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Aims: the aims of this study were to test the efficacy of a training program in order to reduce pain intensity in surgical ICU patients and improving postoperative pain assessment and management., Methods: longitudinal, before and after experimental study. A total of 261 patients, 126 in Group A (before intervention) and 135 in Group B (after intervention) were included. Data were collected prospectively before and after a training intervention and the implementation of a pain management protocol., Results: a significant reduction was observed in pain intensity scores collected at 6 hours (p=.016) 12 hours (p -.001) and 48 hours (p=.005) postoperatively. Intense pain was most observed in Group A than Group B (RR=1.98; 95% CI= 1.05-3.71, p=.0302). A significantly smaller proportion of patients treated after intervention received morphine (p=.036) and propofol (p=.045). Although there has been no increase in pain assessments, the interval (hours/minutes) between drugs administrations was reduced (Group A 6.35 +1.19 vs Group B 6.21 +0.5) (p=.006). Mechanical ventilation lasted longer in Group A (3.67 days + 6.6 vs 2.44 days + 4.45) (MD = 1.23; 95% CI= -0.1541- 2.6141) (p=.0415)., Conclusion: the implementation of the organizational changes on pain prevention in this ICU, using standardized education, led to less pain in surgical ICU patients. However further randomized studies and with larger patient samples are needed.

Background: The aim of this study was to report our experience with subcutaneous defibrillator (S-ICD) implantation., Methods: At our hospital, 7 procedures of S-ICD implantation were performed; 4 of these with ultrasound-guided serratus anterior plane block (SAPB) and 3 with usual local anesthesia followed by sedation., Results: Surgical operations were not burdened with peri- and postprocedural complications, with only one event of limited hematoma of the thoracic wall. Ultrasound-guided serratus anterior plane block was associated with better pain control during the procedure and the postoperative period. The disconnection between latissimus dorsi and serratus obtained by serratus anterior plane block contributed to make the creation of the pocket easier. The technique used is with two incisions., Conclusions: In our experience, S-ICD implantation with the technique of the serratus anterior plane block is safe and effective, and significantly facilitated pain control during the procedure and postoperatively.

Background: Surgical procedures for ano-rectal pathologies are always conditioned by an high percentage of side-effects. Indeed, the prevention of probable complications such as the non tissue-recovery or infection is a fundamental topic to guarantee an adequate follow-up. The aim of this comparative study is to assess the short-term outcomes of the use of a solution salsobromoiodic gel solution in postoperative period of patients undergoing proctological surgery., Materials and Methods: The authors selected retrospectively a population of 80 patients, undergoing surgery for Milligan-Morgan hemorrhoidectomy. Based on the recommended medications postoperatively, patients were divided into two groups: the Group A applied the salsobromoiodic solution gel on the perianal surgical wound in the postoperative period, the Group B did not use any medical facility with the exception of a soap at neutral pH. The clinical features assessed at 5, 10, 15 and 30 days after surgery were: pain, burning and itching lenght, the healing time, the presence or absence of early or late superinfection, the time of re-epithelization, the need for surgical curettage. The subjective evaluation of quality of life was assessed using a Visual Analogue Scale (VAS)., Results: There was a statistically significant reduction in length of postoperative pain in patients of Group A compared to Group B (5.6 vs 10.4 days respectively; p<0.005). There was a more rapid wound healing and re-epithelialization in group A, 15 and 21,3 days, respectively, as compared to Group B, 22.9 and 31.7 days (p<0.005). There were no differences between the two groups in terms of burning, itching and early and late bacterial infection. Two patients in Group B required a surgical debridement of the wound. Patients who used postoperatively salsobromoiodic solution declared a better quality of life., Conclusions: The use of salsobromoiodic gel solution in the postoperative proctological surgery, resulted safe and was effective in reducing postoperative pain, in contributing wounds healing and improving the quality of life, as subjectively assessed by each patient.

Introduction: Over the last few years, many urological laparoscopic operations have been successfully performed by LESS. However, the actual role of LESS in the field of minimally invasive urologic surgery remains to be determined with controversial data about postoperative pain control and almost no results on cosmetic data. The aim of the present study is to describe the technique and report the surgical outcomes of LESS radically nephrectomy (RN) in the treatment of renal cell carcinoma with special emphasis for postoperative pain control and almost no results on cosmetic data., Materials and Methods: LESS-RN was performed in 33 patients with renal tumors. The indications to perform a LESS-RN were represented by renal tumors not greater than T2, and without evidence of lymphadenopathy or renal vein involvement., Surgical Procedure: The Endocone (Karl Storz, Tuttlingen, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and bent grasper and scissors was used. The step sequence of LESS-RN was comparable to standard laparoscopic RN. Demographic data and perioperative and postoperative variables were recorded and analyzed., Results: The mean operative time was 143.7 ± 24.3 min, with a mean estimated blood loss of 122.3 ± 34.1 mL and a mean hospital stay of 3.8 ± 0.8 d. The mean length of skin incision was 4.1 ± 0.6 cm; all patients were discharged from hospital with minimal discomfort, as demonstrated by their pain assessment scores (visual analogue scale: 1.9 ± 0.8). The definitive pathologic results revealed a renal cell carcinoma in all cases and a stage distribution of four T1a, 27 T1b, and 2 T2 tumors. All patients were very satisfied with the appearance of the scars, and at a median follow-up period of 13.2 ± 3.9 mo, all patients were alive without evidence of tumor recurrence or port-site metastasis., Conclusions: LESS is a safe and feasible surgical procedure for RN in the treatment of renal cell carcinoma and has excellent cosmetic results.

