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Abstract Background Postoperative administration of paracetamol or its prodrug propacetamol has been shown to decrease pain with a morphine sparing effect. However, the effect of propacetamol administered intra-operatively on post-operative pain and early postoperative morphine consumption has not been clearly evaluated. In order to evaluate the effectiveness of analgesic protocols in the management of post-operative pain, a standardized anesthesia protocol without long-acting opioids is crucial. Thus, for ethical reasons, the surgical procedure under general anesthesia with remifentanil as the only intraoperative analgesic must be associated with a moderate predictable postoperative pain. Methods We were interested in determining the postoperative effect of propacetamol administered intraoperatively after intraoperative remifentanil. Thirty-six adult women undergoing mammoplasty with remifentanil-based anesthesia were randomly assigned to receive propacetamol 2 g or placebo one hour before the end of surgery. After remifentanil interruption and tracheal extubation in recovery room, pain was assessed and intravenous titrated morphine was given. The primary end-point was the cumulative dose of morphine administered in the recovery room. The secondary end-points were the pain score after tracheal extubation and one hour after, the delay for obtaining a Simplified Numerical Pain Scale (SNPS) less than 4, and the incidence of morphine side effects in the recovery room. For intergroup comparisons, categorical variables were compared using the chi-squared test and continuous variables were compared using the Student t test or Mann-Whitney U test, as appropriate. A p value less than 0.05 was considered as significant. Results In recovery room, morphine consumption was lower in the propacetamol group than in the placebo group (p = 0.01). Pain scores were similar in both groups after tracheal extubation and lower in the propacetamol group (p = 0.003) one hour after tracheal extubation. The time to reach a SNPS < 4 was significantly shorter in the propacetamol group (p = 0.02). The incidence of morphine related side effects did not differ between the two groups. Conclusions Intraoperative propacetamol administration with remifentanil based-anesthesia improved significantly early postoperative pain by sparing morphine and shortening the delay to achieve pain relief.

Stroke occurring during pregnancy is linked to high mortality. Stroke may be directly related to pregnancy (e.g. eclampsia, cerebral venous thrombosis), but all the other causes of stroke are possible. Brain magnetic resonance imaging that is not contraindicated during pregnancy remains the reference in this context. We report the case of a woman with severe headache associated with visual disturbances, without hypertension or proteinuria at 32 weeks of pregnancy. MRI revealed multiple recent cerebral vascular accidents. An echocardiogram detected a papillary fibroelastoma of 5mm. Maternal fetal experts determined it safe to continue the pregnancy. Childbirth at 39 weeks was normal uneventful for the newborn and mother. In the postpartum, despite the theoretical operative indication to resect the small residual papillary fibroelastoma, the patient was followed expectantly because of the stable neuro-cardiologic state. A fibroelastoma can be revealed by a stroke during pregnancy. In the postpartum period, an expectant attitude can be reasonably chosen in case of small size of the fibroelastoma., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objectives: To evaluate postoperative pain management (POPM) practices by anesthesiologists caring for patients with chronic kidney disease (CKD)., Design: Prospective one-time survey endorsed by the French Society of Anesthesia and Intensive Care (SFAR)., Setting: A self-administered online questionnaire was distributed to members of SFAR nationally., Participants: Three hundred seven SFAR members participated in the study., Intervention: Close-ended questions concerned: standard test used to assess renal function, analgesic agent selection and dose adjustment based on the CKD functional stage, and the availability of standard operating procedures., Main Outcomes Measures: The primary end-point was to identify the most frequently prescribed analgesics in case of CKD, variations in practice based on different stages of CKD, and drug dosing adjustments. The secondary end-point was to identify the most commonly used tests to evaluate kidney function., Results: The most commonly used postoperative analgesics were paracetamol (acetaminophen) and morphine. The most commonly used opioid was morphine, relative to oxycodone and sufentanil. Modification of diet in renal disease (MDRD) and Cockcroft equations were used by 39 and 40 percent of anesthesiologists, respectively, to measure kidney function. Six percent of anesthesiologists declared following standard operating procedures for POPM in patients with CKD., Conclusions: There is considerable variability in POPM practices for patients with all stages of CKD. Morphine is favored even in end-stage renal disease. Departments of anesthesiology are insufficiently involved in drafting standard operating procedures.

