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Epidural Analgesia and Pain Management


The effective control of postoperative pain is a component of paramount significance in the management of surgical patients; besides being inhumane, inadequate control of pain among these patients is likely to cause an increase in morbidity or even mortality. According to the evidence, the immune system is suppressed during surgery, and this suppression is in due proportion to the surgery’s invasiveness. A proper application of analgesia is crucial in reducing such a detrimental effect. According to the available data, the most effective technique used in analgesia is the afferent neural blockade.

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Next, epidural opioids, opioids, and clonidine stand out to be highly effective when taken in high doses. Non-steroidal anti-inflammatory agents and opioid therapy controlled by the patient are deemed as equally significant. Proper management of the post-operative pain brings with it various advantages, including the comfort of their pain, which is synonymous with their satisfaction, reduced cardiac and pulmonary complications, earlier mobilization, increased rate of recovery with reduced chances of developing neuropathic pain, a minimized risk of developing deep vein thrombosis, a reduced stay at the hospital and, hence, a reduced cost of care and management of the patient. An epidural that is well-managed is likely to offer the patient with proper analgesia after the operation, allowing them to be free from pain both when mobilizing and at rest.

On the other hand, epidural block obtunds the response of acute stress to surgery. This is what leads to other benefits besides the analgesic ones, including reduced cases of gastrointestinal, cardiac, or respiratory side-effects. The benefits of epidural analgesia are, thus, an issue of widespread understanding among medical professionals, and these analgesic techniques have been well embraced in the surgical practice. Most large studies have focused on the benefits of epidural analgesia and the possible side-effects of using these procedures as compared to other anesthetic approaches, with fewer studies reviewing how such benefits can be measured and their practicability established.

The use of epidural analgesia is targeted at managing pain among patients who have undergone an operation; and, thus, the most effective way through which one can establish how beneficial this procedure involves measuring the changes in the levels of pain, even as this approach is incorporated into the care of these patients. As such, this study is going to investigate how the postoperative pain score can be used to identify the benefits of epidural analgesia as applied among post-operative patients.

Literature Review

Postoperative Pain

Postoperative pain is a significant problem for both minor and major surgical incidents. Some procedures, such as breast surgery, thoracotomy, and hernia repair, result in chronic pain problems (Lavand’homme, Kock, & Waterloos 2005). The control of the postoperative pain is essential since it's inadequate control has outcomes such as increased cases of chronic postsurgical pain, increased postoperative morbidities and a worsening in patient outcomes such as the quality of life (Block, Liu, Rowlingson, Cowan, Cowan Jr, & Wu 2003). The postoperative pain remains clinically significant for outpatient ambulatory surgery patients, even during the optimization of opioid and non-opioid adjuncts (Brennan 2011). While regional analgesics techniques may be employed to reduce the pain control, their use is limited to just a minor subset of all surgical patients.

The postoperative pain, either pain at rest or during activities, is usually a crucial clinical symptom in major surgical procedures. Pain relief is the primary measure of the efficacy of any analgesic regimen (Wheatley, Schug, & Watson 2001). The visual analog pain scale (VAS) is a tool that may be used to quantify the amount of pain. At rest, pain is usually moderate, at about 3 to 4 out of 10 (VAS), a score that occurs even during the administration of parenteral treatment. The pain at rest usually resolves within the first week after surgery (Brennan 2011).

Pain with activities, on the other hand, is usually substantially severe during the first two to three days. The VAS can be as high as 7 to 8. Activities here include walking and coughing. Unlike pain at rest, pain with activities remains moderate/severe for a number of days and weeks after the surgery. Pain is reduced by reducing activities that can evoke it, such as walking and coughing. While greater opioid dosing may be further applied to reduce pain, this is limited by side effects that include ileus, vomiting, and respiratory depression.

As noted, the postoperative pain remedies are usually only effective for a subset of surgical patients. This kind of pain may be managed through a variety of methods including drugs. Block et al. (2003) note that the delivery of medications through the epidural space has the potential to provide benefits such as improved pain control and perioperative pathophysiology, thus reducing the postoperative pathophysiology. Lavand’homme, Kock and Waterloos (2005) note that it has, however, been difficult to identify optimal methods of the pain management, even with the availability of drugs and techniques, as well as the simple nature of incisional pain.