Aim: The aim of this study was to evaluate the effects of low level laser on the postoperative pain of patients who had to undergo third molar surgery., Methods: In a randomized clinical setting, 100 patients were assigned to two groups of 50 in each. Every patient underwent surgical removal of one mandibular third molar (with osteotomy). After suturing the flap, the soft laser was applied to every patient. In group I laser radiation was applied by the dental assistant with output power of 100 mW, in continuous mode with sweeping motion, in group II, the laser hand piece was only brought into position without releasing energy, so that no patient knew which group he belonged to. The patient was given a pain evaluation form where they could determine their individual pain level and duration., Results: The statistical tests showed significant difference in pain level between laser and control group (P<0.001) but no significant difference found in pain duration in two groups (P=0.019)., Conclusion: The result of this study verifies the positive effect of the soft-laser therapy in the postoperative complication after third molar extraction.

During the first Congress of the Italian University Schools of Oral Surgery, held in Rome on 18-20th February, 2010, a task force was convened by the Italian Society of Odontostomatological Surgery (SIdCO) to summarize the data collected from the current literature on selected aspects relating to the mandibular third molar and its removal. The task of the Conference Participants was to review and analyze the pertinent literature and to elaborate conclusive recommendations for the management of the lower third molar. The statements made and the recommendations presented represent the consensus of the Conference, which can be considered the official statement of the SIdCO.

Background: The primary aim of this randomized controlled prospective study (www.clinicaltrials.gov NCT00599144) was assessing effectiveness on pain control after videolaparoscopic cholecystectomy (VLC) of 0.5% Bupivacaine-soaked sheet of regenerated oxidized cellulose positioned in the gallbladder bed., Patients and Methods: We randomized in three equal groups 45 patients that underwent elective videolaparoscopic cholecystectomy: group A - Bupivacaine-soaked sheet of regenerated oxidized cellulose positioned in the gallbladder bed; group B - Bupivacaine infiltrated in the muscular fasciae of the trocars' seat; group C - control group, not using local anesthetic. Six and 24 hours after the intervention we recorded the type of the pain and its intensity, using a visual analog scale (VAS)., Results: We observed no statistically significant difference in pain intensity. Considering the type of pain, 55,56% of patients referred visceral pain, 62,22% parietal pain and 44,44% shoulder pain. Group A shows, at both endpoints, a statistically significant reduction (p < 0.05) of visceral and shoulder pain versus other groups. Moreover, the use of a local anesthetic significantly reduces the use of post-operative pain drugs, both for group A and B., Conclusion: A Bupivacaine-soaked sheet of regenerated oxidized cellulose positioned in the gallbladder bed post-VLC is safe and not economically demanding, and can give advantages in increasing post-operative comfort.

Two kind of total intradermal suture techniques are described in the present report. These procedures allow an effective reduction of post-operative pain of surgical wound, prevent infections, cut down tissutal trauma, achieve better aesthetic results, making easier postoperative patient's management. From January 2001 to December 2007, 1,427 patients underwent surgical treatment and the wounds have been sewn with self-locking knots or intradermal skin closure with introflecting knots. This kind of procedures allow a sharp reduction of postoperative pain as well as the incidence of wound infections. Also the number of wound medication required after surgery is significantly reduced.

Background: The aim of the study was that to evaluate the post-operative pain in case of ano-rectal diseases wether treated by ketorolac, or buprenorphine or tramadol., Materials and Methods: The intensity of post-operative pain was evaluated in 60 patients with hemorrhoidal diseases, fistulae, abscesses and anal neoplasms, divided into three homogenous groups and treated with intramuscular ketorolac (Group I), transdermal buprenorphine (Group II) and tramadol in elastomeric pump (Group III)., Results: The average index of the visual analogue scale, as mean to evaluate the intensity of the post-operative pain, was 1,85 in the first group, 1,20 in the second one and 1,40 in the third group., Discussion: In patients treated with transdermal buprenorphine or with tramadol in elastomeric pump there has been a more quick psycho-physical recovery than in those treated with ketorolac; the management of elastomeric pump represents however for patients cause of concern while the transdermal system is a kind of rational and comfortable way of treatment of the pain, with the advantage of being non-invasive., Conclusions: Better compliance and lower operating costs have given the preference to the use of transdermal buprenorphine for the treatment of diseases of the post-operative pain in the diseases of the anal canal.

Aim: The purpose of this study was to compare the patient's postoperative discomfort when root canal irrigation was performed either with standard sodium hypochlorite or with sodium hypochlorite with the adjunct of a proteolytic enzyme., Methods: Two hundred patients were endodontically treated in two clinics. The type of irrigant to be used during root canal instrumentation was randomly assigned. Final irrigation was done using EDTA 17%. The canals were filled by warm vertical condensation with guttha-percha and the coronal seal was made using IRM. Patients were given a questionnaire to assess pain and swelling and the number of analgesics and other drugs taken during the first week after treatment., Results: A total of 166 questionnaires could have been evaluated. No significant difference was found between groups for pain, swelling and analgesics taken. Moderate pain and swelling was reported only in the first two days after treatment. No antibiotics use was reported. No guttha-percha excess beyond root apex was found by radiographic assessment., Conclusions: The irrigating solution containing a proteolytic enzyme does not produce greater postoperative discomfort as compared to the conventional sodium hypochlorite in patients undergoing endodontic therapy.