Introduction: The treatment of postradical prostatectomy erectile dysfunction (post-RP-ED) and stress urinary incontinence (post-RP-SUI) may require the combined implantation of a penile prosthesis and incontinence surgery. However, there is a lack of consensus regarding which incontinence surgery should be associated with a penile implant., Aims: To evaluate the combined implantation of a penile prosthesis and the adjustable continence therapy ProACT in patients with post-RP-ED and post-RP-SUI., Methods: We implanted the ProACT device and a penile prosthesis synchronously (n = 6) and asynchronously (n = 4) in 10 patients with moderate post-RP-SUI and severe post-RP-ED. We evaluated the effects on urinary incontinence using the ICIQ and PGI-I scores and pad use. We evaluated the effect on sexual function using the EHS and Global Assessment Questionnaire (GAQ), and we evaluated satisfaction with the penile prosthesis on a 5-point scale. Postoperative pain associated with each procedure was evaluated by a numeric rating scale., Results: No cases of urinary retention or prosthesis infection were observed. Postoperative pain was mainly related to penile prosthesis implantation. After a mean follow-up of 22.7 ± 20.9 months (range: 6-53), significant improvements of the ICIQ score (15.3 ± 3.7 vs. 4.7 ± 2.3, P < 0.001) and pad use per day (2.8 ± 1.2 vs. 0.3 ± 0.5, P < 0.001) were observed compared with baseline. According to the PGI-I questionnaire, eight patients described a very much improved (n = 6) or much improved (n = 2) urinary condition. All patients declared an EHS = 4 with the use of penile prosthesis; all patients were very satisfied (n = 6) or satisfied (n = 4) with their penile prosthesis. All patients answered the GAQ positively., Conclusion: The combined implantation of a Pro-ACT device and penile prosthesis represents a feasible therapeutic option in patients with post-RP-SUI and post-RP-ED. The absence of postoperative pain associated with the ProACT procedure may represent the main interest in this therapy., (© 2015 International Society for Sexual Medicine.)

Introduction: Intracavernous alprostadil injection (IAI) is a widely used treatment for sexual rehabilitation (SR) after radical prostatectomy (RP). It is unknown whether the continuation of IAI beyond 1 year continues to improve erectile function., Aims: To assess evolution of sexual function in patients using IAI who are nonresponsive to phosphodiesterase type 5 inhibitors (PDE5i) between 12 (M12) and 24 (M24) months after RP., Methods: We retrospectively studied 75 men with a nerve-sparing laparoscopic RP, who had normal preoperative erectile function, and who regularly used IAI for SR for at least 24 months. At M12, no patients had responded to PDE5i., Main Outcome Measures: At 12 and 24 months, sexual function was assessed with the UCLA Prostate Cancer Index (UCLA-PCI), International Index of Erectile Function (IIEF)-15, and erection hardness score (EHS) with and without IAI. We also assessed the satisfaction rate with IAI, injection-related penile pain, and satisfaction of treatment. Statistical analysis was performed by using t-tests for paired data and Spearman's rho correlation coefficients to assess the relationships between scores at M12 and M24., Results: Improvement of nocturnal erection was noted (UCLA-PCI, question 25); however, no significant difference was found for IIEF-erectile function with (19.60 ± 9.80 vs. 18.07 ± 10.44) and without IAI (4.63 ± 2.93 vs. 4.92 ± 4.15), UCLA-PCI-sexual bother (37.14 ± 21.45 vs. 37.54 ± 19.67), nor the EHS score with (2.97 ± 1.30 vs. 2.57 ± 1.30) and without IAI (0.67 ± 1.11 vs. 0.76 ± 0.10). The rate of satisfaction with treatment decreased over time (66.6% vs. 46.7%, P = 0.013). Improved response to IAI at M12 was not correlated to improvement in spontaneous erections at M24., Conclusion: The response to IAI remained stable after 2 years of treatment, and no significant improvement of spontaneous erections during intercourse attempts was found between M12 and M24. Patients should be informed of the limited effect of IAI on natural erections after 1 year. Yiou R, Bütow Z, Parisot J, Binhas M, Lingombet O, Augustin D, de la Taille A, and Audureau E. Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year? Sex Med 2015;3:42-48.