Brennan (2011) notes that there has been limited success in the development of new treatments for acute postoperative pain due to the limitations of pain models and behaviors. Some of the pain models include antigen-specific inflammation and receptor-specific, chemical stimuli, which are preclinical pain models. Their applicability for the postoperative pain is limited due to their poor translatability to incisional pain mechanisms. All in all, the etiology and treatment of pain due to other clinical conditions is different from that of other pain conditions such as rheumatoid arthritis and fibromyalgia (Brennan 2011). These differences epitomize the difficulty in developing treatment methods for postoperative pain.

A chronic post-surgical pain (CPSP) has been identified as a major problem among patients who undergo surgeries. According to the recent studies, the CPSP and acute post-operative pain remain a continuum of a similar phenomenon (Brennan 2011). Individuals with acute postoperative pain are at an increased risk of developing CPSP. When individuals suffering from acute postoperative pain are exposed to repetitive nociceptive stimulation, they experience a central and peripheral sensitization, which, when it stays beyond the acute postoperative period, develops into the chronic postoperative pain.

The occurrence and severity of such pain are reduced through the blockage of the afferent nociceptive stimulus, which reduces sensitization and pain. It is essential to note that up to 10 percent of all post-operative patients are likely to obtain acute post-operative pain. When susceptible individuals fail to recognize related symptoms, it may lead to the advancement of the pain into CPSP (Brennan 2011).

It is clear that chronic pain has an enormous socioeconomic burden. This condition affects the quality of life of individuals who experience it, with the fact that it is difficult to treat prolonging their suffering (Gerbershagen, et al. 2011). Medical professionals should consider it a clinical priority to minimize the factors behind the development of CPSP, especially when planning analgesia and anesthesia approaches. As much as most of the risk factors, including genetics, age, and psychological status, are unavoidable, others, such as perioperative analgesia, anesthetic, and the type of surgery conducted, can be altered.

Measuring Pain

As noted, pain relief is an essential measure of the efficacy of analgesic treatment. The need for pain relief and pain treatment is determined by assessing the level of pain (Gerbershagen, et al. 2011). Different scales are used in different contexts to quantify pain. In most cases, one scale is applied in a hospital setting to create uniformity among the health care teams when referring to the patient’s pain intensity. Out of all the tools and scales that are used in terms of the interpretation, the self-report of a patient is considered the most significant and useful tool.

As such, it is crucial for health care professionals to ensure that patients assess the intensity of the pain they are experiencing as far as possible to ensure, while they are still able to express and communicate how the experienced pain feels like. It is of paramount significance not only to listen to what the patient says about their pain all the time, but to believe it, as they are the ones feeling it and, hence, can define it. There are various scales used by patients to assess their pain status.

One such scale is the numeric rating scale (NRS 0-10, where 0 = no pain; and 10 = worst pain imaginable). This scale has been validated for measuring the intensity of postoperative pain and is often used to group patients into those who are in need of pain remedies and those who are not (Gerbershagen, Rothaug, Kalkman, & Meissner 2011). The patient is simply required to rate the experienced pain using a certain number.

However, there are certain discrepancies in the cutoff points that are used to determine whether the pain threshold is moderate or high. Another scale that can be used to measure pain is the visual analog scale (VAS). For this scale, the patient is presented with an ungraduated straight line that is close to 100 mm, marked as “no pain” at one end and “worst possible pain” at the other end (Gerbershagen, et al. 2011).

A health care professional then asks the patient to mark a point on the liner that reflects the level of pain that they are experiencing. On the other hand, the verbal rating scale (VRS) is also commonly used in post-operation settings, where a five-point scale is used to rate the patient’s pain. This scale includes five items ranging from highly severe, severe, moderate, mild, to none (Gerbershagen, et al., 2011).

Lastly, facial expressions also determine the level of pain that a patient is in. In this case, the patient is presented with a six-faced pictogram representing different facial expressions ranging from a smiling face to a tearful one, with a number of intermediate expressions. In the hospital setting, the NRS and the VRS are the dominantly used tools of the pain assessment. Nevertheless, when it comes to research, the VAS tool is widely used among researchers.