Aim: The aim of this study was to determine the effectiveness of an incisional infusion of local anesthetics through a continuous-infusion elastomeric pump for the management of postoperative pain after thoracotomy., Methods: A comparative analysis of 40 patients undergoing thoracotomies was carried out. Postoperative pain management with a continuous-infusion elastomeric pump providing local anesthetic into the incisional area was compared with traditional values. Data sources were reviewed for mean narcotic use, pain score, and complications., Results: After thoracotomy procedures, 20 patients received the ON-Q Pain Relief System (I-Flow Corp, Lake Forest, CA, USA). Narcotic use and pain scores were significantly reduced in the ON-Q group. There were no wound healing complications or infections associated with the use of the pump., Conclusion: A continuous infusion of ropivacaine at 4 mL/h through the ON-Q elastomeric infusion pump is a safe and effective adjunct in postoperative pain management after thoracotomy. The use of the ON-Q Pain Relief System results in decreased narcotic use and lower pain scores.

Background: Hypospadias is one of the most common congenital anomalies occurring in approximately (1/300) male births. If it is not surgically corrected the consequences may negatively impact on quality of life in adolescents. The surgery is very invasive and the post-operative phase very painful. To improve the control of post-operative pain, continuous analgesia via epidural catheter was implemented., Aims: To compare the effectiveness in controlling pain of two different regimens: continuous epidural catheter infusion vs oral and rectal non-steroidal pain-killers., Materials and Methods: Comparative study on children undergoing hypospadias surgery. Group A (catheter) was treated with continuous postoperative analgesia via epidural catheter and Group B (scheduled times) with rectal and oral analgesics at scheduled times and on demand, after caudal block. In both groups nurses measured pain with VAS and FLACC scales (score from 0 to 10) for 72 hours after surgery., Results: 41 children were studied (average age 64.1 months, SD 47.3), with 332 post-operative pain recordings (Group A n = 161, Group B n = 171). Mean pain score of Group A was 0.13 (SD 0.3) and 0.45 (SD 0.8) in group B, p = 0.006. The median duration of the epidural catheter was 65 hours, mean 51.8 hours (SD 24.3). During the 1st post-operative medication, the mean pain score in Group A was 1.2 (SD 1.4), and 3.2 (SD 1.8) in group B, p = 0.003. In group A the number of pain scores indicating pain (> 0) where 3.1% while in group B were 10.5%, p = 0.0007., Conclusions: In children undergoing hypospadias surgery, post-operative analgesia with continuous epidural catheter infusion seems to offer a better analgesic coverage than the traditional oral/rectal analgesic treatment at scheduled times and on demand.

The authors analyzed their experience from January 2001 to February 2005 on 117 patients treated with Longo hemorrhoidopexy (46 cases) and Milligan-Morgan hemorroidectomy (71 cases). All the patients were observed after a week and one month after surgical procedure; at 6 months the Authors controlled 70 patients treated with Milligan-Morgan and 33 treated with Longo technique. The pain after 24 hours was the same in two groups but after a week a significative difference between two groups (p<0.05) was registered with a better quality of life for hemorrhoidopexy group. At 6 months pain during defecation was present in two cases of Longo group and in 6 cases of Milligan-Morgan group. In author's experience the Longo technique is a safe treatment with lower postsurgical pain and lower complications.

Intra- and early (first week) post-operative haemorrhages are the most common complications in stapled hemorrhoidectomy PPH (Procedure for Prolapse and Hemorrhoids) and in circumferential resection of the rectal prolapse STARR (Stapled Trans Anal Rectal Resection). Performing PPH and STARR we employed a gelatin based haemostatic sealant with thrombin component (FloSeal) to control intra-operative bleeding and to reduce post-operative bleeding avoiding haemostatic stitches on suture line. We report the preliminary results on 197 PPH and 64 STARR; 44 PPH (22.4%) and 27 STARR (42.2%) were treated by FloSeal. No major post-operative bleeding was observed in all patients treated by FloSeal, compared to 1.3% and 2.7% of hemorrhage respectively in PPH and STARR patients treated without sealant. Post-operative pain was less severe in patients treated by FloSeal, without a difference statistically significant. The data are preliminary and must be confirmed in prospective randomized trials in larger series.

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

Conventional surgery for incisional hernia carries a postoperative morbidity and recurrence rate of more than 12%. The aim of this study was to report our experience with the laparoscopic treatment of incisional hernia with the use of a composite mesh (Parietex, Sofradim, Celbio). The median duration of the operation was 135 minutes. In one patient peritonitis from small bowel perforation occurred on postoperative day 2 and required emergency surgery. The median postoperative hospital stay was 3 days. No complications were observed over a median follow-up period of 12 months. The goal of the laparoscopic treatment of incisional hernia is to decrease the incidence of local complications and the recurrence rate which are seen with traditional open surgery. To this should be added all the advantages of minimally invasive surgery in terms of decreased postoperative pain, length of hospital stay, and sick leave.

