CDC clinical practice guideline for prescribing opioids for pain: United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain ­ United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1­49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1­3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Acute Pain Service in Hungarian hospitals.

BACKGROUND: Surgical procedures play an increasing role among health technologies to treat diseases. Pain often accompanies such diseases, both as a result of their pathology, but also as the side-effect of the intervention itself, and it is not only a burdensome subjective feeling, but adversely affects the recovery process, can induce complications and increases treatment costs. Acute Pain Service Teams are becoming increasingly widespread in hospitals to address post-operative pain, yet we have so far no data on how many hospitals have actually adopted this technology in Hungary. OBJECTIVES: The main objectives of our study were to assess the prevalence of Acute Pain Service Teams, map their structure and operation, as well as to understand the barriers and conducive factors of their establishment in Hungarian hospitals. METHODS: We carried out a survey among the 72 hospitals with surgical departments. The questionnaire was filled in by 52 providers, which gave us a response rate of 72.2%. RESULTS: Our results show, that only two of the responding hospitals have Acute Pain Service Teams albeit their structure and operation are in line with the literature. In the 50 hospitals without such teams, financing difficulties and human resources shortages are mentioned to be the most important obstacles of their establishment, but the lack of initiative and interest on the part of the specialities concerned are also an important barrier. CONCLUSIONS: Lagging behind the more affluent EU member states, but similarly to other Central and Eastern European countries, Acute Pain Service has been hardly adopted by Hungarian hospitals. Hungarian health professionals know the technology and would support its wider introduction, if the technical feasibility barriers could be overcome. Health policy should play a more active role to facilitate change in this area, the investment in which promises a substantial return in terms of health gains and cost savings.

10 kHz High-Frequency Spinal Cord Stimulation for Chronic Thoracic Pain: A Multicenter Case Series and a Guide for Optimal Anatomic Lead Placement.

BACKGROUND: Surgical options for thoracic pain are limited and carry significant risk and morbidity. Spinal cord stimulation has the potential to be used for treatment of thoracic pain, as it has been useful for treating multiple types of chronic pain. Conventional tonic stimulation is limited in the treatment of thoracic pain, as it can produce paresthesia that is difficult to localize. Conversely, high-frequency spinal cord stimulation (HF-SCS) does not activate dorsal column A Beta fibers and does not produce paresthesia, and thus may be more beneficial in treating thoracic back pain not manageable with tonic stimulation. OBJECTIVES: To evaluate (1) the efficacy of 10 kHz HF-SCS for patients with chronic thoracic pain; and (2) appropriate paresthesia-free lead placement and programming targets for 10 kHz HF-SCS for patients with chronic thoracic pain. STUDY DESIGN: Retrospective case series. SETTING: Multisite academic medical center or pain clinic. METHODS: A retrospective chart review was performed on 19 patients with thoracic back pain who underwent HF-SCS implantation. These patients had lead placement and stimulation between the T1-T6 vertebral levels. Outcome measures collected include location of device implant, stimulation settings, and pain scores at baseline, end of trial, and 1, 6, and 12 months postimplant. Follow-up phone calls collected information on if the patient reported functional improvement, improved sleep, or decreased pain medication usage. A Wilcoxon signed-rank test compared differences in mean pain scores across time points. RESULTS: Significantly decreased Visual Analog Scale scores were observed with 17/19 (89.5%) patients demonstrating response to therapy (> 50% reduction in pain scores). These results were sustained relative to baseline at 1, 6, and 12 months postimplant, depending on length of follow-up. Many patients also reported functional improvement (17/19), improved sleep (14/19), and reduction in use of pain medications after implantation (9/19). A total of 15/19 patients reported best relief when contacts over T1 or T2 vertebrae were used for stimulation. LIMITATIONS: This study is limited by its retrospective design. Additionally, including documentation from multiple sites may be prone to selection and abstraction bias. Data were also not available for all patients at all time points. CONCLUSIONS: HF-SCS may be a viable option for significant, long-lasting pain relief for thoracic back pain. There may also be evidence for anatomically based lead placement and programming for thoracic back pain. Randomized, controlled trials with extended follow-up are needed to further evaluate this therapy. KEY WORDS: Thoracic pain, back pain, spinal cord stimulation, high frequency, 10 kHz.

