__________________________________________________________________ __________________________________________________________________ ISSN 1080-3521 EDUCATIONAL SYNOPSES IN ANESTHESIOLOGY and CRITICAL CARE MEDICINE - Italia - Il giornale italiano on line di anestesia Vol 6 No 10 OTTOBRE 2001 __________________________________________________________________ __________________________________________________________________ Pubblicato elettronicamente da: Vincenzo Lanza, MD Servizio di Anestesia e Rianimazione Ospedale Buccheri La Ferla Fatebenefratelli Palermo, Italy E-mail: (lanza@mbox.unipa.it) Keith J Ruskin, MD Department of Anesthesiology Yale University School of Medicine 333 Cedar Street, New Haven, CT 06520 USA Office: 203-785-2802 E-mail: ruskin@gasnet.med.yale.edu Copyright (C) 1996 Educational Synopses in Anesthesiology and Critical Care Medicine. All rights reserved. Questo rivista on-line può essere copiata e distribuita liberamente, curando che venga distribuita integralmente, e che siano riportati fedelmente tutti gli autori ed il comitato editoriale. Informazioni sulla rivista sono riportate alla fine. In questo numero: ATTI CONGRESSUALI ONLINE IX ESRA - ITALIAN CHAPTER CONGRESS 2002 1 Regional anaesthesia for Day case surgery - A. Van Zundert 2 Continuous spinal antaesthesia: Safety and Outcome - M. Moellmann , S. Cord 3 Safety and outcome in the pratice of the peripheral nerve blocks - J. De Andres 4 La qualità, l'outcome e gli indicatori di anestesia - M. Nolli _______________________________________________________ ATTI CONGRESSUALI ONLINE IX ESRA - ITALIAN CHAPTER CONGRESS La redazione di Esia-Italia è lieta di presentare online gli atti del IX Congresso Nazionale ESRA (European Society of Regional Anaesthesia) - Italian Chapter, tenutosi nel Novembre 2002 a Torino. I presidenti, il comitato organizzatore e il comitato scientifico hanno promosso questa iniziativa della pubblicazione dei lavori congressuali sul web, attraverso ESIA. Infatti da una parte essa si inscrive tra gli scopi di costituzione del gruppo ESRA, teso alla divulgazione delle conoscenze sull'anestesia loco-regionale e alla sua sempre più ampia applicazione nei diversi settori clinici, sottolineando i concetti di "Sicurezza e Outcome" che hanno permeato l'intera attività comngressuale, dall'altra si incontra con le finalità di formazione scientifica e tecnica di ESIA-ITALIA, che sfrutta le potenzialità di diffusione e l'immediatezza di approccio, proprie di Internet. Pertanto Esia-Italia dedica alcuni suoi numeri alla pubblicazione dei lavori congressuali e delle comunicazioni migliori, riconosciute dal comitato ESRA. In ogni caso la redazione di Esia-Italia non si riterrà responsabile di errori o di omissioni ravvisabili nei testi prodotti nè dell'eventuale impropria utilizzazione delle tecniche descritte.  _______________________________________________________ ESRA 2002 Italian Chapter - Relazioni 1 - Regional Anesthesia for Day Case Surgery Prof.dr. André van Zundert - Catharina Hospital Eindhoven The Netherlands Ambulatory surgery is an increasing service in all hospitals, all over the world. In the USA, up to 75% of all operations are performed as day case surgery. We too, as anesthesiologists, have a great impact on this service as we can provide general or regional anesthesia techniques to our patients. It has been demonstrated that regional anesthesia provides a better outcome for patients during operations and in the postoperative phase with lower morbidity and mortality figures than general anesthesia. Nowadays, many patients want to be awake during their operation, being in full control over their own body. Types of loco-regional anesthesia which can be used during ambulatory surgery: topical anesthesiainfiltration blocksinstillation into joints / body cavitiesIVRA (Bier’s block)peripheral blocks (e.g. penile block for circumcisions)plexus blockade (e.g. brachial plexus blockade)central neural blockade (e.g. spinal – epidural – CSE)eye blocksPatient advantages when loco-regional anesthesia techniques are used during ambulatory surgery: avoidance of general anesthesiaminimal incidence of postoperative nausea and vomitingimproved and long lasting postoperative pain reliefcommunication with surgeon during interventionpossibility to observe the procedureshortened recovery room timeearlier mobilizationSurgeon and hospital advantages when loco-regional anesthesia techniques are used during ambulatory surgery: accurate assessment of function before wound closurediscussion of operative findings / treatment options with patientoption of direct transfer to