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BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT03937375 (Clinicaltrials.gov).

Skin grafting is one of the most common surgical procedures in the area of non-healing wounds by which skin or a skin substitute is placed over a wound to replace and regenerate the damaged skin. Chronic leg ulcers are an important problem and a major source of expense for Western countries and for which many different forms of treatment have been used. Skin grafting is a method of treatment that decreases the area of chronic leg ulcers or heals them completely, thus improving a patient's quality of life. Skin grafting is an old technique, rediscovered during the first and second world wars as the main treatment for wound closure. Nowadays, skin grafting has a pivotal role in the context of modern wound healing and tissue regeneration. The aim of this review was to track and to analyse the specific outcomes this technique achieved, especially in the last decade, in relation to venous, arterial, diabetic, rheumatoid and traumatic leg ulcers. Our main findings indicate that autologous split-thickness skin grafting still remains the gold standard in terms of safety and efficacy for chronic leg ulcers; skin grafting procedures have greater success rates in chronic venous leg ulcers compared to other types of chronic leg ulcers; skin tissue engineering, also supported by genetic manipulation, is quickly expanding and, in the near future, may provide even better outcomes in the area of treatments for long-lasting chronic wounds.

Pressure ulcers (PUs) are a common problem in critically ill patients admitted to the intensive care units (ICUs) and they account for more than 70% of patients with low serum albumin at admission. The aim of this study was to test the efficacy of intravenous administration of albumin in patients with low serum albumin < 3·3 g/dl. In a 1-year period, a total of 73 patients were admitted to the ICU (males 45, 61·64% and females 28, 38·36%); of these, 21 patients were admitted with hypoalbuminaemia (serum albumin < 3·3 g/dl) and randomised into two groups: 11 patients were treated with 25 g intravenous albumin for the first 3 days within the first week of ICU stay (group A) and 10 patients did not receive albumin (group B). Three patients (27·27%) showed the onset of PUs in group A, whereas seven patients (70%) showed the onset of PUs within the first 7 days of stay in group B. Moreover, ulcers of group B were more severe than those of group A. This study shows that intravenous administration of albumin reduces the onset of PUs in patients admitted to the ICU and in some cases it also reduces the risk of progression to advanced stages of PUs.

Despite the large choice of wide-spectrum antibiotic therapy, deep sternal wound infection (DSWI) following cardiac surgery is a life-threatening complication worldwide. This study evaluated that the use of platelet-rich plasma (PRP) applied inside the sternotomy wound would reduce the effect of sternal wound infections, both superficial and deep. Between January 2007 and January 2012, 1093 consecutive patients underwent cardiac surgery through median sternotomy. Patients were divided into two groups. Group B, the study group, included those who received the PRP applied inside the sternotomy wound before closure. Group A, the control group, included patients who received a median sternotomy but without the application of PRP. Antibiotic prophylaxis remained unchanged across the study and between the two groups. Occurrence of DSWI was significantly higher in group A than in group B [10 of 671 (1·5%) versus 1 of 422 (0·20%), P = 0·043]. Also, superficial sternal wound infections (SSWIs) were significantly higher in group A than in group B [19 of 671 (2·8%) versus 2 of 422 (0·5%), P = 0·006]. The use of PRP can significantly reduce the occurrence of DSWI and SSWI in cardiac surgery.

Critically ill patients are at high risk of developing pressure ulcers (PUs) and patients who develop PUs remain significantly longer in the intensive care unit (ICU) with significantly increased morbidity and mortality. Therefore, the identification of patients at truly increased risk is important. The aim of this study was to examine the association of low serum albumin present at admission in ICU patients with the onset of PUs. We conducted a retrospective cohort study on 610 patients who were admitted to intensive care unit. Level of serum albumin and other biochemical indices, recorded at the time of admission, were collected. We collected information about PU occurrence after admission and conducted a statistical analysis with biomarkers at ICU admission and during hospital stay. The incidence of PU in the ICUs was 31% and about 70% of patients with PUs had hypoalbuminemia at admission. The lowest values of serum albumin in patients with PUs were directly proportional to the severity of ulcers. In this study, we found a close association between serum albumin and PUs. In fact serum albumin was negatively correlated with PU and may be considered one of the independent determinants of PU occurrence in patients admitted to ICUs.