Thirty-five Years of Acute Pain Services: Where Do We Go From Here?

Acute pain services (APS) have developed over the past 35 years. Originally implemented solely to care for patients with regional catheters or patient-controlled analgesia after surgery, APS have become providers of care throughout the perioperative period, with some institutions even taking the additional step toward providing outpatient services for patients with acute pain. Models vary considerably in terms of tasks and responsibilities, staffing, education, protocols, quality, and financing. Many challenges face today's APS, including the increasing number of patients with preexisting chronic pain, intake of analgesics and opioids before surgery, substance-dependent patients needing special care, shorter hospital stays, early discharge of patients in need of further analgesic treatment, prevention and treatment of chronic postsurgical pain, minimization of adverse events, and side effects of treatment. However, many APS lack a clear-cut definition of their structures, tasks, and quality. Development of APS in the future will require us to face urgent questions, such as, "What are meaningful outcome variables?" and, "How do we define high quality?" It is obvious that focusing exclusively on pain scores does not reflect the complexity of pain and recovery. A broader approach is needed-a common concept of surgical and anesthesiological services within a hospital (eg, procedure-specific patient pathways as indicated by the programs "enhanced recovery after surgery" or the "perioperative surgical home"), with patient-reported outcome measures as one central quality criterion. Pain-related functional impairment, treatment-induced side effects, speed of mobilization, as well as return to normal function and everyday activities are key.

"My life is under control with these medications": an interpretative phenomenological analysis of managing chronic pain with opioids.

BACKGROUND: The use of opioids to relieve chronic pain has increased during the last decades, but experiences of chronic opioid therapy (COT) (> 90 days) point at risks and loss of beneficial effects. Still, some patients report benefits from opioid medication, such as being able to stay at work. Guidelines for opioid use in chronic pain do not consider the individual experience of COT, including benefits and risks, making the first person perspective an important scientific component to explore. The aim of this study was to investigate the lived experience of managing chronic pain with opioids in a sample who have severe chronic pain but are able to manage their pain sufficiently to remain at work. METHODS: We used a qualitative research design: interpretative phenomenological analysis. Ten individuals with chronic pain and opioid therapy were purposively sampled in Swedish tertiary care. RESULTS: Three super-ordinate themes emerged from the analyses: Without opioids, the pain becomes the boss; Opioids as a salvation and a curse, and Acknowledgement of the pain and acceptance of opioid therapy enables transition to a novel self. The participants used opioids to regain control over their pain, thus reclaiming their wanted life and self, and sense of control over one's life-world. Using opioids to manage pain was not unproblematic and some of the participants had experienced a downward spiral of escalating pain and uncontrollable opioid use, and stigmatisation. CONCLUSIONS: All participants emphasised the importance of control, regarding both pain and opioid use. To accomplish this, trust between participants and health care providers was essential for satisfactory treatment. Regardless of the potential sociocultural benefits of staying at work, participants had experiences of balancing positive and negative effects of opioid therapy, similar to what previous qualitative research has found. Measurable improvement of function and quality of life, may justify the long-term use of opioids in some cases. However, monitoring of adverse events should be mandatory. This requires close cooperation and a trusting relationship between the patients and their health care provider.

Headache service quality: the role of specialized headache centres within structured headache services, and suggested standards and criteria as centres of excellence.

