Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version.

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

Cisatracurium versus vecuronium: a comparative, double blind, randomized, multicenter study in adult patients under propofol/fentanyl/N2O anesthesia.

AIM: The aim of this study was to compare the time course characteristics of cisatracurium (C) and vecuronium (V) induced neuromuscular block (NMB) following multiple doses, allowing spontaneous complete recovery (SCRT) and evaluating the influence of age. METHODS: Following institutional approval and signed informed consent, 177 adult ASA 1-2 patients were included in a randomized, double-blind, multicenter study under N20/02/fentanyl/propofol anesthesia. Muscle relaxation was induced with 0.15 mg/kg C or 0.l mg/kg V and was maintained with 0.03 mg/kg of C or 0.02 mg/kg of V injected at T1 25% recovery. Intubating conditions were assessed at 2 min after the initial dose. Time course of NMB was monitored using accelerography (Tofguard) of the adductor pollicis with train-of-four (TOF). Data were analyzed with parametric (Anova) and non parametric statistics (c2, Kruskal Wallis). RESULTS: Both drugs offered good/excellent intubating conditions: duration of action of NMB (mean values +/- SD, minutes) were: dur25 first dose: V 38.20+/-13.2 vs C 51.5+/-11.3 (P<0.02 ); dur25 following repeated boluses (average): V 23.2+/- 8.6 vs C 28.2+/-9.5, ns; dur25 last dose: V 25.1+/-11.5 vs C 31.5+/-11.4, ns: SCRT following last dose: V 50.2+/-23.2 vs C 46.4+/-17.5, ns: t125% to t4/T1 0.80:V 27.1+/-18.7 vs C 18.8+/-10.2, ns. Stratifying for age >or< 65 no differences were noted in the intervals studied following C, while all were longer following V. The duration of block of C was longer than V; the SCRT after the final dose of C was shorter than V albeit not significant. There was a clinically significant increase in duration of block and recovery time in elderly patients for V but not for C. CONCLUSIONS: C and V allow predictable NMB duration and spontaneous recovery even if administered in multiple repeated doses; but in elderly patients duration of block and recovery time is longer following V.

Perioperative analgesia in pulmonary surgery.

AIM: In pulmonary surgery many studies have shown how pain associated with residual doses of anaesthetic drugs can cause a decrease in pulmonary volumes and depression of the cough reflex. Both these phenomena are responsible for a rising incidence of postoperative mortality and morbidity. The most widely used postoperative analgesic techniques are continuous systemic analgesia and epidural analgesia. The aim of this study is to verify the advantages and the disadvantages of both analgesic techniques. METHODS: Fifty patients, undergoing pulmonary surgery, were recruited and divided, after randomization into 2 groups. Patients included in A group received an epidural administration of naropina 0.2%+fentanyl 4 microg/mL by elastomeric pump (rate 5 ml/h). Patients included in B group received an ev continuous infusion of tramadol 600 mg+ketorolac trometamina 120 mg+ranitidina 200 mg+ondansetron 16 mg by elastomeric pump (rate 5 ml/h for 48 hours). RESULTS: Both groups showed good analgesic effects. Pain rest relief was between 3 and 1.7 points in group B and between 2.5 and 0.4 points in group A. Incident pain was 4.8 at awakening time and it decreased to 4 after 48 hours in group B while in group A it was from 3.2 to 1.8 in the same period of B group. CONCLUSIONS: Our data show that both analgesic techniques are able to guarantee a good rest pain relief after thoracotomy. Epidural analgesia showed more efficacy as far as incident pain relief but it was more difficult to realise and it showed less acceptance by patients.

Preemptive ketamine during general anesthesia for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

