Knowledge of residual curarization: an Italian survey.

BACKGROUND: The use of neuromuscular blocking agents (NMBAs) is widespread in anesthetic practice; little is known about the current use of these drugs in Italy. This survey was conducted to obtain information about the most commonly used clinical tests and the train-of-four (TOF) ratios that are considered as being reliable for assessing recovery from neuromuscular blockade at the end of anesthesia and the estimated occurrence rates of post-operative paralysis in Italian hospitals. METHODS: The questionnaire was given to Italian anesthesiologists attending the 62nd National Congress of the Italian Society of Anesthesia, Analgesia and Intensive Therapy. Collected data were stratified by age and the total number of surgical procedures performed in the hospitals concerned. RESULTS: Seven hundred and fifty-four correctly compiled questionnaires were collected (response rate 88.7%). Seventy three percent of the respondents only used clinical tests for monitoring the level of neuromuscular blockade. The main clinical tests cited for the evaluation of residual paralysis were keeping the head lifted up for 5 s, protruding the tongue and opening the eyes. TOF was used by 35% of the respondents on a routine basis. Only 24% of the interviewed anesthesiologists reported that before extubation, a TOF ratio of at least 0.9 should be reached. CONCLUSIONS: Most Italian anesthetists assess the recovery from neuromuscular blockade only by clinical signs. There is poor awareness about the inability of such techniques to indicate even a significant amount of residual neuromuscular block. A more extensive use of quantitative instrumental monitoring is required for the more rational use of NMBAs.

Levosimendan pre-treatment improves outcomes in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: The calcium sensitizer levosimendan has anti-ischaemic effects mediated via the opening of sarcolemmal and mitochondrial ATP-sensitive potassium channels. These properties suggest potential application in clinical situations where cardioprotection would be beneficial, such as cardiac surgery. We thus decided to investigate whether pharmacological pre-treatment with levosimendan reduces intensive care unit (ICU) length of stay in patients undergoing elective myocardial revascularization under cardiopulmonary bypass. METHODS: One hundred and six patients undergoing elective coronary artery bypass grafting were randomly assigned in a double-blind manner to receive levosimendan or placebo. Levosimendan (24 microg kg(-1)) or placebo was administered as a slow i.v. bolus over a 10 min period before the initiation of bypass. RESULTS: Tracheal intubation time and the length of ICU stay were significantly reduced in the levosimendan group (P<0.01). The number of patients needing inotropic support for >12 h was significantly higher in the control group (18.0% vs 3.8%; P=0.021). Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.0001) and a higher cardiac power index (P<0.0001). CONCLUSIONS: Pre-treatment with levosimendan in patients undergoing surgical myocardial revascularization resulted in less myocardial injury, a reduction in tracheal intubation time, less requirement for inotropic support, and a shorter length of ICU stay.

Effects of short-term simultaneous infusion of dobutamine and terlipressin in patients with septic shock: the DOBUPRESS study.

BACKGROUND: Terlipressin bolus infusion may reduce cardiac output and global oxygen supply. The present study was designed to determine whether dobutamine may counterbalance the terlipressin-induced depression in mixed-venous oxygen saturation (Svo) in patients with catecholamine-dependent septic shock. METHODS: Prospective, randomized, controlled study performed in a university hospital intensive care unit. Septic shock patients requiring a continuous infusion of norepinephrine (0.9 microg kg(-1) min(-1)) to maintain mean arterial pressure (MAP) at 70 (sd 5) mm Hg were randomly allocated to be treated either with (i) sole norepinephrine infusion (control, n=20), (ii) a single dose of terlipressin 1 mg (n=19), or (iii) a single dose of terlipressin 1 mg followed by dobutamine infusion titrated to reverse the anticipated reduction in Svo2 (n=20). Systemic, pulmonary, and regional haemodynamic variables were obtained at baseline and after 2 and 4 h. Laboratory surrogate markers of organ (dys)function were tested at baseline and after 12 and 24 h. RESULTS: Terlipressin (with and without dobutamine) infusion preserved MAP at 70 (5) mm Hg, while allowing to reduce norepinephrine requirements to 0.17 (0.2) and 0.2 (0.2) microg kg(-1) min(-1), respectively [vs1.4 (0.3) microg kg(-1) min(-1) in controls at 4 h; each P<0.001]. The terlipressin-linked decrease in Svo2 was reversed by dobutamine at a mean dose of 20 (8) microg kg(-1) min(-1) [Svo2 at 4 h: 59 (11)% vs 69 (12)%, P=0.028]. CONCLUSIONS: In human catecholamine-dependent septic shock, terlipressin (with and without concomitant dobutamine infusion) increases MAP and markedly reduces norepinephrine requirements. Although no adverse events were noticed in the present study, potential benefits of increasing Svo2 after terlipressin bolus infusion need to be weighted against the risk of cardiovascular complications resulting from high-dose dobutamine.

Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracic trauma.

BACKGROUND: Blunt thoracic trauma is a major concern in critically ill patients. Repeated lung diagnostic evaluations are needed in order to follow up the clinical situation and the results of the therapeutic strategies. The aim of this prospective clinical study was to evaluate the possible role of lung ultrasound (LU) compared with bedside radiography (CXR) and computed tomography (CT) used as the gold standard in the evaluation of trauma patients admitted to the intensive care unit with acute respiratory failure. METHOD: A total of 15 thoracic trauma patients were studied at intensive care unit (ICU) arrival (T1) and 48 h later (T2) with CT, CXR and LU. We evaluated the presence of pleural effusion (PE) and lung contusion (LC). For this purpose the lung parenchyma was divided into 12 regions so that we could compare 180 lung regions at T1 and T2, respectively. RESULTS: Sensitivity of ultrasound was 0.94 for PE and 0.86 for LC while specificity 0.99 and 0.97, respectively. The likelihood ratio was 94 (rho(+)) and 0.06 (rho(-)) for PE and 28.6 (rho(+)) and 0.14 (rho(-)) for LC. CONCLUSIONS: Ultrasound provides a reliable noninvasive, bedside method for the assessment of chest trauma patients with acute respiratory failure in the ICU.

Activated recombinant factor VII in orthotopic liver transplantation.

UNLABELLED: Orthotopic liver transplantation (OLT) is affected by important alterations of hemostasis. The aim of this study was to evaluate the efficacy of recombinant factor VII activated (rFVIIa) to reduce intraoperative bleeding during OLT. METHODS: Twenty OLT patients were assigned in double-blind way to a rFVIIa group or a control group. Inclusion criteria were hemoglobin > 8 g/dL: INR > 1,5 and fibrinogen > 100 mg/dL. We administered a single bouls of rFVIIa (40 microg/kg) or placebo. We determined INR, partial thromboplastin time, fibrinogen, ATIII, and blood cell counts. Blood products were administered as follows: 4 units of fresh frozen plasma when INR > 1.5, and 1 unit of RBC for Hb < 10 g/dL. The study ended 6 hours after the bolus. RESULTS: No thromboembolic events occurred. The INR was different between rFVIIa group and the controls at T0 (1.9 vs 1.6 P < .021) and during T1 (1.2 vs 1.6 P < .004). The total transfused red blood cells was 300 mL +/- 133 in rFVIIa group and 570 mL +/- 111 in control group (P < .017). The total fresh frozen plasma was 600 mL +/- 154 in rFVIIa group and 1400 mL +/- 187 in control group (P < .001). Total blood loss was greater in the control group than the rFVIIa group: 1140 mL +/- 112 vs 740 mL +/- 131 (P < .049). DISCUSSION: The use of rFVIIa during OLT can reduce the risk of bleeding during surgery. The literature has described cases who did not benefit from the treatment. An adequate cut-off of INR, allowed us to treat only patients at greater bleeding risk.

Fenoldopam and gastric tonometry during orthotopic liver transplantation.

UNLABELLED: The aim of this study was to evaluate the effects of continuous infusion of fenoldopam on splanchnic perfusion in orthotopic liver transplant (OLT) recipients. PATIENTS AND METHODS: We enrolled 40 patients of mean age 57+/-16 years who underwent (OLT). They were randomly divided into two double blinded groups; continuous fenoldopam (0.06 mcg/kg per minute) or placebo infusion. Hemodynamics, gastric tonometry, urine output, renal function parameters, and diuretics use were collected during selected phases of the surgery and postoperatively every 12 hours for 72 hours in the intensive care unit. RESULTS: No significant differences were observed between the two groups concerning hemodynamics, though in the fenoldopam group we observed increased splanchnic perfusion during the whole study period but particularly after arterial unclamping (pHi 7,31+/-0.04 vs 7.28+/-0.05; P < .05) and at 48 hours after surgery (pHi 7.49+/-0.15 vs 7.39+/-0.15; P < .05). Creatinine and blood urea nitrogen values were slightly higher in the placebo group, but this data did not reach statistical significance, while higher doses of furosemide were administered to the placebo group to maintain a urinary output over 200 mL/hour during the whole study. DISCUSSION: In this study we observed that continuous fenoldopam infusion (0.06 mg/kg per minute) improved splanchnic perfusion without affecting systemic pressure. CONCLUSION: Patients undergoing OLT have altered splanchnic perfusion related to cirrhosis, surgical manipulation, and fluid shifts during and after surgery. The use of a splanchnic vasodilator drug improved outcomes in these patients.