Aim: The use of remifentanil in routine clinical practice during the induction and maintenance of general anesthesia as well as the quality of awakening after anesthesia and post-operative pain management have been assessed., Methods: A total of 123 Italian anesthetists were involved; data of 1 295 patients (ASA I-IV) undergoing surgical interventions (range duration of intervention 30-240 min), in which remifentanil was used according to internal anesthesiologic procedures, have been collected. The most common modality of anesthesia induction is to use a syringe pump to start remifentanil administration. The remifentanil dosage mainly used to start the infusion was 0.2 mg/kg/min (29.2% of patients), as well as at the beginning of maintenance of anesthesia (35.1%)., Results: During maintenance of anesthesia, 36% of surgical interventions did not need changes of remifentanil infusion rate, whereas in the rest of the intervention 1 to 4 changes were done. The induction of anesthesia is predominantly intravenous with concomitant use of propofol and TPS, whereas the agents most frequently used during maintenance were sevoflurane (49.8%), nitrous oxide (43.7%) and propofol (35.2%). Awakening was mainly judged rapid in 93% of interventions; the postoperative pain at awakening was judged nil in 61% of cases and severe in 1.5%. The administration of analgesic treatment mainly started prior to the end of intervention (70% cases)., Conclusion: This Drug Utilisation Research study demonstrated that the use of remifentanil according to its peculiar pharmacological profile, such as potent opioid with rapid onset and offset of action, the synergistic effect with propofol and the right management of post-operative pain are widely consolidated in Italian clinical practice.

Aim: The authors performed a prospective study in a series of patients undergoing combined general and epidural anaesthesia for major abdominal surgery in order to define if the epidural catheter inserted for postoperative analgesia induced in the short-term (7-8 postoperative days) any cytopathologically appreciable inflammatory response., Methods: From April to September 2001, 20 consecutive patients undergoing combined general and epidural anaesthesia for major abdominal surgery at the National Cancer Research Institute and Villa Scassi Hospital (Genoa), were recruited after obtaining Institutional Ethics Committee approval and written consent from the patients. The standard technique for epidural anaesthesia was adopted. Preoperatively, all patients received peridurally a dose test of 3 ml of 2% lidocaine (60 mg) followed by 5 ml of ropivacaine 0.75%, and a continuous infusion of ropivacaine 0.375% (5-10 ml/h; maximal dose=20 ml) intraoperatively. As regards the therapeutic management of postoperative analgesia, patients received a continuous infusion of ropivacaine 0.2% for at least 48 hours and supplemental bolus (2 mg/die) of morphine hydrochloride. The epidural catheter was always removed between the 7th and 8th postoperative day, and it was examined by the pathologist according to the Thin Prep 2000 procedure., Results: The cytopathologic examination of the tip of the epidural catheter gave the following findings: amorphous material without cells (n=10); rare granulocytes and histiocytes (n=6); stromal cells (n=3), and rare lymphocytes (n=1)., Conclusion: We were unable to detect any cytopathologically appreciable inflammatory response at the tip of the epidural catheter which could have suggested the occurrence of inflammation in the epidural tissues. Given the positive results of prophylactic epidural administration of small doses of corticosteroids in the reduction of postepidural anaesthesia back pain and their direct membrane action on nociceptive C-fibers, this kind of backache seems to be related to the stimulations of such nociceptors more than to a catheter-related inflammatory response of epidural tissues with possible evolution in peridural fibrosis, as reported following surgical intervention for lumbosacral disease.

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.

Aim: To evaluate the effectiveness and safety of epidural ropivacaine anesthesia in association with light general anesthesia during renal transplantation and compare epidural and endovenous analgesia techniques for postoperative pain control., Experimental Design: prospective randomized study., Setting: Organ Transplantation Center, Department of Surgery, "Tor Vergata" University of Rome, St. Eugenio Hospital, Rome., Patients: 25 patients affected by chronic renal failure were enrolled in this study. Thirteen constituted the combined epidural-general anesthesia group (EPI-GEN), mean age 40.15+/-9.81 years; while the others constituted the general anesthesia group (GEN), mean age 46.75+/-7.45 years. Operation: cadaveric renal transplantation. Group EPI-GEN: epidural anesthesia performed with 12-15 ml of a ropivacaine 0.75% and fentanyl 5 microg/ml solution followed by light intravenous or inhalatory general anesthesia and postoperative epidural analgesia with ropivacaine 0.2% and fentanyl 2 mg/ml. Group GEN: inhalatory or intravenous general anesthesia and intravenous tramadol postoperative analgesia., Measurements: hemo-dynamics, renal function, arterial blood gases analysis, acid-base balance and postoperative pain data was collected and examined., Results: Postoperative epidural analgesia resulted significantly more effective than intravenous tramadol. PaO(2)/FiO(2) ratio was significantly higher in group EPI-GEN patients both on awakening and throughout postoperative observation. Hemodynamics and renal function did not appear to differ significantly., Conclusion: Combined epidural-general anesthesia is as valid a technique as any for renal transplantation; however postoperative epidural ropivacaine analgesia resulted more effective than intravenous tramadol. Respiratory function appeared less affected, facilitating a fast and uncomplicated postoperative recovery.

Intravenous administration of analgesic drugs is one of the most common ways to control post-operative pain. It can be used in almost all kinds of surgical interventions and particularly those of medium and high complexity. Besides, when other techniques are contraindicated because of clinical and/or managing problems, intravenous way finds its best application. Among analgesic drugs NSAID (ketorolac) and opioids (tramadol, morphine, buprenorphine) are most frequently used. As to administration techniques, elastomeric pump is, according to personal experience, a simple-to-manage, practical and precise device with lower cost respect to other administration set. Elastomeric pump is a single use reservoir that allows continuous administration of drugs with a uniform pre-set infusion speed. Finally, guide-lines, showing pre-load and infusion doses of analgesic drugs, based on pain intensity, are presented.

Life care and quality life control would be considered as important as diagnostic and therapeutic steps. Surgical phase has a particular aspect in oncology, as the patient himself requires a curative intent from surgery (it's generally well known that alternative therapies for solid tumors, such as chemotherapy and radiotherapy, are thought to be extreme remedies during advanced study); in fact surgeons first, focused their attention upon life quality either of hospitalized or discharged patients. The aim of this article is to illustrate themes of clinical practice such as the complex emotional reaction of the patient and the pharmacological support for pain control.