In joint initiatives, the European Headache Federation and Lifting The Burden have described a model of structured headache services (with their basis in primary care), defined service quality in this context, and developed practical methods for its evaluation.Here, in a continuation of the service quality evaluation programme, we set out ten suggested role- and performance-defining standards for specialized headache centres operating as an integral component of these services. Verifiable criteria for evaluation accompany each standard. The purposes are five-fold: (i) to inspire and promote, or stimulate the establishment of, specialized headache centres as centres of excellence; (ii) to define the role of such centres within optimally structured and organized national headache services; (iii) to set out criteria by which such centres may be recognized as exemplary in their fulfilment of this role; (iv) to provide the basis for, and to initiate and motivate, collaboration and networking between such centres both nationally and internationally; (v) ultimately to improve the delivery and quality of health care for headache.

Morality in clinical space: treatment of youngsters with functional somatic symptoms in a Western clinical context.

This paper explores the moral implications of treatment of young people with functional somatic symptoms. Based on an ethnographic field study at a Danish pain clinic for youngsters (age 8 to 18), the paper seeks to unearth the cultural, moral values that clinical practice steers by and upholds, and the implications this has for the assessment and management of ill body-selves. Through an exposition of the general practice of the clinic and an investigation of two specific cases of youngsters, it is found that the assessment of symptoms and selves and the goals of treatment are informed by cultural ideals of 'the good self' and 'the good life' in which agency and work ethic - both pertaining to the notion of individual responsibility - figure as prevalent virtues. The study underpins the findings of other researchers who have found that ideals of individual autonomy and responsibility for own life and health permeate the Western health care system and the discourses of ill individuals. The contribution of this article is to portray in ethnographic detail how such a cultural ethics manifests in practice and what implications this have for the treatment of young people with functional symptoms at a specific location and in specific cases. The two cases illustrate that the underlying norms and values can give rise to very different moral assessments of symptoms and selves within the same diagnostic category.

Multimodal Treatment Options, Including Rotating to Buprenorphine, Within a Multidisciplinary Pain Clinic for Patients on Risky Opioid Regimens: A Quality Improvement Study.

Objectives: We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain-the Opioid Reassessment Clinic (ORC)-to inform practice and health system improvement. Design: Controlled, retrospective cohort study. Setting: The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Subjects: We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group). Methods: We compared a priori-defined metrics at the patient, clinic process, and health system levels and compared metrics between groups. Results: During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0-120] vs 0 mg [IQR = 0-20] decrease, P < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP. Conclusions: Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed.

Establishing an Acute Pain Service in Private Practice and Updates on Regional Anesthesia Billing.

Acute pain management is an expanding perioperative specialty and there is a renewed focus on implementing and developing an acute pain service (APS) in nonacademic hospitals (ie, "private practice"). An anesthesiologist-led APS can improve patient care by decreasing perioperative morbidity and potentially reducing the risk of chronic postsurgical pain syndromes. Elements of a successful APS include multidisciplinary collaboration to develop perioperative pain protocols, education of health care providers and patients, and regular evaluation of patient safety and quality of care metrics. Standardization of regional anesthesia procedures and billing practices can promote consistent outcomes and efficiency.

Quality indicators to assess quality of pain clinic care from the perspective of patients with chronic pain: development, usability, comprehensibility, and psychometric quality of the QiPPP questionnaire.

To address the lack of appropriate patient-defined quality indicators (QIs) for assessment of pain clinic care in the Netherlands, we developed the "Quality Indicators Pain Patients' Perspective" (QiPPP) questionnaire. Quality indicators are widely used to measure the quality of the structure, process, and outcome of health care. The Pain Patient United Consortium, together with the University Pain Centre of Maastricht, developed QIs for assessment of care. The aim of this study was to develop QIs from the perspective of patients with chronic pain for assessment of the care provided by a pain clinic, and to validate them on usability, comprehensibility, and psychometric quality in daily pain practice. Quality as defined by patients with chronic pain (in survey and focus groups) was prioritized by consensus and transformed into QI. A first set was tested and fine-tuned, resulting in the QiPPP questionnaire. Five participating pain clinics distributed 200 questionnaires among consecutive patients with chronic pain under treatment. To examine the dimensionality of the QIs, patient responses were analyzed on the basis of reporting frequencies and findings of principal component analysis. For construct validation, the influence of patient characteristics was observed in 3 components. A total of 547 (54.7%) populated QiPPP questionnaires (response rate, 58.9%) were analyzed. The mean score for patient comprehensibility was 8.6 ± 1.4. The final QiPPP questionnaire included 21 QIs (18 process; 3 outcome) distributed over 7 domains. The QiPPP questionnaire was of sufficient psychometric quality and found to be useful and understandable by patients with chronic pain.