Clinical effects of use polymyxin B fixed on fibers in liver transplant patients with severe sepsis or septic shock.

UNLABELLED: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component exclusively found in gram-negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed: PMX is covalently bound to the surface of an insoluble carrier material to inactivate endotoxin in blood without exerting toxicity on the brain or the kidney. The aim of this study was to evaluate the efficacy, safety, and clinical effects of direct hemoperfusion with an immobilized polymyxin B fiber column (DHP-PMX) among liver transplant patients with severe sepsis or septic shock. METHODS: From June 2004 to May 2005, 10 patients (6 men and 4 women) of overall mean age of 55 years (46-65 range) underwent orthotopic liver transplantation (OLT) and developed severe sepsis or septic shock according to The Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all treated patients who received conventional antibiotic therapy, vasopressor or inotropic agents, and ventilatory support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters and dosages of vasopressor or inotropic drugs were assessed at baseline and after each treatment. RESULTS: No adverse events occurred. From baseline to the third treatment the mean arterial pressure increased from 64 +/- 5 mm Hg to 89 +/- 4 mm Hg); while the dosages of dobutamine and norepinephrine were reduced: 6.4 to 1 mcg/kg/min and 1.3 to 0.001 mcg/kg per min, respectively. The PaO(2)/FiO(2) ratio increased: 214 to 291 mm Hg. CONCLUSION: The use of DHP-PMX may be an important aid in patients with sepsis in association with conventional therapy.

Modifications of intracranial pressure after molecular adsorbent recirculating system treatment in patients with acute liver failure: case reports.

UNLABELLED: Cerebral dysfunction may be fatal in patients with acute liver failure (ALF); intracranial pressure (ICP) monitoring may be mandatory to direct measures to prevent further cerebral edema. Recently the introduction of dialysis with the molecular adsorbent recirculating system (MARS) has improved the outcomes among patients with ALF. The aim of this study was to evaluate ICP changes after MARS treatment among patients with ALF. METHODS: Three patients -- 14, 18 and 16 years old -- were admitted to the ICU for acute liver failure induced by HBV in two cases and by acetaminophen in the other one. Because of Glasgow Coma Score (GCS) <8, they were intubated and ventilated to protect the airway and maintain moderate hypocapnia. Invasive monitoring of intracranial pressure MARS treatments were performed in all patients. RESULTS: The patients received MARS treatments every day after their admission to liver transplantation. After MARS therapy the ICP decreased on average from 21 to 7 mm Hg. Significant hemodynamic modifications were not observed and their neurological conditions improved. CONCLUSION: MARS treatment improved the clinical pictures of these patients increasing the available time to obtain an urgent liver graft.

Incidence of fungal infections in a solid organ recipients dedicated intensive care unit.

UNLABELLED: Invasive fungal infections are a significant cause of morbidity and mortality for patients undergoing solid organ transplantation. Our aim was to evaluate the incidence of invasive fungal infections in solid organ recipients within a dedicated intensive care unit (ICU). MATERIALS AND METHODS: From May 2002 to May 2005, 278 patients undergoing solid organ transplantation (105 liver, 142 kidney, 20 lung, 2 combined liver-kidney, 9 combined pancreas-kidney) were admitted to our posttransplant intensive care unit. We retrospectively analyzed data obtained from the ICU stay. Fungal infection was defined by positivity of normally sterile biological samples and by elevated positivity of normally non sterile biological samples. We did not consider superficial fungal infections and asymptomatic colonizations. RESULTS: Forty-six patients (16.5%) developed a fungal infection; at least one mycotic agent was isolated from each patient. Candida albicans was the most common pathogen, isolated from 71 % of infected patients (33 of 46). Infected patients showed a mortality rate of 35%, while that for non infected recipients was 3.5%. Total length of ICU stay was the most significant risk factor among infected patients (30.26 days vs 5.04 days P < .0001). Mean time between transplantation and first positive samples was 6.17 days (SD 8.88). CONCLUSION: Fungal infections in solid organ transplant patients are a major issue because of their associated morbidity and mortality. Candida albicans was the most common pathogen and total length of ICU stay was the most important risk factor.