Aim: The aim of this study was to assess postoperative analgesia after preincisional and postincisional administration of remifentanil., Methods: Randomized trial, 24 hours., Setting: University hospital, hospitalized care., Patients: 48 adult patients scheduled for lumbar vertebral surgery., Interventions: in group R5, patients received an infusion of 0.2 microg kg(-1) min(-1) remifentanil over 5 minutes, followed by a break of 15 minutes before anesthesia was started. Anesthesia was induced by infusion of 0.25 microg kg(-1) min(-1) remifentanil and a bolus of 1.5 microg kg(-1) propofol, followed by a continuous infusion of 2 to 3 microg kg(-1) h-1 propofol and 0.25 microg kg(-1) min(-1) remifentanil until end of anesthesia. In group R20, patients received 0.05 microg kg(-1) min(-1) remifentanil over 20 minutes before the induction of anesthesia. In group RL, anesthesia was induced and maintained with propofol. After surgery began, a remifentanil infusion of 0.5 microg kg(-1) min(-1) was given for 50 minutes, then reduced to 0.25 microg kg(-1) min(-1). The total remifentanil doses were similar in the 3 groups., Measures: patients used patient-controlled analgesia (piritramide) for postoperative pain management. They recorded pain on a numeric rating scale every half hour., Statistics: Kruskal-Wallis test, pairwise Mann-Withney U-test, orthogonal polynomials (pain scores)., Results: PATIENTS given postincisional remifentanil (RL) had the slowest decrease in postoperative pain scores (p<0.01) and the highest cumulative piritramide consumption (p<0.08)., Conclusion: The preincisional administration of remifentanil followed by a continuous infusion of 0.25 microg kg(-1) min(-1) appears to reduce pain scores and piritramid consumption when compared with a postincisional regimen.

Authors compare the results of two groups of patients, with III and IV degree haemorrhoids. The first group (48 patients) were treated with traditional surgery, open or closed. The second group (42 patients) treated with stapling haemorrhoidectomy. The groups were compared in order to determine if a true advantage exists regarding post-operative pain and functional recovery. Authors conclude that stapler haemorrhoidectomy, is somehow better in reducing the pain and offers a quick functional recovery. But the technique must be adopted in selected patients with mucosal prolapse, when the haemorrhoidal plexus is below the dentate line. In those cases, with inveterate mucosal prolapse, and thickened external fibrous tissue, or an irreducible prolapse of the external haemorrhoidal plexus, the choice must be carefully evaluated.

Unlabelled: Acute pain treatment after surgery or trauma, when inadequate, contributes to increased morbidity and prolonged in hospital stay. Acute postoperative pain management can be realised by application of treatment protocols and the regular assessment of the patients clinical conditions. The aim of the ACUTE PAIN SERVICE (APS) is to plan postoperative treatment. According to our experience, besides providing assistance, the APS elaborates results and intervenes through regular audits to improve quality. This system is further enriched through collection of information obtained through an anonymous questionnaire compiled by the patients about forty eight hours after surgery. The questions are expressed such to outline a judgement about patients' satisfaction towards the services supplied by the agency., Objective: Evaluation of effectiveness of pain treatment and level of postoperative wellbeing through continuous observation of the patient., Methods: a retrospective study on about 4400 consecutive patients arriving at the APS in the last 2 years of activity, who have been evaluated at fixed moments using various indicators (VAS at rest/activity, PONV and other discomforts)., Results: Follow-up of the patients showed that: - pain relief, when reached, does not conform well-being; - for certain symptoms of discomfort, specific protocols are necessary; - there are correlations between type of surgery, type of anaesthesia and discomfort, which may be reducible through the right attitude in behaviour and therapy; - antalgic therapy itself can cause several side-effects. The solution of the discomfort problem gets close to the concept of perioperative medicine in which APS action goes beyond pain, towards a more complete pain management.

Over the past few years, increasing emphasis has been placed on the need to improve the management of acute pain. Despite a growing trend in acute pain management, many difficulties are still present for the treatment of postoperative pain. Loco-regional techniques together with an effective pain management should accelerate rehabilitation, decrease risk of postoperative complications and speed return to normal activities. A multimodal approach should be used for a reduction of pharmacological side effects, improving pain reduction. The association between NSAIDs and opioids permits reduction of full dose opioids with better pain relief and less side effects. If NSAIDs are contraindicated, acetaminophen is an alternative, though considered by someone to be an NSAID It's action is believed to result from inhibition of prostaglandin synthesis within the central nervous system. It doesn't cause gastrointestinal ulceration or bleeding, but we have to note that large amounts may lead to hepatic necrosis. Newer NSAIDs (COX-2 inhibitors), affect mainly COX-2, and appear to be associated with less adverse effect. Rofecoxib showed a reduction of morphine consuming after spinal fusion and has been admitted by FDA for the treatment of post operative pain. Newer methods of pain relief, as patient controlled analgesia (PCA), can provide excellent and safe pain relief. When high-tech options such as PCA are used, patients need a management by an anesthesiologist-based acute pain service (APS), allowing a better pain relief with less side effects compared to patients supervised by less experienced medical staff.

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.