BACKGROUND: We evaluated the association between the preoperative use of intraaortic balloon pumping and in-hospital and long-term outcomes in high-risk patients undergoing coronary artery bypass grafting. METHODS: From 714 total patients undergoing coronary artery bypass grafting during a 4-year period, we compared the clinical, biochemical, and echocardiographic findings up to 1 year after surgery between 111 patients who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 12 or greater and received intraaortic balloon pumping preoperatively (group A) and 130 patients who had a EuroSCORE of 5 or less and received no preoperative intraaortic balloon pumping (group B). RESULTS: Group A patients were significantly older, had significantly more comorbid conditions, and had a significantly lower mean preoperative ejection fraction (all p < 0.001). Intraoperative data were comparable between groups, as were lactate and troponin I levels sampled from the coronary sinus. Lactate, troponin I, creatine kinase, and creatine kinase-MB mass showed comparable leakage at all postoperative times. The incidences of in-hospital mortality, perioperative myocardial damage, and acute myocardial infarction and duration of hospital stay were comparable. High-risk patients showed significant improvements in ejection fraction (p < 0.001) and wall-motion score index (p = 0.06) after surgery, but low-risk patients showed no significant change in these variables. The incidences of death, recurrent angina, myocardial infarction, and repeat coronary procedures did not differ significantly between groups. CONCLUSIONS: The preoperative use of intraaortic balloon pumping appears to shift high-risk patients undergoing coronary artery bypass grafting into a lower-risk category and is associated with comparable perioperative troponin leakage and short-term and long-term outcomes similar to low-risk patients not receiving intraaortic balloon pumping.

We evaluated the impact of immediate intra-aortic balloon pumping (IABP) on hospital and mid-term outcome of coronary artery bypass graft (CABG) whenever perioperative acute complications developed. We compared clinical, biochemical, echocardiographic in-hospital results and two-year follow-up outcome of 30 low-risk (EuroSCORE

Postoperative troponin I and lactate elevation are related to cardiac complications after myocardial revascularization. We sought to evaluate earlier predictive value for acute myocardial infarction (AMI) and myocardial damage of troponin I and lactate after myocardial revascularization.In all, 183 consecutive isolated myocardial revascularizations were prospectively enrolled in the study. Troponin I and lactate were sampled preoperatively and intraoperatively from the coronary sinus, and at 12, 24, 48, and 72 hours. Hospital outcome was recorded. Receiver operating curves for coronary sinus troponin I and lactate were constructed to differentiate patients with or without AMI and myocardial damage.Acute myocardial infarction developed in 6 patients (3.2%), with higher troponin I and lactate at all time points (p0.05), longer intubation time (p = 0.003), intensive care unit stay (p = 0.001), hospital stay (p = 0.001), higher atrial fibrillation (p = 0.001), and worse ventricular function (p = 0.001). Myocardial damage developed in 6 patients (3.2%), showing higher troponin I at all time points (p0.001), higher intraoperative lactate (p = 0.04), longer intubation time (p = 0.005), and intensive care unit stay (p = 0.03). Receiver operating characteristic curves demonstrated coronary sinus troponin I greater than 0.94 microg/L (area under the curve [AUC] 0.820 +/- 0.075; sensitivity 90.0%, specificity 68.9%) as a better discriminator between patients with or without AMI than lactate level greater than 2.85 mmol/L (AUC 0.686 +/- 0.090; sensitivity 80.0%; specificity 72.9%); troponin I greater than 0.65 microg/L was a better discriminator between patients with or without myocardial damage (AUC 0.834 +/- 0.061; sensitivity 93.8%, specificity 71.5%), than lactate greater than 2.05 mmol/L (AUC 0.627 +/- 0.067; sensitivity 87.5%; specificity 70.7%).Coronary sinus troponin I and lactate are predictive for cardiac complications after myocardial revascularization. Intraoperative biochemical assays should be routinely performed to establish preventative strategies to reduce further myocardial damage.