Aims: To evaluate pain and embarrassment associated with invasive urodynamics and to determine underlying factors., Methods: One hundred seventy one consecutive patients referred to our department for invasive urodynamics were evaluated using visual numeric rating scales for sensations of apprehension, pain, and embarrassment during several steps of the procedure (scores ranging from 0 [no symptom] to 10 [worst imaginable symptom]). We also investigated the influence of sex, age, information provided before urodynamics, and medical indication on these sensations. The Spearman correlation, non-parametric test, and logistic regression analysis were performed to determine explicative factors for the most painful sensations., Results: The mean age was 61.0 (standard deviation ± 15 years). The mean (95% confidence interval [CI]) apprehension level was 2.9/10 (2.4; 3.4). The mean (95% CI) pain levels at installation on urodynamic table, transurethral catheter insertion (cystometry), and catheter repositioning (urethral pressure profilometry) were 0.3/10 (0.1; 0.5), 1.9/10 (1.6; 2.3), and 1.3/10 (1.0; 1.7), respectively. At catheter insertion, 25% of patients reported a pain level ≥ 4/10. The mean embarrassment level due to urination in front of the doctor was 1.9/10 (1.4; 2.3). Painful sensations reported during the different steps were strongly correlated with each other and with levels of apprehension and embarrassment. Age <54 years (lower quartile) and apprehension level were the only factors associated with painful sensation., Conclusions: Our study confirms that invasive urodynamics is a well-tolerated procedure. However, some patients experience high levels of pain and embarrassment throughout the procedure. Younger age and apprehension were the most influential factors., (© 2013 Wiley Periodicals, Inc.)

Objective: The European Society for Clinical Nutrition and Metabolism (EPSEN) guidelines on nutrition for liver disease patients has been recently updated. The aim of our study was to evaluate perioperative nutrition in cirrhotic patients waiting for liver transplantation (LT)., Study Design: Prospective electronic survey. A standardized questionnaire was sent to the anaesthesiologist of the 18 French adult LT centers. The questionnaire had closed-ended questions to evaluate nutritional practices in cirrhotic patients waiting for a LT., Results: The response rate was 100%. Nutritional status of the cirrhotic patients waiting for LT was assessed by anaesthesiologists (12 centres) and/or hepatologists (11 centres) and more rarely by nutrition physician, dietetics or liver surgeons. Body mass index (13 centres), weight loss (10 centres), albuminemia (10 centres) were the most frequent items used to assess the nutritional status. Before LT, preoperative oral intakes were administered in undernourished patients in only 55% of the cases. Postoperatively, nutritional support was administered between day 1 and 3 after LT., Conclusion: Perioperative nutritional practices in cirrhotic patients waiting for LT are heterogeneous between centers, especially about nutrition assessment. Most of the centres did not follow the actual guidelines., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Objectives: To evaluate the short medium and long-term impact of a quality-improvement program (QIP) in a university hospital using a validated reference tool., Methods: Seven surgical departments were audited before and after implementation of a QIP in postoperative pain management. Audits were conducted in 2005, 2007, 2009 and 2012. In each audit, 10 medical charts from each surgical department were analyzed for 9 quality criteria. A surgical department score (SDS) was calculated for each department (maximum score=90). The surgical departments with a SDS<45 received targeted training sessions., Results: In 2005, three surgical departments had a SDS<45. After the first audit, a targeted training sessions was conducted in the three surgical departments, all seven departments improved their scores with a SDS>45 in 2007. Between 2007 and 2009, all seven departments improved their scores. Conversely, between 2009 and 2012, the SDS diminished in six of the seven surgical departments and four of the nine evaluated quality criteria decreased significantly: right detailed order for postoperative pain analgesia (prescriber identifier, agent used, unit doses, mode of administration; 100% versus 53; P=0.027), appropriate dosing of steps I and II analgesics (96% versus 80%; P=0.041), morphine (90% versus 76%; P=0.039), based on corresponding physician orders and monitor morphine side effects (87% versus 29; P=0.027)., Conclusion: Audits should be performed regularly (at least every two years) for detecting postoperative pain management degradation. Lack of targeted training sessions can explain partially this degradation., (Copyright © 2012. Published by Elsevier SAS.)

