Journal of the College of Physicians and Surgeons Pakistan
ISSN: 1022-386X (PRINT)
ISSN: 1681-7168 (ONLINE)
Affiliations
doi: 10.29271/jcpsp.2026.08.967Emergency surgery has brought about remarkable advancements in the survival of critically ill and trauma patients because of the rapid diagnostic tools, multimodal anaes- thesia, and improvised surgical interventions. Nevertheless, acute pain management of such patients is one of the most significant clinical issues and an aspect of treatment that has not been given due importance.1 Acute pain following emergency surgery is not only a symptom of tissue damage but also causes severe stress on the body, which affects wound healing, impairs immune functioning, and delays overall recovery. Uncontrolled pain after surgery has been linked to higher morbidity, longer hospitalisation, and development into chro-nic pain syndromes.2 Central sensitisation predetermines this acute-to-chronic pain progression as the nervous system is still in a high state of reactivity after severe surgical trauma.
Patients in the emergency operations are often accompanied by massive pain as a result of trauma, infection, ischaemia, or visceral perforation. In contrast to elective surgical patients, emergency cases are frequently haemodynamically unstable, and preoperative optimisation is not possible due to a restriction of analgesic options.3 Suboptimal pain management triggers a sympathetic stress response, which results in tachycardia, hypertension, weakened immunity, and high oxygen demand, which may end up deteriorating the outcome of the surgery.4 Metabolic derangements add to the physiological load of pain in the emergency environment; an increase in catabolic hormones, such as cortisol, further inhibits the process of regeneration needed to heal the surgical site. The extreme pain limits deep breathing and early mobilisation, thus exposing the patient to the risk of atelectasis, pneumonia, venous thromboembolism, and delayed wound healing.5
Beyond the physical agony, untreated acute pain also causes severe psychological effects. Patients with emergency surgery are often filled with anxiety, fear, and helplessness that not only intensifies their pain perception but also reduces their engagement in the care.6 Severe postoperative pain often leads to effects such as sleep disruption, emotional disturbance, delirium, cognitive impairment, and psychological problems in the longer term, with an elevated risk for critically ill and elderly patients. Ineffective early pain management is another signi- ficant contributor to chronic postoperative pain that may worsen quality of life for months or years.7 In many low- and middle-income countries (LMICs), low resource availability adds another layer of difficulty to effective pain management. In teaching hospitals in Sindh and Khyber Pakhtunkhwa, 72.2% of anaesthetists reported that their institutions lacked postoperative pain management guidelines, while only 5% had access to all five essential pain medications, highlighting substantial deficiencies in both institutional guidance and resource availability; thus, global guidelines may need to be adapted locally in Pakistan.8 However, multimodal use of analgesic agents remains variable across centres in Pakistan; the lack of trained personnel and regional anaesthesia expertise in many centres also suggests a need for regional anaesthesia guidelines and capacity building efforts for optimal peri-operative pain management in Pakistan.9
The management of acute pain during emergency surgery should be multimodal and include opioids, non-opioid analge- sics, regional anaesthesia, and non-pharmacological approaches such as patient reassurance, positioning, and early mobilisation. Non-opioid analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs offer further benefits of opioid-sparing effects and enhanced recovery.10 The clinical practice guidelines highlight that multimodal analgesia offers a better approach to pain management as it decreases the use of opioids, enhances early physical activity, minimises complications, and alleviates pain in patients post-surgery effectively. To ensure adequate treatment and maximise recovery, it is vital to monitor pain levels both during post- operative care and after transfer.11 Adequate analgesia also reduces the physiological stress response. It helps stabilise cardiac, respiratory, and metabolic function, while improving sleep quality, patient comfort, and participation in postoperative rehabilitation, thereby enhancing recovery outcomes and overall quality of life.12,13
Advances in technology, such as patient-controlled analge- sia (PCA) and ultrasound-guided nerve blocks, have enhan-ced the management of acute pain through the delivery of more targeted analgesia with minimal systemic side effects. For emergency surgical care, three priorities should be emphasised: routine pain assessment using a standardised tool, implementation of multimodal analgesia protocols, and improved training in and access to regional anaesthesia techniques. The broad implementation of these measures has the potential to improve recovery while minimising complications and long-term consequences; however, in low and middle-income countries, adaptation to local resources and reinforcement of institutional policies for pain management remain crucial.
COMPETING INTEREST:
The authors declared no conflict of interest.
AUTHORS’ CONTRIBUTIONS:
MAAA, MS, AB: Conception and design of the study; acquisition, analysis, and interpretation of the data; approval of the final version of the manuscript to be published.
REFERENCES