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Background and objective: To evaluate the use of remifentanil-propofol administered as target-controlled infusion during awake fibreoptic intubation for anticipated difficult tracheal intubation in acromegalic patients. Method: In all, 20 consecutive acromegalic patients underwent elective endonasal endoscopic transsphenoidal pituitary surgery. After premedication with midazolam 0.03 mg kg-1, initially a target-controlled infusion of remifentanil 1.0 ng mL-1 and propofol 1.5 μ mL-1 was started. The fibreoptic intubation was performed by the same physician experienced with the fibreoptic technique. During the fibreoptic procedure the target concentrations of remifentanil and propofol ranged between 1.0 and 5.0 ng mL-1, and between 1.5 and 3.5 μg mL-1, respectively. Changes in heart rate and mean arterial pressure were recorded during airway manipulation, during tracheal intubation, and at 1 and 3 mm after. On the first postoperative day, patient recall and level of discomfort during fibreoptic intubation were evaluated. Results: Endotracheal intubation was efficaciously and quickly secured in all patients. A significant increase in mean arterial pressure and heart rate was recorded only during tracheal intubation (P < 0.05). Oxygenation was sufficient and no bradypnea or apnoea was recorded. All patients later described their anaesthetic experience as satisfactory. During fibreoptic intubation, remifentanil (ng mL -1) and propofol (μg mL-1)mean effect-site concentrations were 3.2 ± 0.3 and 2.0 ± 1.0, respectively. Conclusion: Remifentanil and propofol target-controlled infusion provided satisfactory conscious sedation allowing for successful oral fibreoptic intubation in acromegalic patients with no recall. [ABSTRACT FROM AUTHOR]

Background: Endoscopic endonasal transphenoidal surgery has been recently proposed as a minimally invasive procedure for the treatment of pituitary adenomas. The main objective of the anaesthesiologist is to induce sufficient haemodynamic control together with rapid recovery at the end of surgery. The aim of this study was to examine recovery profile, surgical operative conditions and haemodynamic differences using remifentanil infusion with either propofol target controlled infusion system or sevoflurane. Method: Forty-four adult patients were enrolled in a prospective, randomized, single-blind, two-group study: Group P received propofol target controlled infusion system and remifentanil; Group S received sevoflurane and remifentanil for maintenance of anaesthesia. Results: No statistically significant differences between the two groups with regards to the haemodynamic changes, operative conditions as assessed by a four-step bleeding score (0-3), were obtained. Recovery times were considerably shorter after emifentanil-sevoflurane in comparison with remifentanil—propofol target controlled infusion system group (7.4 vs. 12.8 mm, P < 0.01). Conclusion: This study demonstrates that sevoflurane-remifentanil gives a faster recovery and equivalent intraoperative status compared with propofol target controlled infusion system with remifentanil for the endoscopic endonasal transphenoidal approach. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Prolonged use of the ProSeal laryngeal mask in ICU: a case report."

Background: Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts' recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment., Methods: A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted., Results: A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided., Conclusions: This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician's decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing., (© 2022. The Author(s).)

Background: Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts' recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm., Methods: A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted., Results: Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided., Conclusions: This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician's decision-making and not to mandate a standard of practice., (© 2022. The Author(s).)

Objectives: Chest trauma is associated with severe pain, which can hamper normal breathing. Serratus Anterior Plane block (SAPB) is a novel technique, which provides analgesia for chest wall surgery. We describe an interesting clinical case about the use of SAPB to improve pain and pulmonary function in a patient with severe chest trauma., Case Presentation: We report the pain management and the clinical evolution of a patient in ICU, with a severe chest trauma, after performing the SAPB. Following the SAPB, the patient had a reduction in pain intensity and an improvement in both respiratory mechanics and blood gas analysis allowing a weaning from mechanical ventilator., Conclusions: Pain control greatly affects mortality and morbidity in patients with chest trauma. SAPB seems to be safer and equally effective in pain control compared to epidural analgesia in patients with chest trauma., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Corticosteroids use in severe and critical COVID-19 patients is recommended by international guidelines, as they reduce mortality. However, the use outside of these indications could be harmful and should be discouraged. The scope of this brief review is to examine the beneficial mechanisms of corticosteroids treatment in COVID-19 and when they should be adopted.

