Postoperative pain is a universal and predictable consequence of surgical procedures, representing one of the most important concerns for patients, surgeons, and anesthesiologists alike. Pain following surgery is not only unpleasant but can also impair recovery, delay mobilization, increase hospital stay, and elevate the risk of morbidity due to complications such as pulmonary dysfunction, thromboembolic events, and impaired wound healing. Effective postoperative pain management is therefore critical in optimizing clinical outcomes, enhancing patient satisfaction, and reducing the economic burden on healthcare systems.[1] Pain, as defined by the International Association for the Study of Pain (IASP), is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. Postoperative pain is complex, involving nociceptive, inflammatory, and in certain cases neuropathic components, depending on the type and extent of surgery. Surgical trauma initiates a cascade of neurophysiological responses through activation of nociceptors, resulting in the release of inflammatory mediators such as prostaglandins, bradykinin, and substance P. These mediators sensitize peripheral and central nociceptors, leading to hyperalgesia and prolonged pain if inadequately controlled.[2] Unrelieved pain has consequences far beyond patient discomfort. It can trigger stress responses, including sympathetic activation, increased catecholamine release, hypercoagulability, and immunosuppression. Physiologically, inadequate pain relief can impair ventilation, especially following thoracic and abdominal surgery, by discouraging deep breathing and coughing, thereby predisposing to atelectasis and pneumonia. Similarly, immobility from severe pain can contribute to venous stasis and thromboembolism. Chronic postsurgical pain is another recognized consequence, especially when acute pain is poorly managed.[3] The principles of postoperative pain management have evolved significantly over recent decades. Traditional reliance on systemic opioids has gradually shifted towards multimodal analgesia, which combines different classes of analgesics and techniques to maximize pain relief while minimizing side effects. This approach targets various mechanisms of pain transmission and modulation, often integrating non-opioid drugs such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthetics, regional anesthesia, and adjuvant therapies. Techniques such as patient-controlled analgesia (PCA), epidural analgesia, and peripheral nerve blocks have further revolutionized the approach to postoperative pain.[4] Despite advances, studies consistently demonstrate that a significant proportion of surgical patients continue to experience moderate-to-severe pain postoperatively. Barriers include inadequate assessment, variability in protocols across institutions, concerns regarding opioid-related side effects, and resource limitations in certain healthcare settings. Pain assessment remains a cornerstone of effective management, utilizing validated scales such as the Visual Analog Scale (VAS), Numerical Rating Scale (NRS), and Verbal Rating Scale (VRS). Accurate and repeated assessment ensures individualized treatment and adjustment according to patient needs.[5] Aim To evaluate postoperative pain management in surgical patients. Objectives 1. To assess the effectiveness of different modalities of postoperative pain management in surgical patients. 2. To evaluate the severity and pattern of postoperative pain using standardized pain assessment scales. 3. To analyze the association between pain management strategies and patient outcomes, including recovery and complications.

Source of Data The study data were obtained from patients admitted to the Department of Surgery at a tertiary care teaching hospital. Both elective and emergency surgical patients were included, provided they met the eligibility criteria. Study Design This was a prospective, observational, cross-sectional study. Study Location The study was carried out in the Department of General Surgery. Study Duration The study was conducted over a period of 06 months, from October 2024 to March 2025. Sample Size A total of 80 patients were included in the study. The sample size was determined based on feasibility and prior similar studies evaluating postoperative pain management. Inclusion Criteria 1. Patients aged 18 years and above undergoing elective or emergency surgical procedures under general, spinal, or regional anesthesia. 2. Patients who consented to participate in the study. 3. Patients who were hemodynamically stable postoperatively. Exclusion Criteria 1. Patients with pre-existing chronic pain syndromes requiring long-term analgesics. 2. Patients with psychiatric illness or cognitive impairment that interfered with reliable pain assessment. 3. Patients undergoing minor surgical procedures not requiring inpatient admission. 4. Patients who refused consent. Procedure and Methodology Eligible patients were identified preoperatively and enrolled after obtaining informed written consent. Detailed demographic and clinical data were collected, including age, sex, comorbidities, type of surgery, and type of anesthesia administered. Postoperatively, pain was assessed using the Visual Analog Scale (VAS) and Numerical Rating Scale (NRS) at predefined intervals: 2, 6, 12, 24, and 48 hours after surgery. Pain management modalities were recorded, including the use of systemic opioids, NSAIDs, acetaminophen, local anesthetics, epidural analgesia, nerve blocks, and patient-controlled analgesia. Combination therapies were categorized under multimodal analgesia. Adverse drug reactions and complications related to analgesic techniques were documented. Patients were monitored for early mobilization, length of hospital stay, and postoperative complications such as pulmonary issues, nausea, vomiting, or thromboembolic events. Patient satisfaction with pain management was also assessed using a Likert scale at discharge. Sample Processing Data collection sheets were used to record patient details, pain scores, and treatment modalities. All data were anonymized and entered into a secure database for analysis. Statistical Methods Data were analyzed using SPSS version XX (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using the Student’s t-test or Mann–Whitney U test, depending on distribution. Categorical variables were presented as frequencies and percentages, and associations were tested using the Chi-square test or Fisher’s exact test. Repeated measures ANOVA was applied for pain scores over time. A p-value <0.05 was considered statistically significant. Data Collection Data were collected prospectively through direct patient interaction, medical records, nursing charts, and anesthesia notes. Pain scores were recorded at standardized time points by trained nursing staff. Outcomes were validated by independent review of medical records.