Diagnóstico y tratamiento médico del dolor irruptivo / Diagnosis and medical treatment of breakthrough pain

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Compliance with Opioid Therapy: Distinguishing Clinical Characteristics and Demographics Among Patients with Cancer Pain.

Background: Because an increase of patients who misuse opioids has been identified in our cancer clinical setting through urine drug testing (UDT) and the Screener and Opioid Assessment for Patient's with Pain-Short Form (SOAPP-SF), we conducted this retrospective cohort study to identify patient characteristics that are associated with UDT that indicates noncompliance. Methods: Over a two-year period, 167 of 8,727 patients (2.4%) seen in the pain clinic and who underwent UDT were evaluated to determine compliance with prescribed opioid regimens. Descriptive clinical and demographic data were collected, and group differences based on compliance with opioid therapy were evaluated. Results: Fifty-eight percent of the patients were noncompliant with their prescribed opioid therapy. Noncompliant patients were younger than compliant patients, with a median age of 46 vs 49 years (P = 0.0408). Noncompliant patients were more likely to have higher morphine equivalent daily doses; however, the difference was not statistically significant. Patients with a history of alcohol (ETOH) (P = 0.0332), illicit drug use (P = 0.1014), and smoking (P = 0.4184) were more likely noncompliant. Univariate regression analysis showed that a history of ETOH use (P = 0.034), a history of anxiety (P = 0.027), younger age (P = 0.07), and a SOAPP-SF score of 4 or higher (P = 0.05) were associated with an abnormal UDT. Conclusions: History of ETOH use, anxiety, high SOAPP-SF score, and younger age were associated with UDT that indicates noncompliance. Given the very small percentage of UDT testing, it is quite likely that a significant number of patients who did not undergo UDT were also nonadherent with treatment recommendations.

Exploring patient experiences of a pain management centre: A qualitative study.

BACKGROUND AND AIMS: To improve care and management of patients with chronic pain it is important to understand patients' experiences of treatment, and of the people and the environment involved. As chronic pain patients often have long relationships with medical clinics and pain management centres, the team and team interactions with the patients could impact the treatment outcome. The aim of this study was to elicit as honest as possible an account of chronic pain patients' experiences associated with their care and feed this information back to the clinical team as motivation for improvement. METHODS: The research was conducted at a large hospital-based pain management centre. One hundred consecutive patients aged 18 years and above, who had visited the centre at least once before, were invited to participate. Seventy patients agreed and were asked to write a letter, as if to a friend, describing the centre. On completion of the study, all letters were transcribed into NVivo software and a thematic analysis performed. RESULTS: Six key themes were identified: (i) staff attitude and behaviour; (ii) interactions with the physician; (iii) importance of a dedicated pain management centre; (iv) personalized care; (v) benefits beyond pain control; (vi) recommending the pain management centre. CONCLUSION: The findings suggest that the main reasons that patients recommended the centre were: (i) support and validation provided by the staff; (ii) provision of detailed information about the treatment choices available; (iii) personalized management plan and strategies to improve overall quality of life alongside pain control. None of the letters criticized the care provided, but eight of seventy reported long waiting times for the first appointment as a problem. IMPLICATIONS: Patient views are central to improving care. However, satisfaction questionnaires or checklists can be intimidating, and restrictive in their content, not allowing patients to offer spontaneous feedback. We used a novel approach of writing a letter to a friend, which encouraged reporting of uncensored views. The results of the study have encouraged the clinical team to pursue their patient management strategies and work to reduce the waiting time for a first appointment.