The spirochete, Borrelia burgdorferi , has a large number of membrane proteins involved in a complex life cycle, that includes a tick vector and a vertebrate host. Some of these proteins also serve different roles in infection and dissemination of the spirochete in the mammalian host. In this spirochete, a number of proteins have been associated with binding to plasminogen or components of the extracellular matrix, which is important for tissue colonization and dissemination. GroEL is a cytoplasmic chaperone protein that has previously been associated with the outer membrane of Borrelia. A His-tag purified B. burgdorferi GroEL was used to generate a polyclonal rabbit antibody showing that GroEL also localizes in the outer membrane and is surface exposed. GroEL binds plasminogen in a lysine dependent manner. GroEL may be part of the protein repertoire that Borrelia successfully uses to establish infection and disseminate in the host. Importantly, this chaperone is readily recognized by sera from experimentally infected mice and rabbits. In summary, GroEL is an immunogenic protein that in addition to its chaperon role it may contribute to pathogenesis of the spirochete by binding to plasminogen and components of the extra cellular matrix.

Giardia duodenalis is a protozoan that causes a gastrointestinal illness called giardiasis. Giardiasis outbreaks in the United States are most commonly associated with waterborne transmission and are less commonly associated with food, person-to-person, and zoonotic transmission. During June to September 2015, an outbreak of 20 giardiasis cases occurred and were epidemiologically linked to a local grocery store chain on Long Island, New York. Further investigation revealed three asymptomatic food handlers were infected with G. duodenalis, and one food handler and one case were coinfected with Cryptosporidium spp. Although G. duodenalis was not detected in food samples, Cryptosporidium was identified in samples of spinach dip and potato salad. The G. duodenalis assemblage and subtype from one of the food handlers matched two outbreak cases for which genotyping could be performed. This outbreak highlights the potential role of asymptomatically infected food handlers in giardiasis outbreaks., (Copyright ©, International Association for Food Protection.)

Background: Sugammadex is a relatively new molecule that reverses neuromuscular block induced by rocuronium. The particular structure of sugammadex traps the cyclopentanoperhydrophenanthrene ring of rocuronium in its hydrophobic cavity. Dexamethasone shares the same steroidal structure with rocuronium. Studies in vitro have demonstrated that dexamethasone interacts with sugammadex, reducing its efficacy. In this study, we investigated the clinical relevance of this interaction and its influence on neuromuscular reversal., Methods: In this retrospective case-control study, we analyzed data from 45 patients divided into 3 groups: dexamethasone after induction group (15 patients) treated with 8 mg dexamethasone as an antiemetic drug shortly after induction of anesthesia; dexamethasone before reversal group (15 patients) treated with dexamethasone just before sugammadex injection; and control group (15 patients) treated with 8 mg ondansetron. All groups received 0.6 mg/kg rocuronium at induction, 0.15 mg/kg rocuronium at train-of-four ratio (TOF) 2 for neuromuscular relaxation, and 2 mg/kg sugammadex for reversal at the end of the procedure at TOF2. Neuromuscular relaxation was monitored with a TOF-Watch® system., Results: The control group had a recovery time of 154 ± 54 seconds (mean ± SD), the dexamethasone after induction group 134 ± 55 seconds, and the dexamethasone before reversal group 131 ± 68 seconds. The differences among groups were not statistically significant (P = 0.5141)., Conclusions: Our results show that the use of dexamethasone as an antiemetic drug for the prevention of postoperative nausea and vomiting does not interfere with reversal of neuromuscular blockade with sugammadex in patients undergoing elective surgery with general anesthesia in contrast to in vitro studies that support this hypothesis.