Epidural Analgesia

Epidural analgesia is a technique aimed at providing pain relief to patients undergoing surgery. Ideally, an epidural analgesic technique should provide effective pain relief for major surgeries with minimal side effects (Wheatley, Schug, & Watson 2001). Such a technique should also obtund a central sensitization and lead to improved outcomes. The role of epidural analgesia in the provision of preemptive analgesia has been considered, with studies recording inconsistent outcomes (Lavand’homme, Kock, & Waterloos 2005). Moreover, the timing of epidural analgesia remains unclear.

There are many potential benefits of epidural analgesia. Nimmo (2004) highlights six areas of potential benefit, including the attenuation of the stress response and thromboembolic complications. With stress responses, Nimmo (2004) notes that there is an inextricable link between postoperative pain and inflammatory as well as the stress response. Attenuation of the stress response is the manner, in which epidural analgesia is postulated to be beneficial. The second area of benefit is the pulmonary function, whereby epidural opioids alongside local anesthetic infusions have been shown to improve postoperative oxygenation while reducing incidences of postoperative atelectasis and pulmonary infection.

Factors, such as impaired central ventilator control, modifications of ventilator/perfusion matching, and unbalanced pulmonary mechanics, lead to postoperative pulmonary dysfunction. Some of the mechanisms, through which epidural analgesia has been hypothesized to improve patient’s conditions, include a pain relief which allows patients to take deep breaths and cough and a possible reduction in pulmonary infection stemming from the reduced postoperative immunosuppression due to a reduction in stress responses to surgery (Nimmo 2004). Epidural analgesia also has cardiovascular benefits. By improving the postoperative oxygen supply, postoperative epidural analgesia reduces incidences of postoperative myocardial infarction.

With thromboembolic complications, the attenuation in stress response improves fibrinolytic function and attenuates the hypercoagulable response to surgery. A fifth potential benefit is in the gastrointestinal function, whereby epidural analgesia lessens the duration of postoperative ileus, by improving intestinal motility and limiting opioid use (Nimmo 2004). These benefits trickle down to the improved postoperative catabolism, leading to further benefits such as total body protein preservation, improved muscle strength, and tolerance. Finally, there are benefits in terms of intraoperative blood loss, whereby there is evidence that intraoperative neuraxial block abates the necessity for blood transfusion.

The improved outcomes of epidural analgesia may not be readily apparent or easily demonstrable for a number of reasons. The first is the use of mortality as an indicator of the benefits of epidural analgesics (Nimmo 2004). Nimmo (2004) contends that due to the improved practice in surgical, anesthetics, and intensive care, mortality is not an appropriate indicator of the efficacy of epidural analgesia. She recommends other measures such as the quality of recovery and the return to normal functioning. Another reason for the lack of apparentness is the failure of epidurals due to a number of reasons such as technical problems, lack of facilities, and lack of acute pain practitioners. Finally, there is also the fact that a postoperative recovery relies on more than just the provision of good analgesia.

Despite the benefits, there are also a number of complications associated with epidural analgesia. There are different complications based on the method of epidural administration. Such complications range from severe to mild, depending on the conditions and efforts put in place to mitigate them. In extreme cases, epidural analgesia can lead to death or permanent neurological deficit. Nevertheless, other severer complications include ischemia of the spinal cord, vertebral canal hematomas, abscess of the vertebral canal, among other forms of neurological injury. When it comes to catheter insertion, some of the complications include dural puncture and neurological damage (Nimmo 2004).

Then there are complications related to the catheter in situations such as epidural abscess, catheter migration, and epidural hematoma. Finally, there are several complications associated with epidural drugs. They include drug errors, hypotension, CNS toxicity, and respiratory depression. There are also a number of other side effects associated with epidural analgesia, namely postoperative nausea and vomiting (Fowler, Symons, Sabato, & Myles 2008) as well as hallucinations and nightmares (Lavand’homme, Kock, & Waterloos 2005).

A number of studies investigate the role of epidural analgesia. In their study, Lavand’homme, Kock, and Waterloos (2005) investigate the timing and role of balanced epidural analgesia as a preventive treatment in patients of major digestive surgery. They randomly assign patients to receive intraoperative and postoperative balanced analgesia by either the epidural or intravenous route. The participants were adult patients undergoing the curative surgical resection of rectal adenocarcinoma. The exclusion criteria included severe hepatic, cardiovascular, renal or psychological disorders, preexisting pain syndrome, alcoholism, analgesic treatment, and inability to comprehend the study protocol.