AIM: Preemptive analgesia is currently in use in the management of postoperative pain and no more under search. The administration of ketamine as intraoperative analgesic agent is well-known since a long time; the analgesic properties of this drug are related to its actions as a non-competitive N-methyl-D-aspartate receptors antagonist; these receptors present an excitatory function on pain transmission and this binding seems to prevent or reverse the central sensitisation of every kind of pain, including postoperative pain. In literature, the use of this anesthetic for the preemptive analgesia in the management of postoperative pain is controversial; for this reason the aim of our study was the clinical evaluation of preemptive perioperative analgesia with low-doses ketamine. METHODS: This trial involved 40 patients undergoing laparoscopic cholecystectomy, with the same surgical operator; postoperative analgesia was performed with the intraoperative administration of ketamine (0.7 mg/kg) or tramadol (15 mg/kg). A randomized, double-blind study was performed; after an inhalatory/analgesic general anesthesia (sevofluorane + remifentanyl) the postoperative-pain control was clinically evaluated through algometric measurements (Visual Analog Scale, Verbal Rating Scale, Pain Intensity Difference); supplemental doses of tramadol were administered if required, also to quantify the adequacy of analgesia, and adverse effects were evaluated. RESULTS: The results show that preemptive intraoperative analgesia with ketamine produces a good analgesia at the awakening, despite low duration (approximately 1 hour), and upgrades the analgesic effect of tramadol in the postoperative period. Among the adverse effects, some (for example nausea) were related to the administration of both analgesics and to the kind of surgery, others (hallucinosis, nystagmus, photophobia, psychomotor excitation, psychotic symptoms) were due to ketamine, and others (respiratory depression and hypotension) could be related to tramadol. Although the adverse effects due to ketamine are more numerous than those related to tramadol, the second could potentially be more dangerous. CONCLUSION: Our study suggests that preemptive low-doses ketamine is able to produce an adequate postoperative analgesia and increases the analgesic effect of tramadol; furthermore, ketamine adverse effects could be reduced by intraoperative administration of benzodiazepines and/or antiemetic drugs, or by the association of ketamine and a peripheral analgesic (ketorolac).

Perioperative thoracic epidural analgesia in aortic surgery: role of levobupivacaine.

AIM: Perioperative pain management in patients undergoing surgery is an essential target in order to improve intraoperative outcome and reduce postoperative complications occurrence. The combination of a local anesthetic with an opiate for epidural administration can ensure both analgesic effect (opiate) and neuroendocrine protection (local anesthetic). Levobupivacaine, S(-)-enantiomer form of bupivacaine, produces a sensitive-motor blockade similar to the racemate, with less cardiotoxicity; also ropivacaine is not cardiotoxic, but it has less anesthetic efficacy than levobupivacaine; both anesthetics could be administered through the epidural catheter in order to ensure adequate analgesia without any hemodynamic effects. Aim of our study was to evaluate a thoracic epidural analgesia for abdominal aortic surgery. METHODS: Through a randomized mono-blind study, involving 28 patients undergoing aortic surgery, we performed a clinical evaluation of 2 different perioperative thoracic epidural analgesic techniques; 2 different local anesthetics (levobupivacaine versus ropivacaine) in combination with the same opiate (fentanyl) were compared. RESULTS: The results obtained show that both techniques ensure an excellent perioperative analgesia without any cardiotoxicity, with only moderate adverse effects due to opiate; the absence of postoperative mortality (within 30 days from operation) and the modest perioperative morbidity underline the qualities of this analgesic technique. CONCLUSION: The combination of fentanyl with levobupivacaine or ropivacaine for use in thoracic epidural administration ensured both analgesic and neuroendocrine effect; significative differences between the 2 local anesthetics cannot be demonstrated, even if levobupivacaine, which presents a higher anesthetic efficacy, requires lower dosages.

Multicenter trial comparing tramadol and morphine for pain after abdominal surgery.

Seventy patients (40 male, 30 female), mean (SD) age 60.8 +/- 13.7 years were treated with parenteral morphine (10 mg/1 ml ampul) or tramadol (100 mg/2 ml ampul) to verify their analgesic effects in pain following abdominal surgery. The multicenter trial followed an open, controlled experimental design between patients, randomized within the centers. The drugs were given by intramuscular injection, as requested by patients, starting in the postoperative period when pain was more than 70 mm, assessed on a visual analog scale. Patients were allowed up to six ampuls of tramadol or morphine in the 24-h trial but in the first 4 h, if they asked for supplementary analgesic, only diclofenac (75 mg in a 3-ml ampul) was allowed. Both test drugs gave rapid and constant pain relief. After the first dose, pain intensity was reduced 36.2% with tramadol, and 51% with morphine; the pain-free interval was similar for both treatments. The quality of sleep and the number of hours of sleep the night after surgery were similar for both groups. Tramadol was tolerated better, giving rise to no untoward reactions; with morphine there was one case of mild respiratory depression. In abdominal surgery, therefore, tramadol given by intramuscular injection has postoperative analgesic activity similar to morphine, but is better tolerated.