Background: The aim of this paper was to determine if there were any significant differences between the effects of fentanyl delivered as a bolus or remifentanil delivered as a continuous infusion on the QT interval and QT dispersion (QTD) during the induction of anesthesia and tracheal intubation., Methods: This was a prospective, randomized and single blind study. A total of 50 ASA I-II patients scheduled to undergo elective minor abdominal surgery were divided into two groups. In the remifentanil group (N=25), patients received a continuous infusion (c.i.) of remifentanil (0.25 mcg/kg · min). In the fentanyl group (N=25), a bolus dose of fentanyl (2.0 mcg/kg) was administered. The QT interval, the difference between QTmax and QTmin (QTD), the heart rate-corrected QT (QTc) and the QT dispersion (QTcD) were calculated using a 12-lead computerized electrocardiogram (ECG)., Results: In both groups, there was no significant change in QT or QTc intervals during the study period. In the remifentanil group, a significant decrease in QTD and QTcD was observed during induction compared with baseline values (P<0.05). There was a significant increase in QTD at 1 min and in QTcD at 1 and 3 min after intubation in the fentanyl group (P<0.05)., Conclusion: Both remifentanil and fentanyl did not prolong the QT interval. QTD decreased after the induction of anesthesia and did not increase after tracheal intubation in patients receiving c.i. remifentanil in comparison with fentanyl. Overall, remifentanil infusion may be the opioid-based treatment regimen of choice in patients at risk of dysrhythmias.

Background: The aim of the study was to evaluate the effects of pneumoperitoneum and head-up position on autonomic cardiac function changes during inhalational or total intravenous anesthesia by using the analysis of QT dispersion and heart rate variability (HRV)., Methods: In this prospective, single-blind study, 30 patients scheduled for elective laparoscopic cholecystectomy were randomly divided in two groups: a sevoflurane-based inhalational anesthesia group (N=15) and an intravenous anesthesia group with propofol (N=15). Propofol 2.0 mg/kg-1 and cisatracurium 0.15 mg/kg-1 during induction of anesthesia and Remifentanil as titrated infusion for analgesia were used in both groups. Pneumoperitoneum was established at 12 mmHg with patients in the supine position. ECG was recorded before the induction of anesthesia; 1 and 3 min after pneumoperitoneum (supine position); 1 and 3 min after shifting the patient to a head-up position (HUP) of 60 degrees; after abdominal deflation; and after awakening. RR interval, QT interval, corrected QT interval (QTc), QT interval dispersion (QTD), corrected QT interval dispersion (QTcD), low-frequency power (LF), high-frequency power (HF) and LF/HF ratio were recorded., Results: The LF/HF ratio increased significantly after 3 min HUP in the SEVO group (P<0.05). QTD and QTcD increased significantly at 3 min after abdominal insufflation and at 1 and 3 min after HUP in both groups (P<0.05)., Conclusion: Statistically significant increases of QTD and QTcD occurred during pneumoperitoneum and HUP, regardless of the anesthetic techniques used. In patients receiving inhalational anesthesia, the LF/HF ratio increased significantly after HUP.

Object: In addition to difficulties with anesthetic and medical management, transsphenoidal operations in patients with longstanding acromegaly are associated with inherent intraoperative challenges because of anatomical variations that occur frequently in these patients. The object of this study was to review the overall safety profile and anatomical/technical challenges associated with transsphenoidal surgery in patients with acromegaly., Methods: The authors performed a retrospective analysis of 169 patients who underwent endoscopic transsphenoidal operations for growth hormone-secreting adenomas to assess the incidence of surgical complications. A review of frequently occurring anatomical challenges and operative strategies employed during each phase of the operation to address these particular issues was performed., Results: Of 169 cases reviewed, there was no perioperative mortality. Internal carotid artery injury occurred in 1 patient (0.6%) with complex sinus anatomy, who remained neurologically intact following endovascular unilateral carotid artery occlusion. Other complications included: significant postoperative epistaxis (5 patients [3%]), transient diabetes insipidus (5 patients [3%]), delayed symptomatic hyponatremia (4 patients [2%]), CSF leak (2 patients [1%]), and pancreatitis (1 patient [0.6%]). Preoperative considerations in patients with acromegaly should include a cardiopulmonary evaluation and planning regarding intubation and other aspects of the anesthetic technique. During the nasal phase of the transsphenoidal operation, primary challenges include maintaining adequate visualization and hemostasis, which is frequently compromised by redundant, edematous nasal mucosa and bony hypertrophy of the septum and the nasal turbinates. During the sphenoid phase, adequate bony removal, optimization of working space, and correlation of imaging studies to intraoperative anatomy are major priorities. The sellar phase is frequently challenged by increased sellar floor thickness, distinct patterns of tumor extension and bony invasion, and anatomical variations in the caliber and course of the internal carotid artery. Specific operative techniques for addressing each of these intraoperative challenges are discussed., Conclusions: Transsphenoidal surgery in patients with longstanding acromegaly frequently poses greater challenges than operations for other types of sellar lesions, yet these challenges may be safely and effectively overcome with the anticipation of specific issues and implementation of various intraoperative techniques.

