Regional Anesthesia and Acute Pain Management

This review addresses the issue of perioperative analgesia in patients with morbid obesity undergoing bariatric surgery. Conventional opioid analgesia is associated with complications, including a high risk of respiratory adverse events, postoperative dyspeptic disorders, and the development of opioid-induced hyperalgesia, particularly in patients with morbid obesity. In this context, multimodal analgesia strategies, including regional anesthesia as their component, represent a promising alternative.

The conducted analytical review of current published data indicates that modern regional anesthesia techniques, including transversus abdominis plane block (TAPB), quadratus lumborum block (QLB), and erector spinae plane block (ESPB), when integrated into multimodal analgesia, provide effective control of postoperative pain, a substantial reduction in opioid burden, and minimization of associated adverse effects. Ultrasound guidance is mandatory when performing blocks in patients with morbid obesity, as it allows overcoming technical difficulties associated with excessive development of subcutaneous adipose tissue.

QLB may surpass TAPB in the duration of analgesic effect and in effectiveness regarding the visceral component of pain, whereas epidural anesthesia, despite its high effectiveness, is associated with technical challenges when performed in this patient population. This review presents a detailed comparative analysis of various regional anesthesia techniques (TAPB, QLB, rectus sheath block [RSB], thoracic paravertebral block [TPVB], epidural anesthesia, IIB/IHB), with assessment of their level of evidence, technical complexity, safety profile characteristics, and spectrum of potential risks. This analysis provides clinicians with a methodological basis for a reasoned choice of the optimal technique, taking into account the type of planned surgical intervention, the level of technical equipment of the healthcare institution, and the individual anatomical and physiological characteristics of the patient. The main limitations hindering the widespread implementation of regional anesthesia techniques in clinical practice are also considered.

BACKGROUND: Effective postoperative pain control in bariatric surgery remains a challenging clinical task, especially in patients with morbid obesity. The erector spinae plane block (ESP block) is a promising regional anesthesia technique that may reduce opioid consumption and improve recovery.

AIM: This study aimed to evaluate the analgesic efficacy of the ESP block compared with standard analgesia in patients undergoing laparoscopic sleeve gastrectomy.

METHODS: A pilot, single-center, prospective, randomized, placebo-controlled study included 20 patients who underwent laparoscopic sleeve gastrectomy: the ESP group (n = 10; 20 mL of 0.5% ropivacaine on each side at the T7 level) and the control group (n = 10; 0.9% NaCl administered using the same technique, sham block). Pain was assessed using the visual analog scale (at rest/during movement) at 2, 4, 6, 12, and 24 hours. Intraoperative hemodynamic parameters, opioid consumption, incidence of postoperative nausea and vomiting, and time to mobilization were recorded.

RESULTS: Patients in the ESP block group had significantly lower visual analog scale pain scores at all time points compared with the control group (p < 0.01). Intraoperative fentanyl consumption and postoperative tramadol consumption were significantly lower in the ESP group (p < 0.01). More stable hemodynamics were observed in the ESP group during the 30–120 minutes after induction, as well as a lower incidence of postoperative nausea and vomiting (10% vs. 80%). Time to first mobilization was significantly shorter in the ESP group (mean 7.1 h vs. 12.3 h, p < 0.01).

CONCLUSIONS: The ESP block provides effective analgesia, reduces opioid requirements, improves hemodynamic stability, and facilitates early rehabilitation in patients after laparoscopic sleeve gastrectomy. The technique may be used as part of multimodal analgesia and ERAS protocols in bariatric surgery.

BACKGROUND: Despite advances in anesthesiology, postoperative pain following open kidney surgery remains a major clinical challenge. High pain intensity in the early postoperative period often leads to increased opioid consumption and a higher risk of complications. Within the ERAS (Enhanced Recovery After Surgery) concept, increasing attention is given to safe regional analgesic techniques that reduce opioid requirements. One such method is the erector spinae plane block (ESP block), whose effectiveness in open urologic surgery is insufficiently studied.

AIM: This study aimed to evaluate the effectiveness of the ESP block as a component of multimodal anesthesia in patients undergoing open kidney surgery during the intraoperative and early postoperative periods.