Background and Objective: Local wound infiltration is a component of multimodal postoperative (p.o.) analgesia. Its implementation in current clinical practice remains unknown. Pain and Regional Anesthesia Committee of the French Anaesthesia and Intensive Care Society (Sfar) aimed to appraise its practice., Method: Postal sample survey based on representative sample of national activity were sent to heads of anaesthesiology departments. The questionnaires included 36 items on single-shot and continuous wound infiltrations (CWI) with considerations about modality of administration, drugs and development limitations. Results in mean [CI95 %]., Results: Response rate was 32 % (n=120). Sample was in accordance with national representation of health institutions. Local infiltration was included in 85 % [79-91] of the p.o. analgesia protocols. Regardless of the surgery, single-shot wound infiltration and CWI were used in more than 50 % of the patients by respectively 58 % [49-67] and 18 % [11-25] of the responders. However, a significant part of the surgeons remained reluctant to CWI. Lack of information and fear of septic complications were the most reported barriers. Peritoneal instillation after laparoscopy was rarely performed, in contrast with intra-articular infiltration after knee arthroscopy, performed systematically or very frequently by 60 % [50-70] of the responders., Conclusion: The practice of local wound infiltration for p.o. analgesia seems presently well established, especially for single-shot injections. CWI is less commonly performed. Several surgical reluctances remain to be overcome. Better information about effectiveness and safety are likely to still improve their practices., (Copyright © 2011 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Introduction: Intracavernous alprostadil injection (IAI) is widely used for sexual rehabilitation (SR) after radical prostatectomy (RP). However, the rate of spontaneous erection recovery with IAI remains unclear, and IAI causes pain that may hinder SR., Aims: To assess SR in IAI users after RP and to evaluate the course and impact on SR of postinjection penile pain., Methods: We prospectively studied 87 patients who underwent nerve-sparing laparoscopic RP, reported normal preoperative erectile function, and used IAI for 12 months. Patients started with 2.5 µg alprostadil and were advised to increase the dose gradually until erection hardness allowed vaginal penetration., Main Outcome Measures: At 6 and 12 months, the International Index of Erectile Function (IIEF-15) and Erection Hardness Score (EHS) were determined with and without IAI, and injection-related penile pain was assessed using a numeric rating scale. Correlations linking penile pain, IIEF-15, and EHS scores were evaluated., Results: The mean alprostadil dose was 8.1 µg after 6 months and 9.9 µg after 12 months. With/without IAI, mean IIEF-15 scores for erectile and orgasmic function and mean EHS score were 14.6/4.6, 4.1/2.1, and 2.5/0.4, respectively, after 6 months; and 17.2/5.4, 4.9/2.6, and 2.7/0.9 after 12 months. Pain scores were 3.2±2.5/10 and 2.5±2.5/10 after 6 and 12 months, respectively. Pain intensity correlated with erectile function (r=-0.23), intercourse satisfaction (r=-0.23), and overall satisfaction (r=-0.24) after 6 months but not after 12 months. Follow-up was short and only patients who used IAI for 12 months were included., Conclusions: In patients who were willing and able to use IAI, erectile function improved after 1 year but remained below preoperative levels. The adverse impact of pain on SR was significant during the first 6 months and diminished over time. These data may help to counsel IAI users with painful erections., (© 2010 International Society for Sexual Medicine.)