Aim: The aim of this study was to evaluate the haemodynamic changes in patients undergoing cytoreductive surgery and intraperitoneal hyperthermic chemotherapy (IPHC) using an echo-Doppler device (Hemosonic 100)., Experimental Design: haemodynamic and cardiac function variables during IPHC, using a closed abdomen technique, were measured with the use of a non-invasive esophageal echo-Doppler monitor., Setting: operating room in an oncologic surgery department in hospital. Fifteen patients, ASA II or III with age ranging from 59 to 66 years were successively studied. All patients were under general anaesthesia with sevoflurane, remifentanil as titrated infusion, and cisatracurium for muscle relaxation. The standard monitoring included ECG, capnometry, invasive measurement of blood pressure and central venous pressure, pulsoximetry, diuresis, esophageal and tympanic temperature. Haemodynamic changes evaluated by an echo-Doppler device were recorded at predetermined times., Results: A significant reduction in stroke volume (SV) and aortic blood flow (ABF) values was recorded (P<0.05) during the abdominal cavity filling, followed by a significant increase in total systemic vascular resistance values (P<0.05). A significant increase in SV, ABF and left ventricular ejection time was recorded 90 min after the start of IPHC procedure (P<0.05) when the body temperature increased. Peak velocity and acceleration values increased significantly at the same time., Conclusions: These results suggest that the echo-Doppler device (Hemosonic 100) provided an easy-to-handle, non-invasive and reliable tool to monitor changes in cardiac parameters during IPHC.

Aim: The transition from intraoperative analgesia to postoperative analgesia must be planned carefully after remifentanil-based anesthesia, due to the short duration of action of remifentanil. The aim of this study is to compare the efficacy and safety of 2 transition strategies using sufentanil or tramadol for early postoperative pain relief in patients who had major abdominal surgery under general anesthesia with remifentanil/sevoflurane., Methods: Sixty patients participated in this double-blind, prospective study and were randomly assigned to either sufentanil (S) group or tramadol (T) group. Twenty minutes before the end of surgery the patients received either a bolus of 0.15 microg kg(-1) sufentanil (group S) or tramadol 100 mg (group T). Mean arterial pressure (MAP), heart rate (HR) and rate pressure product (RPP=systolic arterial pressure (SAP)xHR), analgesia by a verbal rating score (VRS) and sedation by a sedation score (SS) were evaluated at emergence from anesthesia., Results: A statistically significant difference in HR between the 2 groups was recorded at extubation (78+/-13 in group S vs 86+/-24 in group T). A significant decrease of RPP values at extubation and 5 minutes later were found in group S in comparison with group T. VRS values were significantly lower in sufentanil group at 5 and 10 minutes after awakening., Conclusions: Sufentanil provided more effective transition analgesia in comparison with tramadol. The effects of remifentanil dissipated rapidly and analgesia with major opioids was required. A bolus dose of sufentanil 0.15 microg kg(-1) was efficacious in controlling the hemodynamic parameters at awakening from anesthesia. The lower HR values and, consequently the lower RPP values are of utmost importance especially in the aged cardiovascular risk patient.