METHODS: A prospective, controlled study included 116 patients divided into two groups: the main group (n = 60, with ESP block) and the control group (n = 56, without block). Patients older than 18 years with ASA physical status I–III and without contraindications to regional anesthesia were included. Primary outcomes were intraoperative fentanyl consumption, postoperative use of trimeperidine, pain intensity assessed by the numerical rating scale, incidence of nausea and vomiting, need for nonsteroidal anti-inflammatory drugs and paracetamol, and length of stay in the intensive care unit. Statistical analysis was performed using SPSS 25.0; significance level p < 0.05.

RESULTS: ESP block significantly reduced fentanyl consumption: 0.027 ± 0.01 μg/(kg·min) vs. 0.046 ± 0.02 μg/(kg·min) (p < 0.01) and the need for trimeperidine within the first 6 hours (5.0% vs. 55.6%; p < 0.001). Pain intensity on the numerical rating scale was significantly lower in the main group at all observation points (median 0.0 vs. 3.0–7.0; p < 0.001). The incidence of postoperative nausea and vomiting was 10–15 times lower in the main group (p < 0.001), as was the need for nonsteroidal anti-inflammatory drugs and paracetamol. Length of stay in the intensive care unit decreased 3.7-fold (2.88 ± 0.17 h vs. 10.89 ± 3.51 h).

CONCLUSIONS: ESP block in open renal surgery demonstrates high clinical effectiveness as part of multimodal anesthesia, providing marked analgesia, reducing opioid load, and improving postoperative recovery.

BACKGROUND: In women with preeclampsia, the need for continuation of antihypertensive therapy after abdominal delivery persists. Postoperative pain may contribute to the set of factors underlying hypertension. The effect of the transversus abdominis plane (TAP) block on the course of hypertension in women with preeclampsia after cesarean section remains insufficiently studied.

AIM: This study aimed to comparatively evaluate pain intensity, hemodynamic parameters, and the requirement for analgesic and antihypertensive therapy in women with preeclampsia during the first 24 hours after cesarean section under multimodal analgesia alone and multimodal analgesia supplemented with TAP block.

METHODS: Women with preeclampsia (n = 104) were randomized into two groups. Group 1 (n = 54) received multimodal analgesia; group 2 (n = 50) received multimodal analgesia combined with TAP block. The study included assessment of pain intensity using the visual analog scale, blood pressure, and heart rate before surgery and at 3, 6, 12, and 24 hours postoperatively. Blood glucose and serum cortisol concentrations were measured preoperatively and at 12 and 24 hours after surgery. Cardiac index and total peripheral vascular resistance were evaluated before surgery and at 24 hours postoperatively. Analgesic load and antihypertensive therapy were analyzed and compared between groups 24 hours after surgery.

RESULTS: During the first postoperative day, visual analog scale pain scores, as well as blood glucose and cortisol concentrations, were significantly higher in group 1 compared with group 2. The frequency of trimeperidine administration in group 1 was increased twofold (p = 0.000), and tramadol administration increased 45.5-fold (p = 0.000). Antihypertensive therapy was modified as follows: to correct hypotension in 13.0% of patients in group 1 and 46.0% in group 2 (p = 0.002); to correct hypertension in 46.3% and 16.0% of patients, respectively (p = 0.006). These adjustments allowed maintaining target arterial blood pressure values in groups. Cardiac output and total peripheral vascular resistance did not differ between groups before and after surgery. No adverse reactions associated with TAP block were observed.

CONCLUSIONS: TAP block provided lower postoperative pain intensity and reduced opioid consumption in women with preeclampsia after cesarean section. Improved analgesic efficacy reduced the incidence of progression of hypertension by 2.4-fold and increased the number of patients showing a tendency toward resolution of hypertension by 3.5-fold during the first postoperative day. Adjustment of antihypertensive therapy under TAP block conditions had no negative effect on cardiac output or total peripheral vascular resistance. The study is limited by its single-center design and by the inability to exclude the influence of the visceral pain component on hypertension.