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PSH0010.1177/2010105817738794Proceedings of Singapore HealthcareChan et al.

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Original Article OF SINGAPORE HEALTHCARE

Proceedings of Singapore Healthcare

Factors affecting postoperative pain 2018, Vol. 27(2) 118­–124

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DOI: 10.1177/2010105817738794
https://doi.org/10.1177/2010105817738794

post-anaesthesia care unit: journals.sagepub.com/home/psh

A descriptive correlational study

Jason Ju In Chan1, Sze Ying Thong1 and Michelle Geoh Ean Tan2

Abstract
Background: Pain occurring in the post-anaesthesia care unit (PACU) is common, distressing to patients and remains a
management challenge for staff. This study aims to identify the factors affecting pain severity and delay in discharge of patients
from the PACU.
Methods: Data from 590 consecutive postoperative patients in the PACU was collected over one month in 2012 at the
Singapore General Hospital. Patient demographics, surgical, intraoperative anaesthetic and recovery data were collected.
The primary outcome measured was postoperative pain score and secondary outcome was a delay in discharge. Univariate
and multivariate logistic regression were performed to determine preoperative and intraoperative variables that may be
associated with pain and delayed discharge.
Results: The majority (67.6%) of patients reported no to mild pain while 32.3% reported moderate to severe pain; 65.4%
of patients had delayed discharge and 28.3% of these were a result of uncontrolled pain. Factors associated with moderate
to severe postoperative pain included younger age, same day admissions, duration of operation >2 h, abdominal, upper limb
and spine surgeries and use of general anaesthesia. Factors associated with delay in discharge included higher body mass
index, abdominal, spine and superficial surgeries, use of general anaesthesia, moderate to severe pain score and use of nurse
controlled analgesia.
Conclusions: This study identifies predictive factors for postoperative pain and delay in discharge from the PACU. Knowledge
of these factors may help in better clinical judgment for postoperative pain management and can lead to quality improvement
measures for patient management and work flow in the PACU.

Keywords
Retrospective cohort, audit, pain, post-anaesthesia care unit, delay in discharge

Introduction
The Singapore General Hospital (SGH) has over 8700 sur-
geries performed per year (as of 2012). Despite standard
interventions, postoperative pain in the post-anaesthesia care
unit (PACU) remains common. It is distressing to patients and
staff alike and prolongs PACU stay and increases costs.
There have been many advances in the understanding of
postoperative pain management in the last 40 years, with a
large number publications on the topic including practice
guidelines from the American Society of Anesthesiologists
(ASA)1–3 and Procedure Specific Postoperative Pain
Management (PROSPECT) Group.4–7 A number of large
audits have also been carried out to provide data on postop-
erative pain management.8–10
A study by Aubrun et al. on 342 patients showed that 42%
had severe pain in the PACU.11 They found that factors asso-
ciated with severe pain included a higher intraoperative dose
of sufentanil, the use of general anaesthesia and preoperative
1Department of Anaesthesiology, Singapore General Hospital, Singapore
2Pain
Management Centre and Department of Anaesthesiology, Singapore
General Hospital, Singapore
Corresponding author:
Jason Ju In Chan, Department of Anaesthesiology, Block 3 Level 2,
Singapore General Hospital, Outram Road, Singapore, 169608.
Email: jasonchan78@yahoo.com