A survey of acute pain services in the UK.

The organisational state of inpatient pain management in UK hospitals is difficult to determine. We sent an electronic questionnaire to 209 acute pain service leads throughout the UK. Questions were about staffing and service provision. We received 141 responses (67%); 47% of all UK hospitals. Each service was responsible for a median (IQR [range]) of 566 (400-839 [120-2800]) beds. Each acute pain specialist nurse was responsible for 299 (238-534 [70-1923]) beds. The mean (SD) number of consultant hours per week was 5.54 (4.62), delivered by a median of 1.0 (1.0-2.5 [0.2-7.0]) consultant. Overnight cover was provided by 20 (15%) acute pain services, and weekend cover by 39 (29%). Acute pain services commonly (in 50 (35%) hospitals) had roles in addition to acute pain management. Most teams (105, (77%)) reviewed medical patients and patients with chronic pain (in 131, (96%) teams). Half of the services (56, (49%)), reported that they were part of an integrated acute and chronic pain service, however, 83 (59%) did not have any members who work in chronic pain clinics. The majority (79, (70%)) were able to access a nominated chronic pain consultant for advice. Provision of acute pain services throughout the UK is highly variable. The majority do not meet core UK standards.

[Quality assurance of pain care in Austria : Classification of management facilities]. / Qualitätssicherung der schmerzmedizinischen Versorgung in Österreich : Klassifikation schmerztherapeutischer Einrichtungen.

In Austria there is no nationwide coverage of pain management, which meets even approximately international criteria. At present there are about 30 interdisciplinary pain management offices and clinics providing care according to a concept of the Austrian Pain Society (ÖSG), about 10 other outpatient pain clinics are located in district and country hospitals. A few years ago, there still were about 50 pain clinics. Yet closure of outpatient clinics and cost-cutting measures in the health sector jeopardize adequate pain relief for patients with chronic pain conditions.Hence, the supply of care for approx. 1.8 mio. Austrians with chronic pain is not guaranteed due to lack of a comprehensive demand planning of pain care facilities. Furthermore, existing structures such as specialized clinics or emergency services in hospitals are primarily based on the personal commitment of individuals. At present, the various centres for pain management in Austria are run with very different operating times, so that for 74% of the chronic pain patients the desired requirements for outpatient pain management are not met and about 50 full-time pain clinics are missing.Under the patronage of the Austrian Pain Society, various national specialist societies have defined the structure and quality criteria for pain management centres in Austria, include, among others, proof of training, cooperation in interdisciplinary teams or minimum number of new patients per year, depending on the classification of the institution.This stepwise concept of care provision for pain patients is intended as first step to help improve the care of pain patients in Austria!

Dolor postoperatorio: ¿hacia dónde vamos? / Postoperative pain: where are we going?

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Improving satisfaction among established patients in a midwestern pain clinic.

BACKGROUND: A problem in many health care practices is deciding the appropriate appointment length for new and established patients. Patients become frustrated when there is inadequate time to have their needs met, yet when a patient's clinic time is spontaneously lengthened, the provider gets behind in schedule, causing delays and greater frustration for others. AIM: The aims of this evidence based project were to determine whether implementation of a flexible appointment system would improve the current scheduling process in a pain clinic by allowing complex patients the opportunity to schedule a longer clinic appointment and would improve patient satisfaction. DESIGN: This evidence-based practice innovation followed a program evaluation process using a descriptive, existing survey completed by clinic staff and patients. SETTING: A Midwestern pain clinic caring for patients with acute and chronic pain diagnoses. PARTICIPANTS: A convenience sample of 120 patients were surveyed before and after the process change. Thirteen staff members completed the survey on SurveyMonkey pre and post procedural change at the same intervals the patients were surveyed. RESULTS: Patients were more satisfied with the time that they spent in the exam room and the waiting room. The process change improved communication with staff and patients and provided an opportunity to discuss their concerns and health changes prior to their scheduled appointment. CONCLUSION: Allowing an option for flexible scheduling in appointment lengths provided an opportunity to meet patient needs, offer improved service, and improve patient-provider communication.