Background: The use of local anesthesia in non-septic anal surgery is now well established. Tolerance to local injection, duration of local effect and the risk of local or systemic complications still represent unsolved issues. Ropivacaine, a new local anesthetic, seems particularly indicated for this kind of surgery because of its pharmacologic properties which reduce patient's discomfort during infiltration and provide good antalgic coverage in the first hours following the operation., Methods: The first 20 consecutive cases operated with local anesthesia by ropivacaine have been prospectively studied. All patients have been given an 11-point box VAS scale which is used for subjective evaluation of pain., Results: Mean pain score resulted 1.1, 1.6 and 1.4 at 1, 2 and 3 postoperative hours, respectively. Thirty percent of patients subsequently required pain medication up to the first bowel movement. No complications related to the use of ropivacaine has been observed., Conclusions: This new drug can be safely used in the outpatient or Day-Surgery treatment of hemorrhoids.

"Preemptive analgesia" means that analgesia given before the painful stimulus prevents or reduces subsequent pain. The concept of preemptive analgesia originates from basic science and experimental studies. However, in some clinical studies preemptive effect is not always present. The authors think that it happens for: differences among experimental models and clinical reality, wrong use of some pharmacological knowledges, some methodological errors in clinical research. The authors analyze these factors and review in a critical manner clinical studies on preemptive analgesia. In some operations, only one administration of an analgesic drug, before surgery, is not sufficient to produce an evident preemptive effect. Postoperative pain can be reduced making a pharmacological treatment before surgery, for the whole time of painful stimulus. For this reason, the term "preemptive analgesia", like "analgesia given before surgery" is not adequate. The authors suggest that the concept of prevention of postoperative pain is well defined by the term of "balanced periemptive analgesia"; it is a new approach that use many modalities of analgesia in different times to prevent and control painful stimulus for the whole time of its origin: before and/or during operation and, if necessary, in the postoperative period for the residual pain.

Introduction: Personal experience in the treatment of postoperative pain using intrapleural analgesia applied on 50 patients chosen at random in a group of 90 after thoracotomy is reported., Methods: At the end of operation a peridural catheter for continuative infusion was applied in the paravertebral socket by direct transfixion of chest wall. A local anaesthetic has been given (75 mg of bupivacaine 0.50%) through the catheter at 8 hours interval for three times at the most. The degree of analgesia has been valued immediately before and after medicine administration and during the 8 hours interval by recording the cardiocirculatory and haemogasanalytical parameters. The measurement of pain intensity has been achieved by visual analogous just an hour after operation and subsequently every 4 hours during the first post operative day and every 8 hours during the following days., Results: Most of the examined patients (90%), reported a remarkable attenuation of pain, valued by achromatic grey test after 4 hours since the first giving. The catheter has always been removed during the 8th postoperative day and it did not cause intrapleural complications. The method used warrants a good level of analgesia, improving the respiratory per-formance and giving a rapid mobilization, essential items in the reduction of immediate post operative complications., Conclusions: The results confirm the validity of this treatment in the pain control of thoracothomized patients with a positive answer in 45 out of 50 examined patients without remarkable complications.

Objective: To evaluate the effectiveness of a single bolus of epidural (ED) clonidine (C) associated with intrathecal morphine (M) on postoperative analgesia after cesarean section (CS)., Design: Prospective double-blind randomized study., Setting: Obstetric department., Patients: Fourty patients ASA 1-2 submitted to combined spinal-epidural block (CSE) for CS., Interventions: A needle through needle set for CSE was used. The intrathecal block was induced with 2.7-3 ml of isobaric 0.5% bupivacaine (B) and 250 micrograms of M. After ED test with 0.5% B, a single bolus of C 150 micrograms in NS 10 ml (group C, n 20) or NS 10 ml as placebo (group P, n 20) was given through the ED catheter., Methods: The observation for 36 hours evaluated analgesia (VAS until the first dose of additional analgesic, total amount of analgesic and time of first analgesic request) and side effects (variations of arterial pressure and heart rate, motor block, sedation, nausea, vomiting, itching, respiratory depression). Groups were statistically compared., Results: In group C lower analgesic request (significantly between 12th and 18th hour) and significant delay of first request (22.5 +/- 4.1 h) were registered. VAS showed significant trend to opposite sign variations (downwards in group C, upwards in group P) at 1, 2 and 12 hours. In group C lower sistolic arterial pressure at 1 and 4 hours, denser motor block at 2 and 4 hours and mild sedation were observed., Conclusions: A single ED bolus of C 150 micrograms after CS significantly enhances and prolongs the analgesic effect of M 250 micrograms without important side effects.

During the last 10 years the original Pereyra technique of needle bladder neck suspension has been object of more than 36 modifications with the goal to improve long term results and to enhance feasibility. It represents also a part of the so called four corner bladder and bladder neck suspension (anterior suspending sutures) which is at present a reliable and durable manner to manage mild to moderate cystocele; this procedure reestablishes safely and simply support to bladder base, bladder neck and urethra preventing the onset of a denovo stress urinary incontinence. Complications include post-operative pain which could represent a problem in about 16% of the patients: it has been related to the entrapment of the ileoinguinal nerve between prolene sutures and rectus fascia and may be responsible of a delay in the re-establishment of a normal voiding pattern due to the pain elicited during any rectus muscle contraction. We propose a refinement of this procedure which includes the osseous anchoring of the suspending suture through the Mitek G II anchor system. Reduction in postoperative pain and fast recovery of a normal voiding pattern soon after surgery seems to be the most important result of this modification. Osteitis pubis has not been noted. Any improvement in long term durability of the procedure has not yet been determined due to the short follow-up and limited series of cases and the need for subsequent long term follow-up.