We describe a case of brain abscesses in a cirrhotic and diabetic 57-year-old woman showing fever, aphasia, right hemiparesis and seizures. Neuroradiological investigation revealed unilateral cerebritis evolving in multiple abscesses. From blood and surgical drainage samples Listeria monocytogenes grew in pure culture. Despite decompressive craniotomy, the patient died two months after hospital admission.

Critically ill patients are at high risk of developing pressure ulcers (PUs) and patients who develop PUs remain significantly longer in the intensive care unit (ICU) with significantly increased morbidity and mortality. Therefore, the identification of patients at truly increased risk is important. The aim of this study was to examine the association of low serum albumin present at admission in ICU patients with the onset of PUs. We conducted a retrospective cohort study on 610 patients who were admitted to intensive care unit. Level of serum albumin and other biochemical indices, recorded at the time of admission, were collected. We collected information about PU occurrence after admission and conducted a statistical analysis with biomarkers at ICU admission and during hospital stay. The incidence of PU in the ICUs was 31% and about 70% of patients with PUs had hypoalbuminemia at admission. The lowest values of serum albumin in patients with PUs were directly proportional to the severity of ulcers. In this study, we found a close association between serum albumin and PUs. In fact serum albumin was negatively correlated with PU and may be considered one of the independent determinants of PU occurrence in patients admitted to ICUs.

Background The elderly (≥65 yr) are more sensitive to anesthetic agents and generally require smaller doses for the same clinical effect, and drug action is usually prolonged [1]. Minimum alveolar anesthetic concentration (MAC), decreases approximately 6% for every decade. There is altered activity of neuronal ion channels associated with acetylcholine, nicotinic and GABA receptors [2]. The elderly require less doses for pain relief. Morphine clearance is decreased in the elderly. Sufentanil, alfentanil, and fentanyl are twice as potent in the elderly, due to an increase in brain sensitivity to opioids with age. There are changes in pharmacokinetics and pharmacodynamics of remifentanil, which is more potent in geriatric patients. Clearance and the volume of the central compartment decrease with age and the infusion rates should be titrated [3]. Cisatracurium undergoes Hofmann degradation and is unaffected by age [4]. In the peripheral nerve blocks the duration of analgesia may be prolonged with age depending on the baricity of the bupivacaine solution. When using 0.75% ropivacaine for nerve blocks, age is a major factor in determining the duration of motor and sensory block. When general anesthesia carries great risk for the patient, administrating regional anesthesia if possible could provide an excellent solution [5].

Delirium and transient neurologic dysfunctions (TND) often complicate the postoperative course after surgery for acute type-A aortic dissection (AAD). We evaluated the role of clonidine on neurological outcome and respiratory function in 30 consecutive patients undergoing surgery for AAD. Patients were prospectively randomized to receive either clonidine (0.5 microg/kg bolus, followed by continuous infusion at 1-2 microg/kg/h) or placebo (NaCl 0.9%) in on starting and throughout the weaning period from the mechanical ventilation. Incidence of delirium and TND, Delirium Detection Score (DDS), weaning parameters [respiratory rate to tidal volume ratio - f/VT; pressure-frequency product (PFP); partial pressure of arterial oxygen to fractional inspired oxygen concentration (PaO(2)/FiO(2)); partial pressure of carbon dioxide (PaCO(2))], weaning duration and intensive care unit (ICU) length of stay were recorded. The two groups were similar for preoperative and operative variables and also for the incidence of postoperative complications. DDS was lower in the clonidine group (P

Hypoxic hepatitis (HH) is a severe complication of postoperative low output syndrome, associated with high mortality rates despite appropriate drug therapy. Recently several extracorporeal supportive techniques have become available. We describe the case of a 70-year-old woman who developed HH secondary to cardiogenic shock after cardiac surgery. CPFA proved to be a valid tool for concomitant hemodynamic support and organ replacement therapy.