We audited the seven surgical departments of a university hospital before and after implementation of a program aiming to improve practices in postoperative pain management (POPM). Audits were conducted 2 years apart. During each evaluation, 10 medical charts from each surgical department (i.e., 70 charts) were analyzed for 9 quality criteria (five concerning anesthetist practices and four nursing practices). Two scores were calculated: one per department and the other per criteria. After the first audit, the seven departments received recommendations to improve their POPM. Targeted-training sessions were instituted for the three poorest performing departments (scores <4.5 out of 9 criteria). During the period between the two audits, all seven departments improved their scores; a statistically significant improvement was observed in five departments, including the three that had received targeted-training sessions. Moreover, overall scores for seven of the nine evaluated criteria improved, significantly for three criteria. Anesthetists significantly increased their overall score from 2.5 ± 0.8 to 3.7 ± 0.6 out of 5 points (p=.018), while surgical nurses' overall score did not change significantly from 2.3 ± 0.7 to 2.9 ± 0.7 out of 4 points (p=.128). In conclusion, using a standardized and validated instrument to evaluate POPM practices enables the identification of surgical departments requiring practice improvement and those quality criteria requiring reinforcement., (© 2010 National Association for Healthcare Quality.)

After having noted that 25% of prescriptions were not respected by nurses, the Henri-Mondor university hospital in Creteil (AP-HP, 94), carried out an investigation to understand the causes. The results were then circulated to doctors and nurses in order to establish best practice recommendations.

Introduction: Patient satisfaction regarding postoperative pain management (POPM) is not always correlated with pain level relief., Objective: To evaluate the percentage of satisfied patients while splitting satisfaction related with nurses, anaesthesiologists and surgeons during 48h postoperative period., Patients and Methods: The study was performed in 2007 by two investigators in six different surgical suites in a university hospital. Approximatively 15 patients have been randomly selected in each surgical ward. Each patient received during the first or second postoperative day an anonymous questionnaire and was required to complete it with the investigator assistance if necessary. Questions requiring a yes-or-no reply assessed the patient's satisfaction with POPM performed by nurses, surgeons, and anaesthesiologists. In case of dissatisfaction, patients were invited to explain the reasons., Results: Ninety-two patients were included, 5% of the patients were not satisfied with nurse POPM and nearly 15% were not satisfied with anaesthesiologist or surgeon POPM. The main reasons of dissatisfaction with nurses were the excessive delays between requesting and receiving an analgesic and because of the significant discrepancies in POPM between nurses. Patient discontent regarding surgeons was explained by the lack of interest of the latter for POPM. Patient discontent regarding anaesthesiologists was explained by the lack of anaesthesiologist visit in the postoperative period., Conclusion: There is a relationship between patient dissatisfaction and the lack of attention for POPM by surgeons and the lack of postoperative visit by the anaesthesiologist. A postoperative visit by a team of anaesthesia nurses should improve patient satisfaction with POPM.