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Chan et al. 119
treatment with analgesics. Another more recent abstract
showed that 49.6% of the patients had severe pain in the
PACU.12 The study found that younger, females, those with a
lower ASA status and those who had general anaesthesia and
abdominal and orthopaedic procedures were more likely to
have severe pain in the PACU. Locally, there is no updated
data on the incidence of postoperative pain in the PACU.
Studies have shown that severe postoperative pain is asso-
ciated with a delay in discharge from the PACU.13,14 This audit
evaluates the incidence of severe postoperative pain in our
centre and aims to identify the factors affecting pain severity
as well as delay in discharge.
Methods
After obtaining Institutional Review Board approval
(2012/250/D), data from 590 postoperative patients aged 21
years and above in the PACU was collected in February–
March 2012 at SGH. Data was manually collected by the doc-
tor in charge of patient care in the PACU for the main
operating theatre complex of the SGH during office hours
(08:30 to 17:00 hours) in the period stipulated.
All patients above the age of 21 years who arrived in the PACU
in the main operating theatre complex postoperatively were
included in the study, while exclusion criteria included patients
operated outside of the main operating complex (e.g. ambulatory
centre, endoscopy suites) and patients who bypassed the PACU
postoperatively (e.g. directly to intensive care units (ICUs)).
The type of data collected was divided into patient data,
surgical data, intraoperative anaesthetic data and postopera-
tive recovery data. Patient data included age, admission type
(ambulatory surgery admission or same day admission or
inpatient), weight, height, drug allergies, ASA status, presence
of obstructive sleep apnoea, drug dependence, presence of
chronic pain and type of preoperative analgesia given if any.
Surgical data included operation type, specialty, duration
of surgery, whether surgery was open or minimally invasive,
operation site and whether local anaesthesia was given.
Intraoperative anaesthetic data included the type of anaesthe-
sia given, morphine and fentanyl dose used and the use of remifen-
tanil, dexmedetomidine, ketamine, nitrous or any other analgesia.
Postoperative recovery data included maximum pain
score recorded, patient controlled analgesia (PCA) morphine
dose if PCA was used, whether a continuous epidural or
nerve block infusion was used and any top-up doses given,
whether nurse initiated analgesia protocol was used, rescue
morphine and fentanyl doses, any oral analgesics used, time of
admission and discharge as well as reason for delay.
The primary outcome measured was the maximum post-
operative pain score in PACU. Pain score was documented
using numerical rating scale (NRS) 0–10. When the patient
was unable to quantify using the NRS, the categorical verbal
descriptor scale was used and converted to numeric scores
on charting. The postoperative pain scores (1–10) were
dichotomized into two categories: presence of no to mild
pain (pain scores: 0–3) and presence of moderate to severe
pain (pain scores: 4–10).
The secondary outcome measured was a delay in dis-
charge from the PACU defined as longer than 30 minutes. A
delay in discharge defined as longer than 30 minutes’ stay in
the PACU has been the local practice adopted in the depart-
ment in SGH.
Morphine doses used intraoperatively were categorized to
0–0.1 mg/kg dose used, 0.11–0.2 mg/kg used and > 0.2 mg/kg
used. Fentanyl doses were categorized to 0–2 µg/kg dose
used, 2.1–3 µg/kg used and >3 µg/kg used.
Statistical analysis
We used binomial logistic regression for the univariable and
multivariable analyses, as pain severity and delay in discharge
were categorical variables. Preoperative and intraoperative
variables were analysed to look for association with pain in
the PACU; preoperative, intraoperative and postoperative
variables were analysed to look for association with a delay in
discharge from PACU. Significant factors from the univariable
analyses and factors a priori were included in the multivaria-
ble analyses; p values were two sided and values less than 0.05
were considered significant. Statistical analyses were con-
ducted with IBM SPSS version 16.0
Sample size calculation
In our literature search, the incidence of severe pain ranged
from 25% to 42%.11,15 We therefore decided to use the mean
of that range (33.5%) to calculate the sample size. We had
nine covariates and based on the work of Peduzzi et al.16 we
used his formula N = 10 × 9 / 0.335 = 269 to determine the
minimum sample size needed
Results
Patient characteristics
Table 1 summarizes the characteristics of our patients in the
audit. The majority of patients (67.6%) reported no to mild
pain while 32.3% reported moderate to severe pain. The
majority of patients were female (61.4%), with a mean age of
54 years. Most underwent same day admissions (53.9%),
open surgery (70.8%), had no preoperative analgesia (96.6%)
and were given general anaesthesia (81.4%); 65.4% of patients
had delayed discharge from PACU, 28.9% of these being as a
result of uncontrolled pain.
Factors associated with pain severity
A summary of factors associated with moderate to severe
postoperative pain is shown in Table 2. From the multivariable
logistic regression, older patients were less likely to report
moderate to severe pain postoperatively (p < 0.001). Patients
scheduled for surgery on the same day of admission were
2.46 times more likely to have moderate to severe pain (p =
0.048). Surgeries with >2 h duration were 2.33 times more
likely (p = 0.003), those who underwent abdomen surgeries
were 4.46 times more likely (p < 0.001), upper limb surgeries
were 4.03 times more likely (p = 0.003) and spine surgeries
were 2.65 times more likely (p = 0.039) to report moderate
to severe pain postoperatively. The use of general anaesthet-
ics compared with regional techniques had 15.4 times
120 Proceedings of Singapore Healthcare 27(2)