Purpose To evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves body perfusion. Methods 158 coronary artery bypass graft (CABG) patients were randomized to linear cardiopulmonary bypass (CPB) (n=71, Group A) or automatic 80 bpm intra-aortic ballon pump (IABP) induced pulsatile CPB (n=87, Group B). We evaluated hemodynamic response by Swan-Ganz catheter, inflammation by cytokines, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate and renal function (estimated glomerular filtration rate (eGFR), creatinine, and incidence of renal insufficiency and failure). Results IABP induced Surplus Hemodynamic Energy was 15.8±4.9 mmHg, with higher mean arterial pressure during cross-clamping (p=0.001), and lower indexed systemic vascular resistances during cross-clamping (p=0.001) and CPB discontinuation (p=0.034). IL-2 and IL-6 were lower, while IL-10 proved higher in Group B (pConclusion Pulsatile flow by IABP improves whole-body perfusion during CPB.

The growing life expectancy has led the elderly to be increasingly referred to coronary artery bypass grafting. Preexisting comorbidities may benefit from theoretical advantages of pulsatile perfusion during cardiopulmonary bypass (CPB).Prospective randomized trial.Cardiac surgery unit in a university hospital.Eighty consecutive patients older than 70 years.Elective coronary artery bypass grafting on CPB, randomizing to conventional linear CPB (40 patients, group A) or intra-aortic balloon pump (IABP)-induced pulsatile CPB (40 patients, group B).We evaluated hemodynamic response by pulmonary artery flotation catheter, metabolic/splanchnic response by lactate and transaminase, bilirubin, amylase, and renal function (creatinine clearance, creatinine, incidence of renal insufficiency and failure), respiratory response by Pao2/Fio2, respiratory compliance, scoring of chest radiograph, intubation time, and need for noninvasive positive-pressure ventilation, hematologic response by chest drainage, hemocoagulative and fibrinolytic cascades, and transfusions. IABP-related complications were recorded. Two minor IABP-related complications (2.5%) were registered. Hemodynamics was comparable, except for a slightly better cardiac index and indexed systemic vascular resistances at the end of CPB and at intensive therapy unit (ITU) admission (p0.05). Transaminases, bilirubin, amylase, proved lower in group B (p0.05 from ITU admission to 48 hours). Creatinine clearance, serum creatinine, and lactate were better in group B (p0.05), and acute renal insufficiency was accordingly lower (p = 0.02). Respiratory response demonstrated better Pao2/Fio2 and respiratory compliance from aortic declamping to 48 hours, with better scoring of chest radiograph (p0.05 from ITU admission to 48 hours), lower noninvasive positive-pressure ventilation (p = 0.002) and intubation time (p = 0.031) in group B. Lower chest drainage (p0.05 at first and second day), transfusions (p0.05), activated partial thromboplastin time, international normalized ratio, white blood cells, and D-dimer (p0.05 from ITU admission to 48 hours), together with higher platelets, fibrinogen, and antithrombin III (p0.05 from ITU admission to 48 hours) were demonstrated in the pulsated group.IABP-induced pulsatile flow significantly improves whole body perfusion in the elderly undergoing CPB.

Mediterranean spotted fever is a rickettsiosis caused by Rickettsia conorii. Mediterranean spotted fever is considered to be a benign disease, however, approximately 10% of patients present with a severe systemic manifestation in which neurologic involvement occurs. We present a case of an 80-year-old man with a R. conorii infection who developed an acute quadriplegia secondary to an axonal polyneuropathy. The characteristic tache noire was observed on the lateral region of the thigh and elevated IgM antibody titres against R. conorii were detected by an indirect immunofluorescence test.

Chronic tension-type headache (CTTH) is a disorder with daily or very frequent episodes of headache, lasting minutes to days, on 15 or more days a month (180 days/year) for at least 3 months. CTTH is a painful and common experience that negatively influences patient's quality of life. The use of complementary and alternative therapies in its treatment is an interesting and growing phenomenon. The aim of the present study was to evaluate the outcomes of patients undergoing manual lymphatic drainage treatment for CTTH. The findings demonstrate that headache patients reported a reduction in pain frequency and intensity.