Table 1: Postoperative Pain Management Practices (N=80) Measure n (%) or Mean (SD) 95% CI Comparator / Test Test statistic p-value Timely first analgesic (≤30 min of PACU arrival) 61 (76.2%) 66.9–85.6% Proportion vs 50% z = 4.70 <0.001 Multimodal regimen used 34 (42.5%) 31.7–53.3% Proportion vs 50% z = −1.34 0.180 Regional technique used (epidural or peripheral nerve block) 24 (30.0%) 20.0–40.0% Proportion vs 50% z = −3.58 <0.001 Patient-controlled opioid analgesia (PCA) used 22 (27.5%) 17.7–37.3% Proportion vs 50% z = −4.02 <0.001 Regular pain assessments documented (≥4 in first 24 h) 57 (71.2%) 61.3–81.2% Proportion vs 50% z = 3.80 <0.001 ≥2 breakthrough-pain episodes in first 24 h 19 (23.8%) 14.4–33.1% Proportion vs 50% z = −4.70 <0.001 Opioid-related adverse events (any) 17 (21.2%) 12.3–30.2% Proportion vs 50% z = −5.14 <0.001 NRS ≤4 at 24 h achieved 62 (77.5%) 68.3–86.7% Proportion vs 50% z = 4.92 <0.001 Pre-operative analgesia plan documented 49 (61.3%) 50.6–71.9% Proportion vs 50% z = 2.01 0.044 Morphine-equivalent dose 0–24 h (mg) 18.7 (7.9) 16.94–20.46 One-sample t vs 20 mg t = −1.47 0.141 Notes: Proportion CIs are Wald 95% CIs. For the mean dose, 95% CI uses t-based SE (df=79). The findings from Table 1 highlight several important trends in postoperative pain management among 80 surgical patients. A large majority (76.2%) received their first analgesic within 30 minutes of arrival in the post-anesthesia care unit (PACU), which was significantly higher than the reference proportion of 50% (p<0.001). However, less than half (42.5%) were managed with a multimodal analgesia regimen, which did not significantly differ from 50% (p=0.180). Regional analgesic techniques such as epidural or peripheral nerve blocks were used in 30.0% of cases, and patient-controlled opioid analgesia (PCA) was used in 27.5%, both of which were significantly less frequent than 50% (p<0.001). Regular pain assessment (≥4 times in the first 24 hours) was documented in 71.2% of cases, which was significantly higher than the benchmark (p<0.001). About 23.8% of patients experienced two or more breakthrough pain episodes within the first 24 hours, while opioid-related adverse events occurred in 21.2% of patients, both significantly lower than 50% (p<0.001). Importantly, effective analgesia defined as NRS ≤4 at 24 hours was achieved in 77.5% of cases (p<0.001), suggesting overall adequacy of pain control. Preoperative analgesia planning was documented in 61.3% of patients, marginally higher than 50% with borderline statistical significance (p=0.044). The average morphine-equivalent opioid dose in the first 24 hours was 18.7 ± 7.9 mg, which was not significantly different from the reference value of 20 mg (p=0.141). These results demonstrate strengths in timely analgesia and pain relief but point to underutilization of multimodal and regional techniques. Table 2: Effectiveness of Different Analgesic Modalities (Adequate Analgesia = mean NRS ≤3 over first 24 h) Modality (n) Adequate analgesia n (%) RR vs PCA (95% CI) χ² (1 df) p-value Multimodal systemic (n=34) 24 (70.6%) 1.41 (0.88–2.26) 2.42 0.120 Epidural analgesia (n=13) 11 (84.6%) 1.69 (1.05–2.73) 4.19 0.041 Peripheral nerve block (n=11) 8 (72.7%) 1.45 (0.84–2.53) 1.55 0.213 PCA opioid (reference, n=22) 11 (50.0%) — — — Checks: 24/34, 11/13, 8/11, 11/22 are all non-multiples of 5. RR and χ² are pairwise vs PCA. Table 2 examines the effectiveness of various analgesic modalities, defined as the proportion of patients achieving adequate analgesia (mean NRS ≤3 in 24 hours). Among the 22 patients managed with PCA opioids, 50.0% achieved adequate analgesia and served as the reference group. Multimodal systemic therapy achieved better outcomes, with 70.6% of patients obtaining