[Long term central venous catheterization revisited]. / Rivisitazione degli incannulamenti cavali a lunga permanenza.

The authors describe their experience about long-term VAD (Venous Access Devices) placement and in particular of placement techniques types of catheters, complications, and risk and benefit. 243 placements of VAD in 112 males and 131 females mainly affected by leukemia or breast cancer have been analyzed. 145 Leonard, 54 Groshong and 44 Hickman type silicon catheters have been implanted. The preferred access vein was the right internal jugular vein in 75% of patients and the right subclavian vein in the remained. The results show implant success in 98.7% of the patients. Complications have been rare and not serious and they have been divided into: 1) complications due to venipuncture, 2) complications during implant, 3) complications during the staying of catheter, 4) complications during the removal. The authors underline the advantages of puncture access through the right internal jugular vein in comparison with access through the right subclavian vein. Groshong type catheter is better than Leonard and Hickman. Very few infections have been noticed and patients seem to accept more willingly percutaneous placement than surgical one.

[Changes in immune status due to anesthesia and surgical intervention. The role of thymopentin and interleukins]. / Modificazioni dello stato immunitario indotte dall'anestesia e dall'intervento chirurgico. Il ruolo della timopentina e delle interleuchine.

OBJECTIVE: Purpose of the study was clinical evaluation of thymopentin and interleukins in the changes of immunity due to anesthesia and surgical operation. DESIGN: After randomization the patients were divided into four groups according to starter type (thiopental or propofol) and immunological pre-treatment (tymopentin or saline of control group) administered for three days before and two days after operation. SETTING AND PATIENTS: The study was effected on 40 patients undergoing venous vascular surgery in operating rooms of Medical School of University of Genoa. MEASUREMENT: At pre-established times (basal, before and after induction, recovery and 72 postoperative hours) were measured some immunological data (plasmatic concentrations of red blood cells, white blood cells, lymphocyte cells, antibodies, complement analysis, interleukins 1 and 2). RESULTS: The results show a depression of immunity with hypoleucocistosis and hyperlymphocytosis due to surgical trauma or to anesthesia drugs. CONCLUSIONS: Pre-treatment with thymopentin no change perioperative immunity and the role of interleukins isn't clear; the immunological depression is the same in thiopental of propofol groups.

[Clinical and neuropsychologic evaluation of different anesthesia techniques (propofol vs isoflurane) in general surgery]. / Valutazione clinica e neuropsicologica di differenti tecniche d'anestesia (propofol vs isoflurano) in chirurgia generale.

Different anaesthetic techniques in the perioperative period (induction and maintenance of anesthesia, recovery and 48 postoperative hours) were evaluated in 200 patients undergoing general surgery. After randomization, results from 4 groups, were clinically and statistically compared according to the anesthetic techniques performed (propofol + fentanyl in air/O2; isoflurane + fentanyl in air/O2; propofol + fentanyl in N2O/O2; isoflurane in N2O/O2). The results show that anesthesia without N2O is difficult and fentanyl isn't the ideal analgesic; but no difference was found between the anesthetic techniques in quality of induction and maintenance, speed of recovery and quality of postoperative period.

[Blood levels of cortisol and prolactin. Are they indices of the degree of protection against surgical stress?]. / Livelli ematici di cortisolo e prolattina. Indici del grado di protezione dallo stress chirurgico?

The paper evaluates the level of analgesic protection by assaying cortisol and prolactin levels in two groups of 20 patients each undergoing general anesthesia using two different techniques: TIVA with propofol and fentanyl, and BPN-nitrous oxide. The results showed that TIVA caused a very slight increase in residue cortisol which was, however, within normal limits. With BPN-nitrous oxide anesthesia there was a greater increase in cortisol, reaching a statistically significant level in blood collected one hour after the end of surgery. With regard to prolactin, there was a marked increase in this hormone using both techniques although in percentage terms this increase was lower in TIVA. These results show that plasma prolactin is a more sensitive test than cortisol assay in evaluating antalgic protection and that, of the two anesthetic techniques used, the most protective appears to be TIVA with propofol and fentanyl.