Preoperative intra-aortic balloon pumping (IABP) improves the results of complex coronary surgery. However, its insertion may be harmful or contraindicated in cases of severe and diffuse atherosclerosis of the descending aorta and peripheral arteries. We sought to evaluate the efficacy and safety of transbrachial insertion of the new 7.5-Fr IABP to support a severely ill patient with eggshell distal aorta and femoro-iliac arteries undergoing coronary artery bypass grafting (CABG).Case report.An 18-bed adult cardiac surgery unit at a university hospital.A 68-yr-old man with ongoing unstable angina, left main disease, and eggshell calcification in the abdominal aorta and iliaco-femoral arteries, needing IABP for CABG.Percutaneous sheathless right transbrachial insertion of 7.5-Fr IABP, followed by CABG.Fluoroscopy and chest radiograph were used to confirm the exact position of the IABP, in the preoperative and postoperative time, respectively. A digital pulse oximeter was applied to monitor distal perfusion. Anticoagulation consisted of nadroparin 4000 IU daily until the second postoperative day, followed by 150 mg of aspirin daily thereafter. Transbrachial IABP support allowed uneventful CABG and postoperative course, without IABP-related complications. Pulse oximetry demonstrated constant good values, the radial artery pulse was always present, and the hand appeared constantly warm. IABP was withdrawn 20 hrs following surgery, and the patient was discharged home on the ninth postoperative day.The miniaturization of IABP, with the recent introduction of a 7.5-Fr balloon catheter, opens the door for the safe, effective transbrachial method of insertion in patients with severe peripheral atherosclerosis.

We read with a great interest the excellent article by Onorati and co-workers demonstrating that pulsatile cardiopulmonary bypass (PCPB) and off-pump coronary artery bypass (OPCAB) surgery markedly reduced endothelial activation and inflammatory response as compared with linear CPB [1]. What about anti-inflammatory cytokines (except interleukin (IL)-10 already investigated in this study)? Studies have demonstrated that both inflammatory/anti-inflammatory cytokines and growth factors/antigrowth factors are released during conventional CPB [2—5]. Anti-inflammatory cytokines and anti-growth factors (sFlt-1) are considered as an anti-inflammatory response against CPB-induced inflammatory changes. The authors might use their collected blood samples to search for IL-4, IL-13, soluble IL-6 receptor and soluble vascular endothelial growth factor (VEGF) receptor (sFlt-1) and to identify whether the anti-inflammatory response is also impaired during PCPB and OPCAB as compared with linear CPB.

Background The use of halogenated anaesthetics in cardiac surgery is still controversial. Preconditioning and postconditioning are the well described mechanisms that explain the protective myocardial effect of specific drugs in order to prevent the occurrence and/or to reduce the size of a necrotic post-ischemic myocardial area [1]: they play a well recognized role in the “protective effect” of the halogenated anaesthetics. Preconditioning and postconditioning protect the myocardial cell from oxidative stress and take place through the activation of specific receptors and second messengers systems [2]. Desflurane has shown a higher preconditioning and postconditioning power that could be optimal at 6% of Minimum Alveolar Concentration (MAC) [3]. The solubility of the halogenated anaesthetics can be altered during cardiac surgery: Desflurane has shown a rapid wash-in and wash-out profile in cardiac “on pump” surgery [5,6].

Background Alpha-2 adrenergic agonists reduce mortality and myocardial infarction following vascular and cardiac surgery [1]. Few data exist about the weaning phase in this setting.

Background In cardiac surgery patients, hyperglycemia was found to be an independent post-operative risk factor for the development of hyperlactatemia and associated with increased morbidity and mortality [1].