The video-thoracoscopic treatment of spontaneous pneumothorax currently has the same role of laparoscopic cholecystectomy in abdominal surgery. The Authors consider thoracoscopic approach and traditional thoracotomy examining advantages versus disadvantages, comparing 50 patients with spontaneous pneumothorax treated by thoracoscopy, from February 1992 up to February 1995, and 50 patients, previously treated by open surgery. Video-thoracoscopy has the same percentage of recurrences of thoracotomic approach but assures a quicker functional recovery and, above all, a remarkable reduction of pain.

The College of Nurses of Trento (Collegio IPASVI) promoted a call for research works done by nurses, to award a prize to those judged worthy. The three best works were respectively on concordance on triage classification between doctors and nurses; on the results of organizational and educational interventions on the reduction of needle-stick injuries; and on the differences on postoperative pain assessment between nurses and patients. The final reports were later discussed as part of a training exercise aiming at improving the skill of scientific writing and they are published here, together with some comments that emphasize areas of improvement in data analysis and interpretation and some broader issues related to nursing research.

Taking the starting point of a trial conducted on female patients who had undergone laparoscopic gynaecologic operations, which shows a good control of the postoperative pain through intraperitoneal infusion of local anaesthetic during the operation, the authors have proposed to reproduce the study on patients undergoing a laparoscopic cholecystectomy. The trial was conducted on two groups, a 50 patients each, undergoing an intraperitoneal infusion of local anaesthetic (bupivacaine) and placebo (physiologic solution) respectively. The results regarding the rate of patients who had felt postoperative pain (88% in the first group, 96% in the second group) and the different places of it, the pain in the right shoulder particularly (28% in the first group, 22% in the second), the intensity in the time and the different requests of analgesics new recorded. The results don't show statistically significant differences and they are different from the gynaecologic ones. The authors suggest, as reasons for these differences, the various moments of the liquid inoculation (at the beginning of the operation in gynaecology, at the end of it in cholecystectomy) and the Trendelemburg position of patients during the gynaecologic operation, on the contrary of cholecystectomy operations. They suggest, in the end, that the trials esecutions on numerically larger groups could bring more significant results.

Background: Since NSAIDs are competitive antagonists of cyclooxygenase, they prevent the biosynthesis of prostaglandins, responsible for enhanced nociceptive sensitization and primary hyperalgesia. If NSAIDs administration is performed after eicosanoids cascade activation by surgical trauma, already released prostaglandins can exert their hyperalgesic effects for a finite time. Therefore prophylactic administration of NSAIDs (pre-emptive analgesia) should improve their effectiveness on acute postoperative pain., Aim of Study: To assess the analgesic effect of preoperatively administered ketorolac, compared with its administration after surgical trauma., Materials and Methods: Thirty adult patients, ASA physical status I-II, undergoing elective septoplasty, were allocated randomly in two groups, depending on timing of i.v. administration of ketorolac 0.4 mg/kg: 10 min before induction (group I); or 5 min after décollement of nasal septum cartilaginoid plan (group II). No other analgesic drugs were given. Postoperative pain was assessed with objective (SAP, DAP, HR) and subjective (VAS, BS 11) methods at 60, 90, 120, 150, and 180 min after the end of surgery. Rate and severity of any side-effect were recorded., Results: Both VAS and BS 11 showed significant better pain relief after preoperative ketorolac at all time, without any adverse effect. Same result was shown by SAP at 60 and 90 min postoperatively., Conclusions: Due to prevention of nociceptive sensitization of prostaglandins released by tissue trauma, prophylactic NSAIDs administration to surgical patients with mild to moderate postoperative pain can improve their antinociceptive effects.

We herein evaluated the analgesic effectiveness of low doses of buprenorphine with or without a primer and the practicality and usefulness of a constant flow disposable infusion set (Infusor Baxter 2 ml/h). Our series consists of 300 patients, seen between January 1992 and December 1993, randomly distributed in three groups of 100 patients each. All patients were informed before operation about the use of pain Visual Analogical Scale (VAS) and how the infusor works. At the end of the operation all patients had an infusor positioned with a 0.01 mg/kg supplied of buprenorphine diluted to 60 ml with Ringer's Lactate solution. In addition to this, group B patients received an i.v. primer of 0.003 mg/kg of buprenorphine diluted to 10 ml with saline solution and group C patients received an i.v. primer of 0.5 mg/kg of ketorolac diluted to 10 ml with saline solution. VAS, systolic arterial pressure, diastolic arterial pressure, heart rate, respiratory rate, request of analgesics and side effects were evaluated at one hour (T0), six hours (T1), 12 hours (T2), 24 hours (T3) and 36 hours (T4) after operation. Group B and C patients showed significant reduction in VAS compared to group A patients at T0 and T1 but the difference disappeared starting from T2. Group B and C patients showed blood pressure, heart rate and respiratory rate values significantly reduced compared to group A patients at T0 and T1. Such values however then stabilized. Side effects encountered were nausea and vomiting in different percentages in the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors herein present their personal series on the clinical evaluation of the analgesic efficacy of 2 opiodes, peridural morphine hydrochloride (0.5 mg/kg) administered to group A patients, and sublingual buprenorphine (0.4 mg) administered to group B patients in the management of post-operative pain in major abdominal surgery. The study was conducted on 44 patients, both male and female, classified as ASA II and III. Statistical analysis of cardiovascular parameters (BP and cardiac frequency), respiratory frequency and pain score showed an overlapping progression among the two groups. Spontaneous pain decreased significantly to zero at T6 (p < 0.001). However, the necessity to administer buprenorphine more frequently after the sixth hour and the consequent increase in side effects, lead us to believe that the method used for group A patients is more advantageous.