Clinical effects of direct hemoperfusion using a polymyxin-B immobilized column in solid organ transplanted patients with signs of severe sepsis and septic shock. A pilot study.

BACKGROUND: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component found exclusively in gram negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed: PMX is covalently bound on the surface of an insoluble carrier material so that the endotoxin can be inactivated in the blood without exerting its toxicity on the brain and kidney. The aim of this study was to clarify the efficacy, safety and clinical effects of direct hemoperfusion with an immobilized polymyxin-B fiber column (DHP-PMX) in solid organ transplanted patients with severe sepsis or septic shock. METHODS: From June 2004 to May 2005, 15 patients (10 men and 5 women), mean age 55 years old (46-65 range), underwent kidney or liver transplantation and developed severe sepsis or septic shock, as defined by the Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all the patients receiving conventional treatments including antibiotic therapy, vasopressive or inotropic agents, and ventilation support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters, dosage of vasopressor/inotropic drugs were assessed at baseline and after each treatment. RESULTS: No adverse events occurred. From baseline to 3rd treatment, mean arterial pressure (MAP) was increased (from 63+/-5 to 83+/-4 mmHg), while the dosage of dobutamine (from 7.5+/-3 to 3+/-2 mcg/kg/min) and noradrenaline (from 1.3+/-0.45 to 0.05+/-0.02 mcg/kg/min) were reduced. The PaO2/FiO2 ratio increased (from 234+/-38.47 to 290+/-107.48 mmHg). CONCLUSION: The use of DHP-PMX in association with conventional therapy may be an important aid in patients with sepsis.

Extracorporeal circulation with low systemic heparinization during lung transplantation.

BACKGROUND: Some lung transplantation (LT) recipients suffer from pulmonary hypertension and right ventricular dysfunction or failure requiring extracorporeal circulation (ECC) to avoid catastrophic complications during surgery. The extracorporeal support usually requires systemic heparinization which is potentially associated with important side effects. We performed eight LT using preheparinized ECC circuits and an oxygenator associated with a lower level of systemic heparinization without evidence of perioperative complications. PATIENTS AND METHODS: From May 2002 to May 2005, 8 patients (5 men and 3 women) of mean age 22.5 +/- 9.5 years underwent bilateral sequential lung transplantation (BSLT) for cystic fibrosis (n = 6) or idiopathic pulmonary fibrosis (n = 2). All procedures were performed with ECC through a femoro-femoral veno-arterial bypass with preheparinized circuits and an oxygenator. RESULTS: No intraoperative mortality occurred. The mean ECC time was 147.8 +/- 31.3 minutes and the mean heparin administered was 3525 +/- 969.16 UI. No coagulopathy or thrombotic events were observed perioperatively. CONCLUSIONS: Our study confirmed the efficacy and safety of prehepanized circuits and oxygenator for femoro-femoral veno-arterial bypass during LT for patients with severe pulmonary hypertension requiring ECC.

Non-invasive pressure support ventilation in patients with acute respiratory failure after bilateral lung transplantation.

OBJECTIVE: To evaluate non-invasive ventilation (NIV) prospectively in a group of patients developing acute respiratory failure (ARF) after bilateral lung transplantation (BLT). SETTING: General intensive care unit (ICU) of Rome "La Sapienza" University. PATIENTS: Twenty-one patients (18 with cystic fibrosis) undergoing BLT. RESULTS: All consecutive patients developing ARF (according to predefined criteria) and requiring ventilatory support, received non-invasive pressure support ventilation through a face-mask (PEEP 5 cmH2O, PSV 14+/-2 cmH2O) for a mean period of 5+/-4 days. Eighteen out of 21 patients avoided intubation and were discharged from the ICU; 3 patients required intubation: 1 of them survived while 2 developed septic shock and died. CONCLUSIONS: NIV administration was well tolerated and avoided intubation in the large majority of patients (86%); in NIV responders the rate of complications was low and ICU mortality nil. NIV should be considered as an interesting alternative to conventional ventilation in patients who require ventilatory support after BLT.