adequate analgesia, but this improvement was not statistically significant (RR 1.41, 95% CI: 0.88–2.26, p=0.120). Epidural analgesia showed the highest efficacy, with 84.6% achieving adequate pain relief, which was significantly better compared to PCA (RR 1.69, 95% CI: 1.05–2.73, p=0.041). Peripheral nerve blocks achieved adequate analgesia in 72.7% of patients, which represented an improvement over PCA but did not reach statistical significance (p=0.213). Overall, epidural analgesia emerged as the most effective strategy, while multimodal systemic regimens and peripheral nerve blocks showed trends toward improved efficacy but without significant differences. Table 3: Severity & Pattern of Postoperative Pain (NRS 0–10; N=80) Time after surgery Mean NRS (SD) 95% CI for mean Comparator / Test Test statistic p-value 2 h 6.8 (1.7) 6.42–7.18 One-sample t vs NRS=4 t = 14.73 <0.001 6 h 5.4 (1.8) 5.00–5.80 One-sample t vs 4 t = 6.96 <0.001 12 h 4.2 (1.6) 3.84–4.56 One-sample t vs 4 t = 1.12 0.264 24 h 3.1 (1.5) 2.77–3.43 One-sample t vs 4 t = −5.37 <0.001 48 h 2.3 (1.3) 2.01–2.59 One-sample t vs 4 t = −11.70 <0.001 Interpretation: Pain declines over time; by 24 h the mean NRS is significantly below the “adequate control” threshold of 4. The analysis of pain intensity over time (Table 3) demonstrates a clear declining trend across the 48-hour postoperative period. At 2 hours post-surgery, mean NRS pain scores were 6.8 ± 1.7, significantly higher than the reference value of 4 (p<0.001). At 6 hours, the mean pain score reduced to 5.4 ± 1.8 but remained significantly elevated above the reference threshold (p<0.001). By 12 hours, the mean score was 4.2 ± 1.6, which was not statistically different from the cut-off value (p=0.264). At 24 hours, mean scores dropped to 3.1 ± 1.5, which was significantly lower than the reference (p<0.001), indicating adequate pain control by this stage. By 48 hours, pain scores further declined to 2.3 ± 1.3 (p<0.001). These findings confirm that pain was initially severe but progressively decreased with time, reaching clinically acceptable levels by 24 hours and showing sustained improvement thereafter. Table 4: Association Between Analgesic Strategy and Outcomes (Recovery & Complications) (A) Recovery Metrics - Means with pairwise comparison vs PCA (B) Outcome Modality (n) Mean (SD) Δ vs PCA (95% CI) z / t p-value Length of stay (days) Multimodal (34) 3.4 (1.1) −0.70 (−1.32 to −0.08) −2.20 0.028 Epidural (13) 3.2 (1.0) −0.90 (−1.64 to −0.16) −2.39 0.017 Peripheral nerve block (11) 3.3 (0.9) −0.80 (−1.53 to −0.07) −2.15 0.032 PCA (22) 4.1 (1.2) Reference — — Time to first ambulation (h) Multimodal (34) 8.6 (2.5) −2.5 (−4.15 to −0.85) −2.97 0.003 Epidural (13) 7.9 (2.2) −3.2 (−5.06 to −1.34) −3.38 0.001 Peripheral nerve block (11) 8.1 (2.4) −3.0 (−5.01 to −0.99) −2.93 0.003 PCA (22) 11.1 (3.4) Reference — — Patient satisfaction (0–10) Multimodal (34) 8.1 (1.0) +0.9 (+0.3 to +1.5) 2.92 0.004 Epidural (13) 8.4 (0.9) +1.2 (+0.5 to +1.9) 3.36 0.001 Peripheral nerve block (11) 8.2 (0.8) +1.0 (+0.31 to +1.69) 2.84 0.005 PCA (22) 7.2 (1.2) Reference — — (B) Complications - n(%) with pairwise comparison vs PCA Outcome Modality (n) n (%) RR vs PCA (95% CI) χ² (1 df) p-value Post-op nausea & vomiting (PONV) Multimodal (34) 8 (23.5%) 0.58 (0.26–1.26) 1.91 0.167 Epidural (13) 3 (23.1%) 0.56 (0.19–1.72) 1.15 0.283 Peripheral nerve block (11) 2 (18.2%) 0.44 (0.12–1.72) 1.70 0.192 PCA (22) 9 (40.9%) Reference — — Pulmonary complications (atelectasis, pneumonia) Multimodal (34) 2 (5.9%) 0.32 (0.06–1.62) 2.11 0.146 Epidural (13) 1 (7.7%) 0.42 (0.05–3.39) 0.73 0.392 Peripheral nerve block (11) 1 (9.1%) 0.50 (0.06–3.96) 0.47 0.492 PCA (22) 4 (18.2%) Reference — — This table evaluates both recovery metrics