Severe postsurgical pain contributes to prolonged hospital stay and is also believed to be a risk factor for the development of chronic pain. Locoregional anesthesia, which results in faster patient recovery with fewer side effects, is favored wherever feasible, but is not applicable to every patient. Systemic analgesics are the most widely used method for providing pain relief in the postoperative period. Improvements in postoperative systemic analgesia for pain management should be applied and predictive factors for severe postoperative pain should be anticipated in order to control pain while minimizing opioid side effects. Predictive factors for severe postoperative pain include severity of preoperative pain, prior use of opiates, female gender, non-laparoscopic surgery, and surgeries involving the knee and shoulder. Pre- and intraoperative use of small doses of ketamine has a preventive effect on postoperative pain. Multimodal or balanced analgesia (the combined use of various analgesic agents) such as NSAID/morphine, NSAID/nefopam, morphine/ketamine improves analgesia with morphine-sparing effects. Nausea and vomiting, the principle side effects of morphine, can be predicted using Apfel's simplified score; patients with a high Apfel score risk should receive preemptive antiemetic agents aimed at different receptor sites, such as preoperative dexamethasone and intraoperative droperidol. Droperidol can be combined with morphine for postoperative patient-controlled anesthesia (PCA). When PCA is used, dosage parameters should be adjusted every day based on pain evaluation. Patients with presurgical opioid requirements will require preoperative administration of their daily opioid maintenance dose before induction of anesthesia: PCA offers useful options for effective postsurgical analgesia using a basal rate equivalent to the patient's hourly oral usage plus bolus doses as required.

Context: Care-related pain includes pain occurring during transportation, movement, diagnostic imaging, physical examination, or treatment. Its prevalence has never been assessed in a large adult inpatient population., Objective: To identify the procedures likely to induce or increase pain in hospital patients, attempting to separate the most painful from those reported as most frequently inducing pain., Design: A single-day cross-sectional survey conducted in two large French teaching hospitals, including all hospitalized patients, free of communication problems. One third was randomly selected and interviewed about the painful episodes that had occurred or were associated with the procedures performed during the previous two weeks. Patients were interviewed using a structured questionnaire., Results: Six-hundred-eighty-four patients were randomly selected. Six-hundred-seventy-one painful events were reported in 55% of the patients, with an average of 1.8 events/patient. Fifty-two percent of the painful events were associated with procedures performed by non-medical staff; 38% of the painful episodes occurred during procedures involving vascular puncture and 24% during patients' mobilization. In 57% of painful procedures, pain was rated as severe or extremely severe. The most painful procedures were invasive procedures, other than vascular and non vascular punctures (74% of severe and extremely severe painful episodes). Maximum pain intensity was rated higher for procedures that were repeated than for those experienced only once (62% versus 53%, p=0.02)., Conclusion: This survey gives new insight into our daily practice. Proper management of care-related pain should be a major concern of all hospital staff to improve the quality of our health care.

Objective: The World Health Organization (WHO) published guidelines to improve cancer pain control which allow to relieve noceptive cancer pain in 80% of adult patients. Nevertheless WHO recommendations do not include: various ways to start morphine treatment, how to manage opioids adverse effects, severe cancer pain management, postoperative pain and procedure-relatived pain. The goal of this review is to discuss these issues., Data Sources: The data were retrieved from PubMed years 2001 to 2006 (keywords used alone or in combination were: opioids, cancer, pain, pain killers, rotation, intraspinal, ketamine, side effects), the "Standard, Options and Recommendations on cancer nociceptive pain treatments for adult patients" published by the French Union of Comprehensive Cancer Centers (FNCLCC; Fédération nationale des centres de lutte contre le cancer) and the European Association for Palliative Care (EAPC) recommendations on morphine and alternative opioids in cancer pain. Data also include an analysis of studies before 2001 which give information about the pharmacokinetic data of transdermal and transmucosal fentanyl., Study Selection: Studies written in English or French related to the medical treatments (commercialized in France) for nociceptive cancer pain for adult patients were analyzed. Analyzed articles were clinical or experimental studies or metaanalyses. Studies on neuropathic cancer pain, editorials and letters to the editor were discarded., Results: Nociceptive cancer pain is characterized by its frequent instability. More than 50% of patients have paroxystic painful accesses (PPA), either spontaneous or induced by care or mobilizations. Morphine is the main treatment but the prescription of controlled-release morphine must be associated with the prescription of immediate-release morphine to treat the PPA or to transmucosal fentanyl which has a faster onset of action than immediate-release morphine. Morphine treatment can be introduced either by immediate-release morphine or by controlled-release morphine. The introduction of immediate-release morphine is recommended for old or fragile patients, patients with denutrition, hepatic or renal failure. For patients suffering unbearable side effects under morphine or morphine resistant pain, opioid rotation or intravenous morphine or fentanyl are recommended. Spinal opioids administration (by epidural or intrathecal routes) is most often indicated in patients with very severe and resistant pain in terminal disease. In the postoperative period, previous pain treatment must be maintained or increased. Pain bounded to care procedures must be prevented with various and associated treatments: for example, mixed topics lidocaïne-prilocaine for venous or arterial punctures; infiltration of local anaesthetics and inhalation of an oxygen - nitrous oxide mixture for medullary biopsies., Conclusion: Oral immediate or controlled release morphine is the most common and effective pain treatment for most patients with nociceptive cancer pain but rotation with other opioids or alternative routes of administration must be discussed quickly if pain persits or if adverse effects occur.