Predictive value of interleukin 6 (IL-6), interleukin 8 (IL-8) and gastric intramucosal pH (pH-i) in major abdominal surgery.

OBJECTIVE: To study plasma concentrations of interleukin 6 (IL-6) and interleukin 8 (IL-8) in patients with splanchnic hypoxia, as documented by gastric intramucosal measurements (pH-i), during major abdominal surgery and the relationship between IL-6 and IL-8 concentrations and postoperative complications as well as clinical outcome. DESIGN: A prospective study. PATIENTS: Twelve patients scheduled for major abdominal surgery with no evidence of coexisting infectious disease. RESULTS: Six out of seven samples from patients with postoperative complications showed intraoperative pH-i levels lower than 7.32 and IL-6 levels higher than 300 pg/ml. Seven out of nine samples from patients without complications showed pH-i levels higher than 7.32 and IL-6 levels lower than 300 pg/ml. The difference in the pattern of distribution was statistically significant (p < 0.01). Only two out of seven samples of patients with postoperative complications showed intraoperative pH-i levels lower than 7.32 and IL-8 levels higher than 60 pg/ml. It was not possible to identify a clear distribution pattern of data points for IL-6 and IL-8 during the postoperative period. CONCLUSIONS: Intraoperative splanchnic ischemia, as documented by gastric intramucosal pH-i, is directly correlated to the increase of IL-6 plasma levels and to the incidence of postoperative complications, while IL-8 levels showed no correlation with surgical complications.

[Functional urination disorders in patients recovering in an intensive care unit for more than 30 days]. / I disturbi funzionali della minzione in pazienti ricoverati in unità di terapia intensiva (ICU) per più di 30 giorni.

Patients in rest-homes, intensive care units, long hospitalization and dialysis and whoever stays in a hospital continuously or occasionally for long periods of time may run into the well-known and typical complications of prolonged hospitalization. We have studied the urologic aspect in all the cases of the Medical- Surgical Emergency Institute in the Hospital of Ancona (seated in Torrette), over the period 1990-96, in patients hospitalized for at least 30 days. All the patients were followed and studied with the same method, though taking into account their different pathological conditions. They were treated by the same medical and paramedical staff. The same antibiotic therapy and the same checkup were adopted for all of them. We have noticed that out of 122 patients the most frequent pathologies have been urinary infections (19%); while sepsis with different pathogenesis was recorded in 4% of the patients. The method of study applied during and after the hospitalization was used also in rehabilitation centres and included: urologic examination, rectal touch (in men), direct X-ray of the abdomen, ultrasound of the urinary tract, X-ray urography, if required; moreover urodynamic examination, MRI of encephalon and spinal marrow in patients with neurological lesions. The catheter was removed in all the patients and none of the following conditions were observed: vesical lithiasis, abscesses, fistulae in penoscrotal angle, urethrostenosis, injuries to renal emunctory. In conclusion we believe that the functional symptoms of minction--be they of obstructive or irritable nature--are not existent and that the urologic prognosis in long term patients in excellent, provided that prophylaxis is carried on against hospital urinary infections as their occurrence is very frequent and therapy is expensive. It can also be stated the patient hospitalized in ICU will not present damages to the urinary tract, even if he/she has been hospitalized because of injuries to the urinary tract, provided that the urologic tutoring, together with the action of the physician handling the Emergency, follow the rules for asepsis, the best biocompatible materials are use, infections are monitored, the extensions of cerebrospinal injuries are examined and therapeutic axioms, such as barren and clean intermittent catheterism, are finally adopted.

[Anesthesia for inguinal hernioplasty: a comparison of techniques]. / Anestesia per ernioplastica inguinale: tecniche a confronto.