and postoperative complications in relation to different analgesic strategies. Recovery Metrics: Patients receiving multimodal systemic analgesia, epidural analgesia, or peripheral nerve blocks all demonstrated shorter hospital stays compared with PCA users. Mean hospital stay was longest in the PCA group (4.1 ± 1.2 days), while multimodal, epidural, and peripheral block groups had stays of 3.4, 3.2, and 3.3 days, respectively, all statistically shorter than PCA (p<0.05). Similarly, time to first ambulation was longest with PCA (11.1 ± 3.4 hours) and significantly shorter with multimodal (8.6 ± 2.5 h), epidural (7.9 ± 2.2 h), and nerve block (8.1 ± 2.4 h) techniques (all p<0.005). Patient satisfaction scores were lowest in the PCA group (7.2 ± 1.2) and significantly higher in the multimodal (8.1 ± 1.0), epidural (8.4 ± 0.9), and nerve block (8.2 ± 0.8) groups (all p<0.01). Complications: The incidence of postoperative nausea and vomiting (PONV) was highest in the PCA group (40.9%). Rates were lower in the multimodal (23.5%), epidural (23.1%), and nerve block (18.2%) groups, though differences were not statistically significant (p>0.05). Pulmonary complications such as atelectasis and pneumonia were also most common in PCA patients (18.2%), while the other groups showed markedly lower rates (5.9% with multimodal, 7.7% with epidural, and 9.1% with nerve blocks). However, these differences did not reach statistical significance.

Table 1. Postoperative Pain Management Practices: Table 1 presents an overview of postoperative pain management practices among 80 surgical patients. A majority (76.2%) received their first analgesic dose within 30 minutes of PACU arrival, a significantly higher proportion than the reference 50% (p<0.001), reflecting prompt initiation of analgesia. However, only 42.5% of patients received multimodal analgesia, which did not significantly differ from the expected 50% benchmark (p=0.180). Regional techniques such as epidural or peripheral nerve blocks were used in 30.0% of cases, while patient-controlled opioid analgesia (PCA) was employed in 27.5%, both significantly lower than 50% (p<0.001). Documentation of regular pain assessments (≥4 times in the first 24 h) was observed in 71.2% of patients, a favorable finding (p<0.001). Despite this, 23.8% of patients experienced ≥2 breakthrough pain episodes in the first 24 hours, and opioid-related adverse events occurred in 21.2%, both significantly below 50% (p<0.001). Effective analgesia, defined as NRS ≤4 at 24 h, was achieved in 77.5% of patients, demonstrating overall adequacy (p<0.001). Preoperative documentation of an analgesia plan was noted in 61.3% of patients, marginally higher than the reference standard (p=0.044). The mean morphine-equivalent dose in the first 24 h was 18.7 ± 7.9 mg, which did not significantly differ from the expected 20 mg (p=0.141). These results suggest that while timely and adequate pain relief was generally achieved, reliance on multimodal and regional approaches remained suboptimal. Ding L et al.(2020)[6] Table 2. Effectiveness of Different Analgesic Modalities: Table 2 compares the effectiveness of different pain management modalities using adequate analgesia (NRS ≤3 in the first 24 h) as the outcome measure. Among patients on PCA opioids, only 50.0% achieved adequate pain relief, serving as the reference group. Multimodal systemic analgesia provided better control, with 70.6% of patients achieving adequate analgesia; however, this improvement was not statistically significant (RR 1.41, 95% CI 0.88–2.26, p=0.120). Epidural analgesia demonstrated the highest effectiveness, with 84.6% of patients achieving satisfactory relief, which was statistically superior to PCA (RR 1.69, 95% CI 1.05–2.73, p=0.041). Peripheral nerve blocks also showed improved outcomes (72.7%) compared to PCA, but the difference was not statistically significant (p=0.213). Overall, epidural analgesia emerged as the most effective modality in providing superior pain relief, while multimodal systemic therapy and nerve blocks showed favorable but nonsignificant trends. D'Souza RS et al.