Nociception Level-Guided Multimodal Analgesia with External Oblique Intercostal Plane Block in Laparoscopic...

Effective perioperative analgesia remains essential in laparoscopic cholecystectomy (LC), where pneumoperitoneum produces the most intense nociceptive stimulus despite the minimally invasive nature of the procedure. Objective monitoring of nociception using the nociception level (NOL) index may optimize intraoperative opioid titration; however, its integration into multimodal analgesia (MMA) strategies incorporating regional techniques has not been adequately studied. The study was conducted using a double-blind design in which patients and the postoperative outcome assessor were blinded to group allocation, whereas the investigator performing the EOIP block was necessarily unblinded. This randomized controlled trial investigated whether NOL-guided MMA, including an external oblique intercostal plane (EOIP) block, improves intraoperative nociceptive control and early postoperative pain compared with conventional intravenous analgesia. Sixty-two ASA I-II adults undergoing elective LC were randomized to receive either an EOIP block with dexketoprofen and magnesium infusion or intravenous dexketoprofen alone. In both groups, remifentanil infusion was titrated according to predefined NOL thresholds, and anesthetic depth was maintained using BIS monitoring. NOL values during pneumoperitoneum were significantly lower in the MMA group (mean difference: 13.51; 95% CI: 4.68-22.34; p < 0.004), indicating superior attenuation of peak nociceptive responses. Emergence pain scores were also reduced in the MMA group (p < 0.001), whereas total remifentanil consumption did not differ between groups. Sevoflurane requirements and extubation times were significantly lower in the MMA group, suggesting a potential anesthetic-sparing effect. No differences were observed in postoperative opioid rescue, nausea/vomiting, or other adverse events. These findings demonstrate that NOL-guided MMA incorporating EOIP block enhances intraoperative nociceptive stability and improves early postoperative analgesia without increasing opioid use. Larger multicenter studies are warranted to confirm these results and further refine NOL-integrated multimodal analgesic strategies.