Background Pain is one of the complications that most often interfere with patient discharge after interventions performed on a day surgery basis. During the first postoperative hours, up to 40% of patients may experience moderate or severe pain, leading to delayed discharge or unplanned overnight hospitalization [1,2]. The use of a multimodal postoperative treatment plan is recommended. The combined effects of NSAIDs and/or paracetamol, weak opiates (codeine, tramadol) and local anesthetics administered and/or injected by various routes during the perioperative phase should be take in account. To permit rapid discharge, the possible use of NSAIDs with a prevalent impact on COX-1 and potent opioids at recommended therapeutic doses should take into account potential adverse effects (gastric bleeding and/or bleeding of the surgical wound site, NSAIDs induced renal damage, respiratory depression, delayed canalization, nausea, vomiting, excessive sedation, difficulty in urinating, pruritus induced by potent opioids, postoperative hyperalgesia resulting from elimination of rapid half-life intraoperative opioids such as alfentanil and remifentanil) [1-3].

Introduction The pathophysiology of sepsis consists of two phases. A first phase characterized by a substantial increase of pro-inflammatory mediators including cytokines and systemic inflammatory markers, and a second phase (immunoparalysis, immunodysregulation) associated with the rise of anti-inflammatory mediators. In this study we prospectively analyzed 52 consecutive patients with diagnosis of systemic inflammatory response syndrome (SIRS) at hospital admission to evaluate prognostic and early diagnostic performance of interleukin-10 (IL-10), soluble CD25 (sCD25) and interferon-γ (IFN-γ) and to confirm the prognostic accuracy of the sequential organ failure assessment (SOFA) score. Methods Patients were divided in two groups (group 1, n = 28 patients with bacteremic SIRS and group 2, n = 24 patients with non-bacteremic SIRS) and then stratified into survivors (n = 39) and nonsurvivors (n = 13). Serum markers were evaluated on the day of hospital admission (D-1) and on the 7th day of hospital stay (D-7). Concentration of sCD25 was evaluated by a sandwich ELISA kit. Levels of IL-10 and IFN-γ were quantified by a cytokine biochip array by the evidence investigator analyzer. Differences between groups were established by the Mann-Whitney test. Accuracy, sensitivity and specificity of diagnostic markers were evaluated by the receiver-operating characteristic curve analysis. Multivariate analysis was carried out to evaluate whether studied biomarkers are independent predictors of poor outcome in prognosis, and of bacteremic SIRS in diagnosis. Results IL-10, sCD25 and SOFA scores of survivors and nonsurvivors were significantly different both at D-1 (P = 0.0014; P = 0.014 and P = 0.0311 respectively) and at D-7 (P = 0.0002, P = 0.014 and P = 0.0012 respectively). Between the above groups IFN-γ level was significantly different only at D-7 (P = 0.0013). Moreover IL-10 and sCD25 were significantly higher in bacteremic versus non-bacteremic SIRS patients at D-1 and at D-7 (P < 0.05). IFN-γ values showed a significant decrease (P < 0.05) in patients of group 1 only at D-7. The diagnostic accuracy of IL-10 and sCD25 was confirmed by the analysis of the AUROCC at D-1 and D-7 respectively. Multivariate analysis revealed that sCD25 and IL-10 are independent predictors of a poor outcome for our patients during the first day of hospital admission. Conclusions IL-10 and sCD25 gave a significant contribution to prognostic evaluation and early diagnosis of bacteremic SIRS. SOFA score appeared to be a reliable prognostic tool in this subset of patients.

Background Older adults are a heterogeneous group but generally have a higher peak and longer duration of action from opioids. Monitoring cumulative effects from analgesics is particularly important for older adults [1]. Older adults should be first asked to describe their hurting or pain in their own words. Pain intensity should be measured with a consistent scale, after making sure that the individual understands the scale [2]. The pain thermometer, verbal description scale, and faces pain scale have all been used successfully with older adults, but older adults tend to have difficulty accurately reporting their pain with the 100-millimeter visual analog scale. Postoperative pain assessment during movement provides a more accurate pain measure than assessment at rest. Cognitively impaired older adults capable of verbal communication are generally able to report their pain and report pain intensity similar to cognitively intact individuals [3]. It might be necessary to try different pain scales if the older adult does not respond to the initial pain scale. Cognitively impaired older adults demonstrate more nonverbal pain behaviour on movement than those who are cognitively intact [4]. Family members can often identify behaviours indicative of pain in cognitively impaired older family members.