The preventive effect of epidural analgesia was assessed based on the development of residual pain and postoperative wound hyperalgesia of up to 1 year after the procedure. The study was proposed to 85 consecutive patients, of whom 79 successfully went through the entire duration (Lavand’homme, Kock, & Waterloos 2005). Their study outcomes demonstrated that continuous perioperative epidural analgesia has preventive treatment benefits on the development of residual postoperative pain. Another significant finding was the superiority of effective neuraxial block over efficient parenteral analgesia.

However, it is crucial to note that these complications that come with epidural analgesia can be effectively avoided or reduced. In order to achieve this, it is necessary to first compare and properly select the epidural analgesia by the patient, while carefully considering the associated risk of infection and perioperative anticoagulation factors (Fowler, et al. 2008). In addition, it is essential for proper considerations to be put in place to ensure that the process of epidural insertion is only carried out using effective aseptic techniques. In the contemporary context, most health care professionals use chlorhexidine as the antiseptic element used in penetrating the skin.

Nevertheless, it is still possible for the nerve to be injured upon the chlorhexidine’s introduction into the space of epidural. This has called for extra care when using this solution, especially in terms of ensuring that there is no contact between the catheter and the epidural needle, as well as the chlorhexidine. In addition, prior to starting the procedure, it is imperative to ensure that the skin is completely dry (Lavand’homme, et al. 2005). It is also critical for the technique used to insert to be fastidious in order to prevent the development of complications.

Health professionals must avoid multiple attempts, especially when the patient experiences dysesthesia or pain during insertion. Lastly, it is essential for the post-operative epidural analgesia management to be adequate to ensure timely identification and management of any form of complications in order to reduce the risk of developing a permanent neurological injury as well as ensure that the benefits are experienced at an optimal rate (Fowler, et al. 2008).

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Patient-Controlled Analgesia

Patient-controlled analgesia is commonly used in managing pain among patients who have undergone abdominal surgery. This technique involves the use of intravenous (IV) opioids among these patients, whereby it is administered in small doses upon experiencing pain (Layzell 2014). Patients experience relief from pain upon binding of the opioids to the opioid receptors found in the urinary tract, spinal cord, brain, and gastrointestinal tract, peripheral nerve endings, and lungs. Nevertheless, just like epidural, as much as opioids relieve pain, they may expose individuals to various complications in abdominal surgery cases and, hence, reduce the rate of recovery. Some of these side effects include gastric ileus prolongation, vomiting, nausea, dizziness, and sedation (Layzell 2014). Nevertheless, as compared to other methods of administering opioids, PCA reduces the side effects related to opioids.


This chapter outlines the methods and materials that will be used for the research study. It proposes the roles of various research participants at their respective levels. In addition, it also proposes the possible time schedules, during which different stages and activities of the research will be accomplished.


This study, which is aimed at investigating the use of postoperative pain scores to identify the benefits of epidural analgesia, will be conducted between May and July 2016. However, the data of the commencement of the study will be dependent on the outcome of the approval process by the Medical Faculty. Once the medical committee approves the investigation, the study will run for a period of 2-3 months, which may also be subject to the prevailing conditions during the actual study. In this case, the study will include the patients with major conditions of thoracoabdominal or abdominal surgeries with a continuous need for Postoperative Epidural (EPI) or intravenous analgesia.

This study will not be randomized. In cases, where there will be contraindications to the epidural blockade, patient's refusal to participate in the study, or where the underlying surgical procedures will not lead to the need of epidural analgesia, then a remedial procedure will be employed, in which a continuous intravenous morphine infusion will be commenced postoperatively. If there will be patients undergoing minor surgical operations, they will be given intermittent opioids postoperatively, based on the provisions of the departmental procedures.

In this study, there will be thoracoabdominal (esophagectomy) surgeries, the upper abdominal ones will be defined as gastrectomy, including liver resection, pancreatic resection, reflux, as well as diaphragmatic surgery. Other than the upper abdomen, there will also be the lower abdominal sections handled, which will include rectum amputation, radical prostatectomy, surgery of the colon, as well as a cystectomy.