Background: The authors conducted a patient-based survey of practices to fully describe the assessment and the management of pain and sedation of a large cohort of mechanically ventilated patients during their first week of intensive care unit (ICU) stay., Methods: A total of 1,381 adult patients were included in a prospective, observational study in 44 ICUs in France. Pain and sedation assessment, analgesic and sedative use, and analgesic management during procedural pain were collected on days 2, 4, and 6 of the ICU stay., Results: The observed rates of assessment on day 2 for sedation (43%) and analgesia (42%) were significantly smaller than that of use of sedatives (72%) and opioids (90%), also noted on days 4 and 6. The use of protocols/guidelines for sedation/analgesia in the ICU reduced the proportion of patients who were treated, although not evaluated. A large proportion of assessed patients were in a deep state of sedation (40-50%). Minor changes in the dosages of the main prescribed agents for sedation (midazolam, propofol) and analgesia (sufentanil, fentanyl, morphine, remifentanil) were found across 6 days of the patient's ICU stay. Procedural pain was specifically managed for less than 25% of patients; during those procedures, the proportion of patients with pain significantly increased from the baseline pain evaluation., Conclusions: Excessively deep states of sedation and a lack of analgesia during painful procedures must be prevented. To facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it seems crucial to promote educational programs and elaboration of protocols/guidelines in the ICU.

Objective: Pain management in patients having a subarachnoid haemorrhage was assessed in French intensive care unit of neurosurgical centres., Study Design: Nationwide survey., Methods: A standardized postal questionnaire was sent to senior doctor of every neurosurgical centres in France inquiring pain scores assessment, analgesics used and their routes of administration, centre's opinion about efficacy of pain management., Results: Of the 34 centres, 24 returned completed questionnaires. Fifty four per cent of the centres evaluated pain intensity with a non valid pain score. In the case of patients in the comatose, pain was not evaluated in fifty four per cent of the centres. Paracetamol and morphine were the most currently used analgesics drugs. Morphine was administered subcutaneously by 75% of the centres. Six centres used also PCA. Thirty-seven percent of the centres were reluctant to use opioids and 75% to use NSAIDS., Conclusion: The majority of the centres considered pain management in patient suffering from subarachnoid haemorrhage (SAH) was not optimal and stressed the need to establish a well validated pain rating scale dedicated to SAH patients.

The << Standards, Options and Recommendations >> (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French cancer centres, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. Objectives : To establish the Standards, Options and Recommendations clinical practice guidelines for the management of procedure related pain (lumbar puncture, bone marrow aspiration or biopsy, blood sampling) in adult oncology patients. To define, on the basis of the critical appraisal of the best available evidence and expert agreement, the clinical situations in which a pain preventive strategy should be implemented. Methods. Medline(R) was searched using specific search strategies from January 1966 to August 2003. Literature monitoring was performed to identify controlled clinical trials published between August 2003 to September 2004. In addition several Internet sites were searched in July 2003. Results. A total of 12 references, corresponding to 10 randomised clinical trials, were identified. Clinical guidelines have been defined for each invasive procedure.