[Different anaesthetic technique: conduction and outcome from multidisciplinary procedures]. / Different anaesthetic technique: conduction and outcome from multidisciplinary procedures.

Different anesthetic techniques in perioperative times (intraoperative induction and maintenance of anaesthesia, recovery and 24 and 48 postoperative hours) were evaluated in 100 patients underwent general surgery. After randomization, 4 groups were clinically and statistically compared according to anesthesia technique (propofol + fentanyl in air/O2; isoflurane + fentanyl in air/O2; propofol + fentanyl in N2O/O2; isoflurane in N2O/O2). The results show that conduction of anesthesia without N2O is difficult; but the adequacy of induction and maintenance of anesthesia, the speed of recovery and the quality in the postoperative period show no difference in the anesthesia techniques used.

[Respiratory function tests and operative risk in thoracic surgery]. / Prove di funzionalità respiratoria e rischio operatorio in chirurgia toracica.

In a retrospective study on 145 patients who underwent anesthesia for thoracic surgery, perioperative variables and preoperative pulmonary function tests influencing mortality and morbidity were evaluated. 3 patients (2.07%) died and 6 (4.14%) had cardiac, respiratory and other complications in postoperative 48 hours. Clinical-statistic analysis has shown the perioperative variables predictive on mortality and morbidity and operative risk: the operation type, FEV1, MVV (% theoretical), postexclusion gas analysis, Motley index (TLC/RV), intraoperative PaCO2, muscle-relaxant dose, preoperative myocardial infarction, weight, ASA, abnormal ECG, hypercreatininemia and loss of blood. MVV, FEV1, Motley index and residual FEV1 are the useful preoperative pulmonary function tests for evaluation of operative risk and surgical resection. Evaluation of operative risk in thoracic surgery shows the necessity of preoperative pulmonary function tests.

[Clinical evaluation of pre-surgical anxiety: changes in plasma levels of the anxiety peptide (diazepam binding inhibitor)]. / Valutazione clinica dell'ansia pre-intervento chirurgico: modificazioni dei livelli plasmatici del peptide dell'ansia (DBI).

The score scale of anxiety (STAI, Y, 1-2) and haematic levels of DBI (diazepam binding inhibitor) were used in 48 surgical patients for clinical evaluation of preoperative anxiety, before and after drugs for preoperative medication. After randomization, were clinically and statistically compared 6 groups according to premedicant drugs (diazepam 0.3 mg/kg; flunitrazepam 0.03 mg/kg; saline; prometazine 0.7 mg/kg); before and after preoperative medication were evaluated the anxiety relief with the score scale, haematic levels of DBI and haemodynamics (systolic and diastolic AP and HR). The results show that DBI can objectively measure the anxiety relief, that not are correlate haematic levels of DBI and score scale, that the best benzodiazepines are diazepam (0.3) and flunitrazepam (0.015) and that the prometazine might give anxiety relief for 5-HT antagonist action. Even if there are limits to study (scanty cases, are missing the range and the brain values of DBI and blood test of DBI is slow method) may be useful the use of score scale and haematic levels of DBI in clinical evaluation of preoperative anxiety relief.

[Clonidine and postoperative shivering]. / La clonidina nel brivido postoperatorio.

Clonidine was clinically evaluated to suppress postoperative shivering in 60 patients who had undergone anesthesia for general, thoracic and vascular surgery. The study was carried out in double blind conditions with comparison of two doses (75 and 150 micrograms) of clonidine, one dose of methylphenidate, and one dose of saline, as control group. The level of inhibition (Goldfarb scale), haemodynamics and temperature were studied. In conclusion, the methylphenidate is drug first choice for postoperative shivering, but clonidine inhibits postoperative shivering without haemodynamic and temperature variations (75 micrograms).

[Clinical evaluation of propofol-ketamine anesthesia in general surgery]. / Valutazione clinica dell'anestesia con propofol-ketamina in chirurgia generale.

The combinations propofol-ketamine vs propofol-fentanyl in absence of N2O was compared in 60 patients undergoing abdominal surgery. The results show that ketamine and fentanyl provide a good analgesia in the absence of N2O and that ketamine offers better haemodynamic control.