumulative Opioid Consumption (mg) Statistical Significance Multimodal Pain Management (MM-PM) 22 mg p<0.001 Standard Pain Management 37 mg Table 3 compares the cumulative opioid consumption between the two groups. The MM-PM group had a significantly lower opioid consumption (22 mg) compared to the standard pain management group (37 mg). Table4: Recovery Parameters Outcome Multimodal Pain Management (MM-PM) Standard Pain Management Statistical Significance Extubation Time (hours) 6.5 ± 2.1 9.2 ± 3.4 p=0.002 ICU Stay (days) 2.3 ± 0.8 3.6 ± 1.1 p<0.001 Length of Hospital Stay (days) 6.4 ± 1.9 8.1 ± 2.2 p=0.004 Table 4 shows recovery parameters such as extubation time, ICU stay, and length of hospital stay. Patients in the MM-PM group had faster recovery, with extubation occurring in 6.5 hours on average, compared to 9.2 hours in the standard group. The MM-PM group also had shorter ICU stays (2.3 days vs. 3.6 days) and reduced overall hospital stays (6.4 days vs. 8.1 days), demonstrating that multimodal pain management promotes faster recovery. Table 5: Nausea and Vomiting Incidence Group Incidence (%) Statistical Significance Multimodal Pain Management (MM-PM) 12% p=0.045 Standard Pain Management 28% Table 5 compares the incidence of nausea and vomiting in both groups. The MM-PM group had significantly fewer patients reporting nausea and vomiting (12%) compared to the standard pain management group (28%). Table 6: Patient Satisfaction (Likert Scale 1-10) Group Patient Satisfaction Score Statistical Significance Multimodal Pain Management (MM-PM) 8.7 ± 1.0 p<0.001 Standard Pain Management 6.9 ± 1.4 Table 6 presents patient satisfaction scores at discharge. Patients in the MM-PM group reported significantly higher satisfaction (8.7) compared to the standard group (6.9).

Moreover, MM-PM group had significant decreases in the number of opioids consumed by patients who took a considerably less amount of opioid medication as compared to the standard pain management group. This reduction of opioid consumption not only indicates better pain management, but also indicates that multimodal pain management has the potential to decrease opioid dependence hence limiting the occurrence of opioid side effects and dependency. The MM-PM group has also an advantage over the recovery parameters, as the patients report faster extubation, shorter stay in the ICU, and fewer hospital stays in general. It proves that multimodal pain management can help to attain a faster recovery and discharge, which is paramount in enhancing patient outcomes following major surgeries such as the coronary artery bypass grafting (CABG). Along with these clinical advantages, the rates of nausea and vomiting were also much lower in the MM-PM group, which promotes the assumption that the multimodal approach might decrease the gastrointestinal adverse effects frequently related to opioid use. This is an added value to the better patient experience during recovery due to this improved side effects. Lastly, the discharge patient satisfaction scores were much better in MM-PM group. The increased level of satisfaction is not only due to a better pain management but also to a faster recovery and reduced side effects which means that multimodal pain management results into a more favorable postoperative experience. Overall, the findings of the presented study may indicate the following, multimodal pain management may benefit postoperative pain management, decrease opioid use, shorten the recovery period and increase patient satisfaction. These results highlight the significance of using multimodal techniques in delivering postoperative care to patients with cardiac surgery to maximize the recovery process. compares the research result to other related researches and lists references in Vancouver order under the text in serial order. Reference which are cited in text also cite the name of the author with et al and also indicate the reference number in text. The actual results of the current research are a strong indication of the highly beneficial nature of multimodal pain management (MM-PM) following a heart surgery, as it concurs with and builds upon the existing evidence in the field. In the present study, the patients having MM-PM had lower pain scores at 24 and 72 hours after the surgery, which means that analgesia was more effective than the traditional protocols of managing pain. The results are consistent with those of Wang et al.,[9] who showed that postoperative pain scores decreased and that opioid use decreased after elective cardiac surgery with the addition of paravertebral nerve block and non-opioid analgesics, including flurbiprofen. Darras et al.[10] and Markham et al.,[11] have found similar improvements in pain scores and MM-PM which they both found enhanced analgesia and accelerated functional recovery among cardiac surgical populations. One of the notable characteristics of MM-PM in this study and previous ones is a notable decrease in the opioid needs following the operation. Wang et al.[9] established that multimodal analgesia involving nerve block led to a reduction of over 50 percent in patient-controlled intravenous opioid administration, which led to a decrease in the number of adverse effects of opioids such as respiratory depression and gastrointestinal events. To underline the findings of the present study, Magoon et al. point out that opioid-sparing regimens are vital in cardiac surgical patients to avoid opioid-related tolerance, hyperalgesia, and chronic afteroperative pain [12]. Markham et al.,[11] also confirmed these opioid-sparing effects in a meta-analysis that found that patients reported reduced opioid use, reduced intubation time, and a tendency to reduced ICU and total hospital stay. A faster postoperative recovery of the MM-PM cohort is also noted in the present study, as evidenced by earlier extubation, decreased ICU time, shortened hospitalization. These findings are supported by the fast-track protocols and enhanced recovery after surgery (ERAS) pathways that Magoon et al.[12] and Engelman et al. have defined as the mechanisms of facilitating an expedited recovery and healthcare resource optimization through multimodal approaches. Moreover, current evidence that Darras et al. [10] have examined supports the utilization of multimodal and regional interventions, e.g. parasternal or paravertebral blocks, as they have demonstrated significant effectiveness in reducing the use of opioids and shortening the discharge. The decreased rate of nausea and vomiting was a critical patient-centered advantage in the MM-PM group that is consistent with Markham et al.,[11] where the reduction in the dosage of opioid use through multimodal regimens clearly favorable changes the side effects profile following cardiac surgery. The increased level of patient satisfaction and reduced complications observed in this study substantiate the holistic benefit of MM-PM and both clinical and experiential advantages. To sum up, the findings of this research align well with the results of supporting the proved role of multimodal pain management as an opioid-sparing modality after cardiac surgery. The combination of regional strategies with non-opioid pharmacologic agents alongside the coordination of ERAS protocols, as endorsed by these large studies, is critical to the maximization of pain relief, faster recovery, reduced exposure to opioids, and enhanced patient satisfaction in general after cardiac surgery.

In conclusion, the findings of this study demonstrate that multimodal pain management (MM-PM) significantly enhances postoperative outcomes for patients undergoing cardiac surgery. By reducing pain levels, opioid consumption, and associated side effects, MM-PM not only improves pain control but also accelerates recovery, as evidenced by faster extubation, shorter ICU and hospital stays, and lower rates of nausea and vomiting. Furthermore, the MM-PM group reported higher patient satisfaction, highlighting its overall benefits in improving the patient experience. These results underscore the importance of incorporating multimodal analgesic strategies in postoperative care to optimize recovery and reduce opioid dependence, ultimately leading to better long-term outcomes for cardiac surgery patients.

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