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Study Design

This research will utilize the analytic experimental study design. As such, the researcher will be involved in the manipulation of the intervention in the study, namely epidural analgesia, as applied to the patients and recording the outcomes. Being a case-control study, this study will involve matching the pain scores of two groups of postoperative patients, including those who have been exposed to epidural analgesia as the intervention for pain management and those who have been offered a placebo to create a perception of the pain management. The study design has been selected with the intent of establishing not only the changes in the pain scores of post operated patents but also determining the actual impact of epidural analgesia in regard to the management of pain as compared to cases, where it is not applied.

Target Population

The target population of this study includes patients who have undergone thoracoabdominal surgeries (esophagectomy), the upper abdominal surgeries, such as gastrectomy, including liver resection, pancreatic resection, reflux, as well as diaphragmatic surgeries. Other than the upper abdomen, there will also be the lower abdominal sections handled, which will include rectum amputation, radical prostatectomy, surgery of the colon, as well as a cystectomy. Such patients are exposed to postoperative pain. Such pain includes the development of acute postoperative pain, which is likely to further develop into chronic postoperative pain. With their initial pain scores being at high levels, such patients are the perfect subjects for determining changes in the pain levels with the exposure to epidural analgesia as a pain management intervention.


The researcher will utilize the convenience sampling in this study, whereby the sample population will be selected based on their convenience as compared to the requirements of the study. As such, it is essential for the researcher to include the sample persons who have undergone surgeries, specifically the aforementioned surgical procedures. This nonprobability approach to sampling has been selected based on the specificity of the requirements of the study and the need to reduce the cost of sampling and selection of participants.

A sample size of 200 participants will be handpicked from the study population in the hospital setting and allocated to one of the two groups involved in the study, namely the experimental group and the control group. The researcher will be actively involved in the manipulation of the interventions in order to establish the impact of epidural analgesia on the pain scores among the participants.

Patients exposed to the placebo may be switched to an intervention based on their state of pain and need for management. The sample population will be informed of their participation in the study, and their consent will be obtained before their inclusion in the study. Nevertheless, none of the patients will be informed of the details of the study procedure, including the use of a placebo to manage some of the patients, as this is likely to interfere with the behavior of the patients during the study.


The selection of the thoracic or the lumbar vertebral interspace, which will be used for the epidural catheter will be based on the extent of the dermatomal surgical procedure, the ease with which the researcher will conduct the catheter insertion, as well as the views and recommendations of the attending anthologist. One of the early clinical impressions expected will involve the thoracic catheter placement, which will be a significant step in the process of reducing the possible chances of lower limb weakness. In the case of lower limb weakness, it will be most likely to occur in the postoperative period, during which the procedure will utilize the available 0.25% bupivacaine solution. In such a case, the anthologist will have a chance to carry out a thoracic epidural placement.

The identification of the epidural space will be carried out based on the provisions and recommendations of the departmental routines. In this case, to achieve more accurate outcomes, with the effective patients' participation, the procedure will register their participation in a sitting position, as well as a midline approach. Furthermore, the exercise will also involve the use of the loss-of-resistance as a technique, including the use of a saline-filled 10 ml syringe.

When performing the insertion exercise, it will be critical to remember that the epidural catheter should be inserted at a depth of about 4-6 cm into the available epidural space. When fixing the catheter, the procedure will involve the use of a transparent adhesive dressing. The use of the transparent adhesive dressing will enhance the easy routine supervision of the insertion site. In cases, where a portion of the catheter remains unused, it will be crucial to tap the material along the midline of the back.

Perioperative Management

The study proposes to use the rectal midazolam or parenteral opioids as an alternative to the premedication of the patients. The premedication choice will be based on the prevailing aesthetic management procedures, as well as the decision made by the attending anesthesiologist based on the departmental routines. The general process of inducing the anesthesia will be conducted using the propofol or the thiopental, fentanyl, or non-depolarizing relaxant. After the induction of the anesthesia, the maintenance will be conducted with oxygen, nitrous oxide, with the help of a volatile agent. This procedure will utilize a low-flow circuit, as well as mechanical ventilation.

Data Collection

The data collection techniques will involve basic experiments as well as clinical observations. Dose adjustments, the documentation of the NRS scores for the different levels of pain, both at rest as well as mobilization, and the registration of adverse effects will be conducted on a daily basis by an attending anesthesiologist. The idea behind taking the data on a daily basis will help in monitoring any possible changes and also facilitate the process of making an average observation of the overall monitoring procedures at the end of the study. For the case of respiratory depression, this study will define the limits as less than 8 breaths per minute of the observation.