Table 1.  Patient Characteristics. Table 1. (Continued)

Characteristic No. % Characteristic No. %

No. of patients 590 100   Lower limbs 177 30.0

Gender   Upper limbs 45 7.6
 Male 228 38.6  Spine 33 5.6
 Female 362 61.4  Superficial 47 8.0
Age, mean (SD) 53.6 (15.7)   LA by surgeon
Admission type  No 528 89.5
 ASC 44 7.5  Yes 62 10.5
 SDA 318 53.9 Anaesthesia
 Inpatient 228 38.6  GA 480 81.4
Weight, mean (SD) 65.9 (15.9)    Others 110 18.6
BMI, mean (SD) 25.7 (5.72)   Morphine, mean (SD)
Drug allergy   Morphine dose, mg 1.5 (2.93)  
 No 468 79.3 Morphine, mean (SD)
 Paracetamol 5 0.8   Morphine dose, mg/kg 0.083 (0.074)  
 NSAID 25 4.2 Fentanyl, mean (SD)
 Opioids 5 0.8   Fetanyl dose, µg 60.5 (52.32)  
 Non-analgesia 87 14.7 Fentanyl, mean (SD)
ASA   Fentanyl dose, µg/kg 0.93 (0.85)  
  ASA 1 113 19.2 Remifentanil
  ASA 2 326 55.3  No 543 92.0
  ASA 3 and 4 151 25.6  Yes 47 8.0
OSA Dexmedetomidine
 No 588 99.7
 No 568 96.3
 Yes 2 0.3
 Yes 22 3.7
Ketamine
Drug dependence  No 581 98.5
 No 589 99.8  Yes 9 1.5
 Yes 1 0.2 Nitrous
Chronic pain  No 564 95.6
 No 588 99.7  Yes 26 4.4
 Yes 2 0.3 Other analgesia
Preop. analgesia  No 582 98.6
 No 570 96.6  Yes 8 1.4
 Paracetamol 9 1.5 Pain
 NSAID 6 1.0   No to mild pain 399 67.6
  Moderate to severe pain 191 32.3
 Opioids 5 0.8
Delay in discharge from PACU
Speciality
 No 204 34.6
 GS 142 24.1
 Yes 386 65.4
 Ortho. 204 34.6
Delay in discharge reason
 Hand 13 2.2
  No delay 204 34.6
 O&G 85 14.4
  Delay due to pain 170 28.9
 ENT 41 6.9
  Delay due to other reasons 216 36.6
 Colorectal 34 5.8
 Dental 7 1.2
ASC: ambulatory surgery; SDA: same day admission; BMI: body mass index;
 Cardiothoracic 14 2.4 NSAID: non-steroidal anti-inflammatory drug; GS: ; ASA: American Society of
 Plastics 43 7.3 Anesthesiologists; OSA: ; GA: general anaesthesia; Preop.: preoperative; Or-
 Others 7 1.2 tho.: orthopaedic; O&G: obstetrics and gynaecology; ENT: ear, nose, throat;
Duration MIS: minimally invasive surgery; Abdo.: abdomen; Gynae.: gynaecological; LA:
; PACU: post-anaesthesia care unit ; ASC: ambulatory surgery centre; GS:
  <1 h 271 45.9
General Surgery; OSA: Obstructive Sleep Apnoea; LA: Local Anaesthetic.
  1–2 h 207 35.1
  >2 h 112 19.0
increased likelihood of having moderate to severe postopera-
Operation type
 Open 418 70.8
tive pain (p < 0.001).
 MIS 172 29.2
Operation site Subgroup analysis for pain severity in
  Head and neck 92 15.6 abdominal surgeries with or without regional
 Thorax 22 3.7 anaesthesia
 Abdo. 98 16.6
 Gynae. 76 12.9
Of interest, only 15.3% of patients who had abdominal sur-
gery had regional anaesthesia. Of patients who had
Chan et al. 121