New surgical and modern anaesthesia techniques for inguinal hernioplasty have significantly reduced the duration of the procedure and the postoperative length of hospital stay. From 1994 to 1998, 405 patients with a mean age of 54.7 years (range: from 18 to 90) undergoing inguinal hernioplasty were studied. Four different anaesthetic techniques were used: (i) surgical field infiltration (SFI) with 0.5% carbonated lidocaine + 0.125% bupivacaine (193 pts.) in which monitored anaesthesia care was administered with propofol (3 to 4 mg/kg/h) when necessary; (ii) epidural anaesthesia with 2% lidocaine + fentanyl 100 mg (137 pts.); (iii) general anesthesia with isoflurane and fentanyl in N2O:O2 (48 pts.); and (iv) intrathecal anaesthesia with 1% hyperbaric bupivacaine 1-2 ml (25 pts.). Intra- and postoperative complications, intraoperative sedation, postoperative supplemental drugs for analgesia and postoperative length of hospital stay were recorded. The data obtained were analyzed statistically using Student's t-test Anova, Bonferroni post hoc analysis, chi square, and P values less than 0.05 were considered significant. Intraoperative hypotension/brachycardia were observed in 4 patients (2%) in the SFI group and in 6 patients (4%) in the epidural group. Sedation was required in 29.5% of patients in the SFI group and in 15.3% in the epidural group (P < 0.05). Postoperative supplemental analgesic drugs administered and length of hospital stay were similar in the 4 groups. No difference in intra- and postoperative complications was observed among the 4 groups. Patients who required sedation in the SFI group were significantly more numerous than those with epidural anaesthesia. In conclusion, both SFI and epidural anaesthesia are safe and suitable for the inguinal hernioplasty procedure, without intra- or postoperative complications.

[Preliminary verification of a mathematical model for evaluating the operative risk in a personal caseload]. / Prime verifiche di un modello matematico di valutazione del rischio operatorio effettuate su una casistica personale.

The authors applied a mathematical model of evaluation of operative risk to a group of patients undergoing general and obstetric-gynecologic surgery. They verified that all risk factors identified by this mathematical model really influenced operative morbidity and mortality in the present study too. In this univariate analysis, anesthetic technique was found to influence patients' outcome, so it must be included in multivariate analysis protocols. Therefore, this mathematical model showed to be of value in assessing operative risk factors.

Neuromuscular block in Italy: a survey of current management.

BACKGROUND: Little is known about current use of neuromuscular blocking agents by Italian anesthetists. This paper reports the results of a survey conducted to obtain information about current management of neuromuscular block in Italy. METHODS: A questionnaire was given to Italian Anesthetists attending the 64nd National Congress of the Italian Society of Anesthesia, Intensive Care, Analgesia and Intensive Therapy S.I.A.A.R.T.I. (Parma, 13th-16th October 2010). Collected data were stratified by age, geographical location, and the total number of surgical procedures performed in the hospitals concerned. RESULTS: One thousand four hundred forty patients correctly compiled questionnaires were collected. 50% of respondents used clinical tests to monitor the level of neuromuscular blockade. The main clinical tests cited for the evaluation were: keeping the head lifted up for 5 seconds, protruding the tongue and opening the eyes. Train-of-four was used by 50% of respondents on a routine basis. Only 33% of anesthetists reply that a train-of-four ratio of 90% or more is the safe level prior to extubation. CONCLUSION: Clinical signs are used by most of the Italian anesthetists to assess the recovery from neuromuscular blockade. There is poor awareness about their inability to indicate even a significant degree of residual neuromuscular block. A more extensive use of quantitative instrumental monitoring is required for the more rational use of neuromuscular blocking agents.

ITalian Observational Study of the management of mild-to-moderate Post-Operative Pain (ITOSPOP).

BACKGROUND: The multicenter observational ITalian Observational Study on the management of mild-to-moderate PostOperative Pain (ITOSPOP) was carried out in 24 hospitals to describe current postoperative pain management in Italy and the intensity of pain experienced by patients during the first 48 hours after surgery. METHODS: Adult patients, after surgery expected to result in mild-moderate postoperative pain, underwent six evaluations. The primary endpoint was the level of organization and standardization of postoperative pain management. Secondary objectives included the intensity of postoperative pain, and an assessment of incident pain, postoperative analgesic and concomitant treatment administration. RESULTS: Only 16.7% hospitals had an acute pain service and 41.7% hospitals applied a standardized protocol for postoperative pain management. The majority (>60%) of the 1952 patients monitored underwent all six assessments, >70% of which were performed by a physician. The proportion of patients with moderate pain decreased during the study period, but almost 10% of patients still experienced moderate pain at study end. Mild pain was reported by 50% of the patients for the entire study duration. At the final assessment, 5% of patients still presented with incident pain frequently interfering with daily activities. Most patients were treated with analgesics, but 20% of patients did not receive any pain medications despite experiencing pain. CONCLUSION: The level of organization and standardization of postoperative pain management in Italian hospitals remains low. Postoperative analgesic treatment remained suboptimal and almost two-thirds of patients continued to experience pain.