Furthermore, sedation, for this study, will be defined as a type of difficulty that will arouse the patient verbally, or in a case of pain that is stimulated. Further data will be recorded from a common patients' observation, such as nightmares and hallucinations, patients entering the state of mental confusion, and dizziness, most of which will be recorded by the attending nurses. In order to achieve a wholesome sense of the patients' observation, it will also be essential for the attending nurse to take notes of the cases of nausea as well as vomiting by the patients under the study. The patients' pain scores will be recorded in order to determine any changes in such scores as the epidural analgesia treatment continues.


There will be a continuous comparison of the data between the various groups by the sets of unpaired t-test. In cases of the ordinal data, the comparison will be conducted by the chi-squared tests. The NRS scores for the different levels of pain among the patients will be analyzed through repeated analysis of the variance, as well as pairwise comparisons using the Mann-Whitney µ-tests. The statistical significance of the study will be stated as a P-value lower than 0.05. It is without a doubt that epidural analgesia is a highly effective method in the management of post-operative pain.

As such, this study is to be conducted based on the already established knowledge base on the impact of the intervention on the management of pain among post-operative patients. Nevertheless, this study is determined to contribute to the already existing knowledge on the pathophysiology of pain reduction through the application of epidural analgesia as the pain management technique. As much as most studies have linked epidural analgesia with benefits of pain management among post-operative patients, a few have managed to quantitatively link the two.

As such, this study aims at taking a distinctive approach to the topic by using the various readings concerning pain at different levels of the intervention, in determining if changes in the application of epidural analgesia are reflective of changes in the pain scores. This will ensure the establishment of the relationship between the epidural analgesia and management of pain among post-operative patients. In addition, by comparing the experimental group to the control group, who will not be exposed to the epidural analgesia intervention but a placebo, the researcher will be able to effectively determine the effect of epidural analgesia on the pain management and the underlying factors of such an effect, especially whether such factors are clinical or psychological as determined by the pain scores of the group on placebos.

Ethical Considerations

The permission of the study will be sought from the medical faculty at the institution of research. The ethics committee at the medical faculty will subject the study to the rigor of scrutiny, considering the extent to which it complies with the ethical considerations set by the medical faculty. Since the approval process involves the consultation of various stakeholders in the medical faculty, it is hoped that the approval consent will be reflective of the ethical compliance of the study. The permission will also be sought from the participants of the study, whereby a written consent will be presented to them, which they will be required to sign as approval of being involved in the study.

Before being presented with the consent, the participants will be informed of the specifics of the study, with an exception of the information concerning the use of a placebo as this may affect the outcomes of the study. However, the researcher will consult with the health care team to ensure that the participants are guaranteed safety throughout the health process and that they are not subjected to any process that can be detrimental to their health or infringing any of their social or cultural rights.

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It is essential to note that some patients experience the ‘nocebo effect’ when given placebos. This involves a negative response to placebos that may range from mild experiences, such as nausea and headaches, to critical complications such as cardiac arrest. Therefore, in order to ensure that this research is well considerate of the health of the patients, and approval will be sought from IRB, which will determine the applicability of the research methodology and the use of placebos with regard to the safety of the participants.


It is evident that the management of pain among post-operative patients is an issue of paramount significance both to the health care professionals and the patients involved. As such, it is crucial to ensure that proper measures are put in place to facilitate the patients' healing process, part of which a pain minimization becomes integral. This research study will provide a vast amount of the primary data, based on which conclusive remarks can be established in view of the benefits of epidural analgesia to the management of post-operative pain. This will allow the researcher to put to rest any doubt pertaining to how effective this technique is in terms of the management of pain.

In addition, it will offer a highly dependable and reliable source of evidence that will be applied by practitioners even as they embrace an evidence-based practice, especially when it comes to rating the effectiveness of the pain management approach, with reference to the pain scores. The conclusion of this research will also allow for the identification of gaps in research related to pain management using epidural analgesia, which will contribute to creating more opportunities for further research in the same area. Lastly, the research will provide the information that can be well incorporated in the educational curriculum, thus ensuring proper preparation of students entering the medical profession with regard to dealing with pain among post-operative patients.

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