Table 2.  Factors associated with Pain Severity.

Characteristic % who reported Unadjusted univariable model Adjusted multivariable model

moderate to
  severe pain OR 95% CI p value OR 95% CI p value

Gender
 Male 33.3 Ref Ref  
 Female 31.8 0.93 0.65–1.33 0.690 1.31 0.80–2.13 0.278
Age, mean 53.6 0.97 0.96–0.98 <0.001 0.96 0.94–0.97 <0.001
Admission type 0.104  
 ASC 18.2 Ref.a Ref.  
 SDA 32.7 2.19 0.98–4.87 0.056 2.46 1.01–6.01 0.048
 Inpatient 34.6 2.39 1.06–5.38 0.036 1.91 0.73–5.03 0.189
Weight, mean 65.9 1.01 1.00–1.02 0.020 1.01 0.998–1.03 0.080
ASA 0.161  
 1 30.1 Ref. Ref.  
 2 35.9 1.3 0.82–2.06 0.264 1.75 0.98–3.12 0.057
  3 and 4 26.5 0.84 0.89–1.44 0.520 1.72 0.82–3.62 0.153
Duration 0.012  
  <1 h 27.3 Ref. Ref.  
  1–2 h 29.5 1.11 0.75–1.66 0.603 1.20 0.74–1.94 0.455
  >2 h 50.0 2.66 – <0.001 2.33 1.32–4.12 0.003
Operation type
 Open 33.7 Ref. Ref.  
 MIS 29.1 0.81 0.55–1.19 0.272 0.67 0.42–1.08 0.096
Operation site 0.001  
  Head and neck 28.3 Ref. Ref.  
 Thorax 36.4 1.45 0.54–3.87 0.457 2.89 0.96–8.72 0.059
 Abdo. 45.9 2.16 1.18–3.94 0.013 4.46 2.17–9.17 <0.001
 Gynae. 38.2 1.57 0.82–2.99 0.175 2.02 0.94–4.33 0.070
  Lower limbs 21.5 0.694 0.39–1.24 0.216 1.87 0.93–3.75 0.079
  Upper limbs 42.2 1.86 0.88–3.90 0.104 4.03 1.62–10.03 0.003
 Spine 45.5 2.11 0.93–4.81 0.740 2.65 1.05–6.68 0.039
 Superficial 23.4 0.78 0.34–1.75 0.540 0.98 0.39–2.46 0.962
Anaesthesia
  Spinal + others 4.1 Ref. Ref.  
 GA 37.9 14.2 5.14–39.3 <0.001 15.4 4.82–49.1 <0.001

aAllreferences were coded as 0 and subsequently in consecutive running order numbers.

