[Postoperative epidural analgesia]. / Analgesia epidurale post-operatoria.

Epidural analgesia with local anesthetics and opioids is one of the most effective methods for postoperative pain control. In critical patients it seems to improve outcome as well as pain control. This technique works better when started in the intraoperative time. Epidural analgesia is safe on surgical wards if nursing staff is trained in managing epidural catheters and in early detection and treatment of major and minor side effects. Nursing staff cooperates with the Acute Pain Service doctors and nurses who are on call on a 24 hour basis. Many perspective and retrospective studies showed a very low incidence of major side effects with epidurals. So we can consider it safe and effective even if we consider its invasiveness.

A recovery room-based acute pain service.

AIM: Despite routine postoperative pain management improves recovery and reduces postoperative morbidity and overall costs, and the availability of a large armamentarium of analgesic techniques and drugs, a significant portion of patients do not receive adequate postoperative pain control. We describe a recovery room (RR) based acute pain service model. METHODS: Guidelines on postoperative pain and therapeutic protocols were instituted in January 1999. The analgesic endpoint was a visual analogic scale (VAS) below 4 for all surgical patients for the first 48-72 h. The RR, run by one anesthesiologist and 2 nurses and one assistant, acted as a coordination centre. Discharge from the RR was subject to achieving effective analgesia. Nurses of each ward monitored VAS along with vital signs, administered rescue doses if necessary, and reported to the RR nurse when needed. RR nurses monitored the patient at least twice daily and reported to the anesthesiologist. We have distributed an anonymous questionnaire, within surgical wards, to both surgeons and nurses to evaluate their perception of pain management and of this acute pain service (APS) model. RESULTS: VAS was maintained significantly <4. Analgesic drug consumption increased between 1997, 2000 (first year of APS) and 2004. The auditing process confirmed the desire of all professional figures to be informed and involved in acute pain management as part of a coordinated and systematic approach to the surgical patient. CONCLUSION: A RR-based APS can effectively act as coordinating centre for acute pain treatment without adjunctive personnel.

[Severe and prolonged EEG depression after induction of general anesthesia for carotid endarterectomy. Report of a clinical case]. / Grave e prolungata depressione elettroencelografica all'induzione di un'anestesia generale per TEA carotidea. Descrizione di un caso clinico.

A large number of methods are available for intraoperative neurologic monitoring during endarterectomy, although no single method is infallible. Debate over choice of regional or general anesthesia for this surgery persists because of differing conclusions of various studies of risks and benefits. The case of patient undergoing left carotid endarterectomy under general anesthesia is described, in whom after the induction of anesthesia with: midazolam 2 mg, fentanyl 50 g, propofol (fractionate dose of 180 mg) and cisatracurium 12 mg, a total EEG depression occurred persisting for over 10 minutes and was followed by slow recovery, during the awakening of the patient. No significant hemodynamic changes were noted during the induction. No neurologic deficit was observed in the patient after arousal. It is suggested that the probable reason for the EEG response is the particular sensitivity of the patient to some of the induction drugs or to their association. Two weeks later surgery was successfully performed using cervical plexus block, without any anesthetic support. Regional anesthesia allows continuous neurologic assessment of the awaken patient, it is the most sensitive method for detecting inadequate cerebral perfusion and function.