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Although postoperative pain remains incompletely controlled in some settings, increased understanding of its mechanisms and the development of several therapeutic approaches have substantially improved pain control in past years. Advances in our understanding of the process of nociception have led to insight into gene-based pain therapy, the development of acute opioid-induced hyperalgesia, and persistent postsurgical pain. Use of specific analgesic techniques such as regional analgesia could improve patient outcomes. We also examine the development of new analgesic agents and treatment modalities and regimens for acute postoperative pain.

As humanity presses the boundaries of space exploration and prepares for long-term interplanetary travel, including to Mars, advanced planning for the safety and health of the crewmembers requires a multidisciplinary approach. In particular, in the event of a survivable medical emergency requiring an interventional procedure or prolonged pain management, such as traumatic limb injury or rib fracture, anesthetic protocols that are both safe and straightforward to execute must be in place. In this daring discourse, we discuss particular considerations related to the use of regional techniques in space and present the rationale that regional anesthesia techniques may be the safest option in many medical emergencies encountered during prolonged space flight.

Volatile halogenated gases and nitrous oxide used as part of a balanced general anesthetic may contribute to global warming. By avoiding volatile inhalational agent use, regional anesthesia may reduce greenhouse gas emissions and help prevent global warming. We present a theoretical calculation of the potential benefits and a real-life example of how much regional anesthesia may reduce greenhouse gas emissions.

Interest in natural language processing, specifically large language models, for clinical applications has exploded in a matter of several months since the introduction of ChatGPT. Large language models are powerful and impressive. It is important that we understand the strengths and limitations of this rapidly evolving technology so that we can brainstorm its future potential in perioperative medicine. In this daring discourse, we discuss the issues with these large language models and how we should proactively think about how to leverage these models into practice to improve patient care, rather than worry that it may take over clinical decision-making. We review three potential major areas in which it may be used to benefit perioperative medicine: (1) clinical decision support and surveillance tools, (2) improved aggregation and analysis of research data related to large retrospective studies and application in predictive modeling, and (3) optimized documentation for quality measurement, monitoring and billing compliance. These large language models are here to stay and, as perioperative providers, we can either adapt to this technology or be curtailed by those who learn to use it well.

Background Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. Methods Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1. Results Twelve components of preoperative care were considered. Consensus was reached after three rounds. Conclusions These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.