OR; odds ratio; CI: confidence interval; ASC: ambulatory surgery; SDA: same day admission; ASA: American Society of Anesthesiologists; MIS: minimally
invasive surgery; Abdo.: abdomen; Gynae.: gynaecological; GA: general anaesthesia.

abdominal surgeries without regional anaesthesia 52.4% had
moderate to severe pain compared with 13.3% of patients
who had abdominal surgeries with regional anaesthesia.
Out of the patients who had spinals, 85.5% had lower
limb surgeries, 81.6% had orthopaedic procedures and
82.4% were obese (defined as having a body mass index
(BMI) > 30 kg/m2).
Factors associated with delay in discharge
A summary of factors associated with a delay in discharge
from the PACU is shown in Table 3. Higher BMI was associ-
ated with a delay in discharge from the PACU (overall p =
0.024). Patients who had abdominal surgeries were 2.18
times more likely (p = 0.049), spine surgeries 3.88 times
more likely (p = 0.038) and superficial surgeries 2.73 times
more likely (p = 0.037) to have a delay in discharge from
PACU. Patients who had general anaesthesia were 4.41 times
more likely (p < 0.001) and patients who had moderate to
severe pain score were 10.4 times more likely (p < 0.001) to
have a delay in discharge from the PACU. Patients who had
nurse initiated analgesia in the PACU had a 3.86 times
increased likelihood of delay in discharge (p = 0.017).
Pain severity associated with delay in
discharge from the PACU
Patients who had moderate to severe pain were 10.2 times
more likely to have a delayed discharge compared with those
who had no pain (p < 0.001), as shown in Table 4.
Discussion
Our study showed that 32.3% of our patients reported mod-
erate to severe postoperative pain. Patients having a delay in
discharge from the PACU numbered 65.4% and 28.3% of
these were as a result of uncontrolled pain. The factors asso-
ciated with moderate to severe postoperative pain include
122 Proceedings of Singapore Healthcare 27(2)

Table 3.  Factors associated with delay in discharge.

Characteristic % delay in Unadjusted univariable model Adjusted multivariable model

discharge
  OR 95% CI p value OR 95% CI p value
BMI 0.024  
 <18.5 50.0 Ref.a Ref.  
 18.6–25 66.0 1.94 0.90–4.16 0.089 3.54 1.36–9.18 0.009
 25.1–30 70.2 2.36 1.06–5.22 0.035 4.28 1.58–11.59 0.004
 >30.1 69.1 2.24 0.97–5.19 0.059 4.83 1.69–13.86 0.003
Operation site 0.069  
  Head and neck 64.1 Ref Ref  
 Thorax 72.7 1.49 0.53–4.18 0.45 1.34 0.41–4.32 0.630
 Abdo. 77.6 1.93 1.02–3.66 0.043 2.18 1.00–4.73 0.049
 Gynae. 64.5 1.02 0.54–1.91 0.96 0.97 0.46–2.07 0.943
  Lower limbs 55.4 0.69 0.41–1.17 0.17 1.69 0.84–3.40 0.140
  Upper limbs 62.2 0.92 0.44–1.93 0.83 0.80 0.30–2.15 0.659
 Spine 78.8 2.08 0.81–5.30 0.13 3.88 1.08–13.98 0.038
 Superficial 72.3 1.46 0.68–3.15 0.33 2.73 1.06–7.00 0.037
Anaesthesia  
  Spinal + others 29.9 Ref Ref  
 GA 72.3 6.16 3.82–9.92 <0.001 4.41 2.34–8.28 <0.001
Pain score  
  No to mild 52.1 Ref Ref  
  Moderate to severe 93.2 12.58 6.93–22.8 <0.001 10.4 5.08–21.3 <0.001
Nurse controlled analgesia  
 No 62.0 Ref Ref  
 Yes 92.5 7.62 3.01–19.3 <0.001 3.86 1.27–11.71 0.017

aAll
references were coded as 0 and subsequently in consecutive running order numbers.
OR; odds ratio; CI: confidence interval; BMI: body mass index; Abdo.: abdomen; Gynae.: gynaecological; GA: general anaesthesia.