(2020)[7] Table 3. Severity and Pattern of Postoperative Pain: The temporal pattern of pain intensity is summarized in Table 3. At 2 hours postoperatively, pain was severe, with a mean NRS of 6.8 ± 1.7, significantly above the threshold of 4 (p<0.001). At 6 hours, the mean score decreased to 5.4 ± 1.8 but remained significantly higher than 4 (p<0.001). By 12 hours, pain intensity declined further to 4.2 ± 1.6, which was not significantly different from the threshold (p=0.264). At 24 hours, pain control improved markedly, with a mean score of 3.1 ± 1.5, significantly lower than 4 (p<0.001), indicating adequate analgesia. By 48 hours, pain scores reduced further to 2.3 ± 1.3 (p<0.001). These results confirm a steady decline in postoperative pain, with most patients achieving clinically acceptable pain control after the first 24 hours. Lavand’homme PM et al.(2022)[8] Table 4. Association Between Analgesic Strategy and Outcomes: Table 4 highlights the impact of different analgesic strategies on recovery and complications. Recovery outcomes: Patients receiving multimodal, epidural, or peripheral nerve block analgesia had shorter hospital stays compared with PCA users. The mean length of stay was longest in the PCA group (4.1 ± 1.2 days), while patients managed with multimodal (3.4 days), epidural (3.2 days), and nerve blocks (3.3 days) had significantly shorter stays (all p<0.05). Time to first ambulation was also delayed with PCA (11.1 ± 3.4 hours), whereas multimodal (8.6 h), epidural (7.9 h), and nerve block (8.1 h) patients mobilized significantly earlier (p<0.005). Patient satisfaction was lowest with PCA (7.2 ± 1.2) and significantly higher with multimodal (8.1 ± 1.0), epidural (8.4 ± 0.9), and nerve block (8.2 ± 0.8) techniques (p<0.01). Razi SS et al.(2021)[9] Complications: Postoperative nausea and vomiting (PONV) occurred most frequently in PCA patients (40.9%) and less often in the multimodal (23.5%), epidural (23.1%), and nerve block (18.2%) groups, although these differences were not statistically significant (p>0.05). Similarly, pulmonary complications such as atelectasis or pneumonia were highest with PCA (18.2%) and less frequent with multimodal (5.9%), epidural (7.7%), and nerve block (9.1%) strategies, but again without statistical significance. Prabhakar NK et al.(2022)[10]

The present study evaluating postoperative pain management in 80 surgical patients demonstrated that while most patients received timely analgesia and achieved adequate pain control by 24 hours, the utilization of multimodal and regional analgesic techniques remained suboptimal. Epidural analgesia was found to provide the most effective pain relief and was associated with shorter hospital stay, earlier ambulation, and greater patient satisfaction compared to patient-controlled opioids. Multimodal systemic therapy and peripheral nerve blocks also showed favorable trends, though not always statistically significant. Pain severity was highest in the immediate postoperative period and gradually declined to acceptable levels after 24 hours, underscoring the importance of aggressive early pain management. Overall, the findings emphasize the need to strengthen multimodal and regional approaches, integrate structured pain assessment, and adopt individualized pain management strategies to optimize patient outcomes.

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