Aim: Transition from the end of remifentanil infusion and postoperative analgesia must be planned carefully owing to remifentanil's (R) rapid offset. Intraoperative morphine has been used for the transition to postoperative analgesia following remifentanil-based anesthesia. Sufentanil (S) is a very potent opioid with high micro-receptor affinity, a much wider therapeutic index and a lower fractional receptor occupancy. These pharmacological and dynamics features make sufentanil an interesting alternative to morphine for immediate postoperative analgesia., Experimental Design: perspective, randomized, single blinded and comparative study. Institution: neurosurgical operating theatre at University., Patients: 96 patients, aging from 25 to 67 years, ASA class I-III, undergoing neurosurgical operations, were studied., Interventions and Measurements: the anesthetic management was: premedication: atropine 0.01 microg kg(-1) + remifentanil 0.20 microg kg(-1) min(-1); induction: propofol 2.0 microg kg(-1) + cisatracurium 0.15 microg kg(-1); maintenance: sevoflurane 0.8% + remifentanil (titrated infusion) cisatracurium. All patients received ketorolac 30 mg i.v. 1 hour before the end of surgery and ketorolac (60-90 mg) + tramadol (200-300 mg) by elastomeric pump; patients were divided into 2 groups: group T receiving tramadol 100 mg and group S receiving a bolus dose of sufentanil 0.10 microg kg(-1), 30 and 15 minutes before the end of surgery respectively. Recovery time, postoperative analgesia evaluated by VAS, cardiocirculatory parameters and side effects like nausea, vomiting, shivering, muscle rigidity, sedation and respiratory depression were recorded., Results: VAS was significantly lower in Group S. Recovery time was shorter in Group T than in Group S (8.8 +/- 3.6 vs 11.6 +/- 4.6 min), no statistically significant differences between groups as regards nausea, vomiting and shivering. Short-lasting respiratory depression was detected in 3 cases in Group S., Conclusion: At the emergence much better control of the transition phase in patients treated with sufentanil: smooth recovery with better tolerability of the endotracheal tube; efficacious analgesia along with cardiocirculatory stability.

The role of analgesia and sedation in intensive care units (ICU) is ancillary to other intensive care strategies, nevertheless they permit that every other diagnostic and therapeutic procedure is safely performed by keeping the patient pain-free, anxiety-free and cooperative. Commonly used opioids in ICU include morphine, fentanyl, sufentanil and remifentanil. The choice among opioid drugs relies on their pharmacokinetics and their pharmacodynamic effects. Cardiovascular stability observed with fentanyl and sufentanil indicates their use in hemodynamically compromised patients. Short-acting remifentanil offers several advantages in patients requiring prolonged infusions. The organ-independent metabolism of this newer molecule may be valuable in patients with multiple organ failure. The main indications for opioid analgesia and sedation in ICU include: 1) Anxiety, pain and agitation: in turn, they can increase cardiac workload, myocardial oxygen consumption and rate of dysarrhythmias; 2) immediate postoperative period after major surgery; 3) short-term invasive procedures. Potential advantages offered by opioids in the ICU setting also include: a) Cardiac protection: in animal models, it has been observed that delta-opiate receptor stimulation confers a preconditioning-like protective effects against myocardial ischemia; b) Neuroprotection: recent studies suggest that mu- and kappa-opiate receptors are involved in ischemic preconditioning against seizures in the brain. During opioid therapy in the ICU, drug tolerance and withdrawal symptoms should be anticipated and the dose adjusted accordingly.

