Advanced Clinical Approaches in Perioperative Pain Management

Background and Objectives: Effective postoperative analgesia is essential for enhanced recovery after bariatric surgery. The erector spinae plane block (ESPB) has emerged as a promising regional anesthesia technique, but its impact on postoperative pain control, opioid requirement, patient and surgeon satisfaction, and stress response in obese patients undergoing sleeve gastrectomy remains unclear. This study aimed to evaluate the effects of bilateral ESPB on postoperative analgesia requirements, pain scores, patient and surgeon satisfaction, hemodynamic stability, postoperative stress response, and perioperative hematologic and biochemical parameters in ASA II–III patients with a body mass index (BMI) > 30 undergoing sleeve gastrectomy. Study design was a prospective, randomized, single-blind clinical trial. Materials and Methods: After obtaining ethics committee approval (Şanlıurfa Harran University Hospital, date: 23 January 2023; decision no: HRÜ/23.02.09) and written/verbal informed consent, 60 patients aged 18–65 years, BMI > 30, ASA II–III scheduled for elective sleeve gastrectomy were included. Patients were randomized into two groups: those receiving bilateral ESPB (Group E, n = 30) and those without ESPB (Group C, n = 30). Demographic characteristics, ASA scores, comorbidities, and surgical duration were recorded. Preoperative venous samples were collected into hemogram (WBC, lymphocyte, neutrophil) and biochemistry tubes (CRP, cortisol, glucose). Standard monitoring (ECG, SpO₂, NIBP) was applied intraoperatively, and vital parameters (HR, MAP) were recorded throughout. Postoperatively, HR, MAP, Numerical Rating Scale (NRS) scores at 0, 2, 4, 8, and 24 h, opioid requirement, patient and surgeon satisfaction (Likert scale), postoperative hemogram and biochemistry values, and side effects or complications were documented. All patients received dexketoprofen as baseline analgesia, with tramadol HCl administered as rescue analgesic. Results: All 60 patients completed the study. There were no statistically significant differences between the groups regarding age, BMI, or surgery duration. Comorbidities were similar between groups. Intraoperative and postoperative HR and MAP values showed no significant differences. Postoperative NRS scores at the 0, 2, 8, and 24 hours were significantly lower in Group E compared with Group C. Both patient and surgeon satisfaction scores were higher in Group E. Rescue analgesic (tramadol HCl) consumption in the postoperative ward was significantly reduced in Group E. Cortisol levels, particularly at the 24th postoperative hour, showed a significantly smaller increase in Group E, suggesting a reduced surgical stress response. No significant differences were found between the groups regarding postoperative side effects or complications. Conclusions: Preoperative bilateral ESPB is an effective component of multimodal analgesia in sleeve gastrectomy. The block significantly reduces postoperative pain intensity, lowers NRS scores, improves patient and surgeon satisfaction, and decreases opioid requirements. Additionally, ESPB appears to attenuate the postoperative stress response, as reflected by smaller increases in cortisol levels. These findings support the routine incorporation of ESPB in perioperative pain management strategies for gastric sleeve surgery. Full article

Background and Objectives: Intraoperative hypotension (IOH) is of great importance in preventing diseases such as postoperative myocardial infarction, acute kidney injury, and mortality. This study aimed to develop and validate machine learning and deep learning models that predict IOH using both biosignals and personalized clinical information for each patient. Materials and Methods: In this retrospective observational study, we used the VitalDB open dataset, which included intraoperative biosignals and clinical information from 6388 patients who underwent non-cardiac surgery between June 2016 and August 2017 at Seoul National University Hospital, Seoul, South Korea. The predictive performances of models trained with four waveforms (arterial blood pressure, electrocardiography, photoplethysmography, and capnography) and clinical information were evaluated and compared at time points at 5 min before the hypotensive event. To predict hypotensive events during surgery, we developed two predictive models: machine learning and deep learning. In total, 2611 patients were enrolled in this retrospective study. Machine and deep learning algorithms were developed and validated using raw waveforms and clinical information as inputs. Results: Gradient boosting machine showed predicted IOH with an AUROC and accuracy of 0.94 (0.93–0.95) and 0.88 (0.86–0.89). A hybrid CNN-RNN model also showed similar performance with an AUROC and accuracy of 0.94 (0.93–0.95) and 0.88 (0.87–0.89). Conclusions: This study developed and validated machine and deep learning models to predict IOH using waveform data and covariate values. In the future, we anticipate that the results of our study will contribute to predicting IOH in real time in the operating room and reducing the occurrence of IOH. Full article

Background and Objectives: Ultrasound (US)-guided peripheral regional anesthesia (pRA) is gaining increasing importance in emergency medicine as an effective, low-ridsk alternative to general anesthesia (GA), procedural sedation (PS), or opioid therapy. By enabling rapid, direct pain management in the emergency department (ED), pRA can help preserve scarce surgical and anesthetic resources and, in some cases, avoid inpatient admissions. The aim of this study was to analyze the indications, techniques, and clinical impact of pRA in the orthopedic-focused ED of an affiliated hospital. Materials and Methods: All pRA and PS procedures performed over a six-year period were retrospectively reviewed among 35,443 orthopedic-trauma emergency patients. pRA was carried out under US guidance with standardized monitoring. Diagnoses, block techniques, effectiveness, and complications were analyzed descriptively. Results: A total of 1292 patients (3.7%) underwent either pRA (n = 1117; 3.2%) or PS (n = 175; 0.5%). pRA was performed in 22% of cases for interventions such as reductions or extensive wound management. In 78%, pRA was applied for analgesia, for example, in the diagnostic work-up and treatment of non-immediately operable fractures, lumbago, or arthralgia. The most common pRA techniques were brachial plexus blocks (54%) and femoral nerve blocks (25%). Fascial plane blocks (6.1%) and paravertebral blocks (1.5%) were rarely used. PS was performed in 175 of 1292 patients (13%), although pRA would have been feasible in 159 of these cases. No complications of pRA were observed, and GA could routinely be avoided. Conclusions: US-guided pRA proved to be an effective and safe alternative to PS, GA, or systemic analgesia for selected indications, allowing immediate treatment without the need for operative capacities. To ensure safe application, these techniques should be an integral part of the training curriculum for ED personnel. Full article