Table 4.  Pain severity associated with delay in discharge from PACU.
Characteristic OR 95% CI p value
Pain severity
  No pain Ref.  
  Mild pain 1.16 0.69–1.95 0.580
Moderate to severe pain 10.2 4.97–20.9 <0.001
Adjusted for gender, age, admission type, weight, ASA status, duration of
operation, operation type, operation site and anaesthesia used.
OR: odds ratio; CI: confidence interval; Ref.: reference; ASA: American
Society of Anesthesiologists.
younger age; duration of surgery >2 h; site of surgery being
abdominal, upper limb and spine; and the use of general
anaesthesia. The factors associated with a delay in discharge
from the PACU include higher BMI; site of surgery being
abdominal, spine and superficial; use of general anaesthesia;
use of nurse controlled analgesia and moderate to severe
pain scores.
There are numerous factors that affect postoperative
pain.10,17 The association of younger age group and operative
site (abdominal or orthopaedic surgeries) with more severe
postoperative pain is in concordance with previous stud-
ies.18,19 The use of regional techniques lowering incidence of
postoperative pain is also in agreement with previous
work.11,20,21There have been conflicting findings regarding
the association of gender and postoperative pain. Our study
did not find any significance in this association and this was
found similarly in a previous study.22 Prolonged surgical
duration is associated with greater surgical stress to the body
and likely greater tissue trauma. This was significantly associ-
ated with postoperative pain, which is in congruence with a
previous study.22
Same day admissions appear to be a significant factor asso-
ciated with increased pain severity postoperatively as com-
pared with day surgery cases. Patients with higher pain scores
are likely to be admitted rather than sent home as a day surgi-
cal patient. The use of pre-emptive analgesia and multi-modal
analgesia techniques has been shown to provide good post-
operative pain control.23 However, in our study data there
was a large percentage of documented ‘no analgesia’ given
preoperatively (96.6%). Our study focus was not designed to
look at pre-emptive analgesia or multi-modal analgesia tech-
niques affecting postoperative pain. Instead we focused on
overall intraoperative factors that may affect postoperative
pain. The cut off points for moderate to severe pain in the
NRS ranged from 4 to 6 in non-cancer pain in a previous
review article.24 We chose to use pain scores > 4 as our cut-
off for moderate to severe pain.
For the secondary outcome measure of factors affecting a
delay in discharge from the PACU, a delay in discharge was
defined as more than a 30 min stay in the PACU. Literature
on the definition of a delay in discharge is varied, with a range
from 30 min to 2 h.25–28 Our choice of 30 min as the cut-off
is based on our institutional practice and different from previ-
ous studies.29–31 Nurse initiated analgesia was set up in our
institution to reduce delay in patients with pain in PACU
receiving analgesia. Patients with higher pain scores and
Chan et al. 123
needing nurse initiated analgesia are significantly associated
with a delay in discharge from the PACU.
We acknowledge several limitations to this study. First,
there was no data collected on the ethnicity of patients
despite the large varied population characteristic in our cen-
tre. Ethnicity has been shown to be a predictive factor in
postoperative pain in previous studies.32,33 The data collected
over the one-month period may represent seasonal presen-
tation of certain case types although this may have minimal
effect on the results due to the high caseload in our centre.
Second, the data collection over the period stipulated was
carried out by different doctors in charge in the PACU on
different days. Although the data collected is standardized,
there is possibility of observer and reporting bias as different
interviewers may influence patient reports on pain score.
Third, patients with more severe pathology and long duration
of surgery tend towards postoperative direct ICU admission,
bypassing the PACU and excluded from the data in this study.
Our study focuses on postoperative pain in the PACU and
excludes postoperative pain presenting outside of the PACU
(e.g. patients who are directly admitted to the ICU or patients
in ambulatory centres). For the secondary outcome of delay
in discharge, our study did not address non-clinical issues that
may affect delay in discharge from the PACU, such as inade-
quate manpower, resources or beds or inefficiency in patient
transfer processes. Patients may have been required to wait
for bed availability even when they were fit for discharge from
the PACU.
This study opens up further areas of improvement for
postoperative pain management and managing reasons for
delay in discharge from the PACU. The results allow us to
target our efforts in any interventions or quality improve-
ments for patient care in the PACU. Further study into non-
clinical factors affecting delay in discharge could also be
conducted.
Declaration of conflicting interests
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in
the public, commercial or not-for-profit sectors.
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