Background: To evaluate the efficacy of propofol as the sole anaesthetic agent for the anaesthetic management of the trigeminal rhizolysis., Experimental Design: retrospective study., Setting: operating room of the Neurosurgery Department at University., Patients: 200 patients were studied, 115 males and 85 females, with mean age of 62.8 +/- 3.6 years, ASA status I, II or III and with various underlying medical problems., Interventions: patients were premedicated with atropine 0.01 mg/kg i.v. 10 min before the induction of anaesthesia. The induction dose of P was titrated to the desired level in according to age and clinical conditions. After induction of anaesthesia the surgeon started the needle placement through the foramen ovale in the trigeminal cistern., Measurements: during both procedures the mean dose of P, induction and recovery times, side effects and complications and quality of anaesthesia were assessed. Statistical analysis of the data was carried out using ANOVA for repeated measures and Bonferroni "t"-test and a value of p < 0.05 was considered to be significant., Results: Anaesthesia was successfully induced after a mean dose of 1.9 mg/kg of P during PG and of 2.1 mg/kg during PR. A few side effects and short recovery time were recorded in all cases. P also provided an adequate cardiovascular stability during PG and PR., Conclusions: In conclusion, P can be considered suitable for this particular neurosurgical procedure requiring short period of anaesthesia and rapid recovery time in order to communicate with the neurosurgeon during the sensory testing.

Background: The aim of this study was to evaluate the effects of mivacurium on the cerebrospinal fluid pressure (CSFP) in patients requiring muscle relaxation to facilitate mechanical ventilation and on the intracranial pressure (ICP) in patients undergoing neurosurgery., Experimental Design: prospective study., Setting: ICU in a hospital and operating room in a neurosurgery department at University., Patients: 12 patients, GCS 6-7, with a mean age of 62.6 +/- 6.2 were studied in ICU and 10 patients, ASA I-II, with a mean age of 58.6 +/- 6.4 were studied in the operating room., Interventions: all patients received mivacurium as single bolus dose of 0.2 mg/kg i.v., Measurements: Heart rate, SAP, DAP and MAP were recorded at different times. In ICU CSFP was measured via a catheter in lumbar subarachnoid space and in operating room ICP was measured via an intraventricular catheter. CPP was evaluated as the difference between MAP and ICP. Statistical analysis was carried out using ANOVA for repeated measures and Bonferroni "t"-test and a value of p < 0.05 was considered to be significant., Results: Mivacurium was found not to influence or to increase ICP or CSFP. No significant changes in cardiocirculatory parameters were recorded in all patients., Conclusions: In conclusion, mivacurium can be considered a suitable and manageable neuromuscular blocking drug in the management of patients with intracranial pathology.

A new experimental trial to investigate the usefulness of early therapeutic measures in case of acute I.V.D. has been performed, on the basis of a previous already reported experience. A combined treatment consisting of hemodilution and revascularization starting 16 hours after the onset of cerebral ischemia was tested. The study was performed in a population of 20 New Zealand male rabbits in which an acute cerebral ischemia was achieved by means of extracranial ligation of both common carotid artery and of one vertebral artery. The animals were divided into two groups. 1st group: no treatment; 2nd group: revascularization + hemodilution. Better results were observed in treated group considering either CBF rates or histological changes.

The beta-endorphin-like-immunoreactivity (beta-ELI) has been evaluated both in plasma and in cerebrospinal fluid (CSF) in 30 patients during trans-sphenoidal surgery. Blood and liquoral samples were collected in five conditions: (1) "reference", (2) "pain", (3) "analgesia", (4) "end", and (5) "24th hour". A significant rise of both plasma and liquoral beta-ELI levels (p less than 0.00001 and p less than 0.08, respectively) when compared to basal ones occurred following the painful stimulation due to the divarication of the nasal mucosa by speculum. A significant decrease (p less than 0.01) was noticed for plasma concentrations at the third sample followed by a new significant increase at the end of the operation, (p less than 0.05 when compared to the third sample and p less than 0.01 when compared to the reference sample). In CSF, beta-ELI levels decreased at the third sample (p less than 0.01 when compared to the painful levels) and at the end of surgery (p less than 0.01, p less than 0.01 and p less than 0.05 vs first, second and third samples, respectively). Twenty-four hours after surgery either plasma and liquoral beta-ELI levels decreased (p less than 0.05). The modifications of the opiatergic system after acute painful stimuli should be, hence, characterized by an early rise followed by a progressive decrease of beta-ELI concentrations. The increase of plasma beta-ELI levels, at the end of surgery, could be due to pituitary manipulation with massive release in the peripheral blood.