Experiencia clínica con desflurano para anestesia pediátrica fuera de quirófano / Clinical experience with desflurane for paediatric anaesthesia outside the operating room

Objetivo. El desflurano se ha empleado en pacientes pediátricos en diversas indicaciones quirúrgicas. En nuestro estudio presentamos su utilidad clínica en anestesia para procedimientos diagnóstico-terapéuticos en áreas alejadas de quirófano en una población pediátrica sin patología respiratoria conocida. Material y métodos. Se analizaron retrospectivamente, en 2.702 historias de la base de datos informatizada, las anestesias generales en las que se empleó desflurano en la sala de procedimientos de la Unidad de Dolor Infantil durante los años 2013 y 2014. Se incluyeron datos demográficos, tipo de procedimiento, técnica anestésica, tipo de manejo de la vía aérea, colaboración del paciente e incidencia de complicaciones anestésicas. Resultados. Se incluyeron 876 pacientes pediátricos, con una media de edad de 8,8 años. Los principales procedimientos fueron aspirados medulares (23%), punciones lumbares (20%), panendoscopias (15%), o colonoscopias (5%). La inducción fue intravenosa, con propofol, en el 26% de los casos e inhalatoria, con sevoflurano, en el 74% restante. El mantenimiento se realizó con remifentanilo y concentraciones medias (± DE) teleespiratorias de desflurano de 6,2±2,1%. El manejo de la vía aérea fue a través de cánulas nasales o mascarilla facial en ventilación espontánea. La efectividad fue del 98% y la incidencia de efectos secundarios fue de 15%, siendo los principales: agitación (6%), cefalea (4%), náusea-vómito (3%), y laringoespasmo (2%). Conclusión. El mantenimiento con desflurano a concentraciones cercanas a la CAM-hipnótica en ventilación espontánea a través de cánulas nasales o mascarilla facial demostró ser eficaz, con una rápida recuperación y con una baja incidencia de efectos adversos (AU)

Background. Desflurane has been used in paediatric patients for several surgical indications. This article analyses the efficacy and safety of desflurane for diagnostic-therapeutic procedures in remote areas far from operating room in a group of selected patients with no known associated respiratory disease. Material and methods. A retrospective analysis was performed on 2,072 general anaesthesia procedures stored in a computer database, in which desflurane was used in a Paediatric Pain Unit during the years 2013 and 2014. An analysis was also performed using the patient demographics, type of procedure, anaesthetic technique, type of airway management, patient cooperation, and incidence of anaesthetic complications. Results. The study included 876 patients, with a mean age of 8.8 years. The main procedures were bone marrow aspirates (23%), lumbar punctures (20%), panendoscopies (15%), and colonoscopies (5%). Induction was intravenous with propofol (26%) or inhalation with sevoflurane in the remaining 74%. Maintenance consisted of remifentanil and desflurane at mean end tidal concentrations of 6.2±2.1%. The airway was managed through a nasal cannula or face mask in spontaneous ventilation. The effectiveness was 98%, and the incidence of side effects was 15%, which included agitation (6%), headache (4%), nausea-vomiting (3%), and laryngospasm (2%). Conclusion. The maintenance with desflurane (at concentrations close to the hypnotic-MAC in spontaneous ventilation) was effective, with a rapid recovery, and with a low incidence of adverse effects (AU)