The aim of the study was to assess the efficacy of the preoperative sodium Naproxen administration to reduce analgesic requirements in the postoperative period. 75 patients (ASA I-II), 50 male and 25 female, aged between 25 and 70 years and weighed between 50 and 90 kg, undergoing lumbar laminectomy were subjected to the same anesthetic technique. Patients were allocated randomly to one of three groups. Group I received intravenous sodium naproxen (550 mg) immediately after induction of anesthesia. Group II received intravenous sodium Naproxen (550 mg) at the end of surgery. Group III received intravenous normal saline immediately after induction of anesthesia. Postoperative every patient was given by request intramuscular Buprenorphine (0.3 mg) for pain relief (at 6 h intervals). Buprenorphine requirements in the group I were significantly lower than in either of the other groups (p < 0.01 and p < 0.0001 respectively), while significant differences were not observed between group II and III. Moreover the 54% of patients in the group I did not require analgesic drugs in the postoperative period in opposition to the 20% of pts. in the group II and the 12% of pts. in the group III (p < 0.05 and p < 0.01 respectively). We conclude that NSAIDs when given before tissue damage may prevent nociceptor sensitisation and probably reduce hyperexcitability of the spinal cord. Preoperative administration of NSAIDs provides better protection against peripheral nerve sensitisation than postoperative administration.

The efficacy and tolerability of a new pharmaceutical formulation of a non-steroid anti-inflammatory drug, nimesulide were studied in a double blind study in comparison with flurbiprofen and diclofenac sodium, in 150 patients suffering from postsurgical pain-inflammatory symptoms. The three drugs, administered in a dose of one suppository twice a day for 10 days, showed marked anti-inflammatory, analgesic and antipyretic activity and produced a significant, progressive improvement in the typical symptoms of the inflammatory state. Nimesulide evidenced the greatest speed and duration of therapeutic action. Assessment on the efficacy and tolerability as expressed separately by the physician and the patients were positive in almost all cases of the three treatments.

To evaluate the role of internal sphincterotomy with hemorrhoidectomy on postoperative pain, 50 patients with III and IV degree hemorrhoids were subdivided in two groups. Patients of Ist group underwent classic Milligan-Morgan operation; in the IId group, Arnous-Parnaud's hemorrhoidectomy was performed. Ist group's patients needed analgesic in the immediate postoperative period and during hospital stay until clinic healing. IId group's patients needed analgesic only in the first postoperative hour. No significative differences were seen between two groups about mean hospital stay and both clinic and anatomic healing. Two patients of Ist group developed postoperative stenosis and underwent reoperation. Long-term results were good in the two groups of patients. The effectiveness of sphincterotomy on both postoperative pain and prevention of postoperative stenosis is confirmed.

Two-hundred-forty-eight patients undergoing abdominal surgery were admitted to a multicentric clinical trial. The patients were randomly assigned to a single i.v. dose of ketoprofen or acetylsalicylic acid, 15 minutes after the end of operation. Ketoprofen showed a better analgesic activity with a statistically significant difference at 2 and 4 hours after administration. Two patients treated with ketoprofen reported vomiting and skin rash respectively. The results of this study confirm the efficacy of ketoprofen for the prophylaxis of postoperative pain in abdominal surgery.

Twenty eight elderly patients scheduled for urologic surgery were randomly assigned to receive in a double blind fashion subarachnoid hyperbaric bupivacaine 15 mg with the addition of 50 micrograms (group A, n = 7), 25 micrograms (group B, n = 7), 12.5 micrograms (group C, n = 7), of fentanyl or 1 ml of saline (group D, n = 7) for a total volume of 4 ml. The pattern of breathing and the ventilatory response to CO2 were studied before 90, 150, 480 minutes after the subarachnoid injection. In group A mild pruritus and sedation occurred in 5 patients, nausea, vomiting and periodic breathing occurred in 2 patients. In group B mild pruritus and sedation were observed in 4 patients, nausea, vomiting in 2 patients. No significant changes in VE, Vt/Ti and Ti/Ttot were observed between the groups. Patients receiving 50 micrograms of fentanyl showed a slope VE/PET CO2 significantly below baseline values at 90 and 150 minutes (p less than 0.05). In this group the baseline values were restored after 480 minutes. No side effects were observed in group C and D. 25 micrograms fo fentanyl is the only dose with a significant analgesic effect without any respiratory depression.

The adequate treatment for acute patellar dislocation is still controversial. The Authors describe a new surgical arthroscopic technique to repair medial retinaculum rupture, which is the most common lesion in the acute patellar dislocation. Compared to arthrotomy arthroscopic treatment eliminates post-operative pain and shows the same advantages in reducing recurrences.

In a double blind, controlled clinical study, 40 patients, 20 of whom were subjected to mastectomy or quadrantectomy and 20 to inguinal hernioplasty, were randomly assigned to two treatment groups of 20 subjects each, balanced by type of operation. Treatment lasted 3 days and involved the administration of 3 suppositories per day of nimesulide or diclofenac sodium. Independently of the type of operation, a significant reduction in pain symptomatology (spontaneous pain, pain on active and passive movements) and in inflammatory symptomatology (hyperaemia and tumefaction) and a good control of body temperature was observed for both treatment groups. No changes in arterial pressure or laboratory examinations were observed in either group, nor there were any noteworthy adverse reactions.