second-stage recoveryshortened patient recovery room timereduced postoperative nursing requirementsoverall reduction in facility costs.Disadvantages of the use of loco-regional anesthesia during ambulatory surgery: additional time requirements (discussion with patient – block insertion – onsettime block) what in case of prolonged blocks, urinary retention and delayed dischargepotential nerve damageRequirements of a good Regional Anesthesia Service for Outpatient Surgery: planning procedure pre-operative assessment – policlinic anesthesiaoral and printed information – videoregional anesthesia block corner (block room) adequate professional help – trained nursesadequate monitoring and recovery after care – patient instructionsThe success of regional anesthesia depends on a well- informed patient and operating team, a good organization, adequate well-trained personnel, a dedicated and well equipped block room corner separate from the OR, a good knowledge of anatomy, an adequate position of the patient during the block insertion, adequate care and aftercare of the patient. The patient can, depending on his preference, be given the possibility to listen to music, see his operation on video,… Of course a knowledgeable anaesthesiologist, capable of performing regional anesthesia techniques is crucial. Monitoring should always be applied and patients should be checked postoperatively for side effects and pain experience. The worst case scenario is that the regional anesthesia block does not result in what you, the patient, or the team expects from the block: e.g. the patient has to be given general anesthesia, supplemental sedation or analgesics, the patient has to stay overnight, the patient has to be readmitted for raisons of severe pain or postoperative nausea and vomiting, bleeding problems,… Using more regional anesthesia blocks also safes on anesthesia costs. It has been demonstrated that the anesthesia technique used is the most important determinant of discharge time. The operating time is now pure surgical time, which means that there is no time needed for induction or reve rsal of anesthesia if regional anesthesia techniques are used. Central neural blocks are used frequently, but both epidural and spinal techniques have disadvantages. Peripheral nerve blocks are more and more used. Newer blocks as the Pippa block, the vertical infraclavicular block, the poplitea block,… are a welcome addition in the armamentarium of the modern anesthesiologists. They often provide excellent and long-lasting pain relief, which allows a faster recovery and an early discharge of the patient. Rarely complications are seen and the blocks are well-tolerated by the patients and easy to perform, providing excellent analgesia. This even allows effective physiotherapy to be given at an earlier stage, again contributing to a faster recovery from the operation. Peripheral nerve blocks can also be used when central blocks do not result in 100% satisfactory blocks. It is essential that anesthesiologists master these blocks, including peripheral nerve blocks (e.g. penile block, selective blocks of the nn. medianus, ulnaris, radialis, ankle block,…). The latter are often sufficient enough on their own to produce to result in adequate analgesia during the operating, avoiding the more central and plexus blocks. Overall when the well-trained anesthesiologist provides the right block for the right indication in the right patient, with the right equipment, the outcome should be excellent. Therefore the question arises: Can we afford NOT to use regional anesthesia for outpatient surgery?2 - Continuous Spinal Anaesthesia, Safety and Outcome M. Moellmann, S. Cord The concept of continuous spinal anaesthesia (CSA) was first described by the British surgeon Dean in 1907 (1) who left the spinal needle in place during an operation. In 1939, Lemmon (2) introduced the malleable needle and the split mattress technique to overcome the problems of needle trauma and breakage. Tuohy (3) introduced the catheter technique - he used a no.4 ureteral catheter inserted through a 15 gauge needle. Throughout the following years, the fear of CSA resulting in high incidence rates of postdural puncture headache (PDPH) and neurological complications, along with the development of the epidural technique, discouraged the frequent use of CSA. Since the incidence of PDPH depending on cerebrospinal fluid loss is due to needle size and tip configuration (4), Hurley and Lambert introduced micro catheter systems in an effort to reduce frequency of PDPH associated with spinal anaesthesia (5). Thus, CSA technique became suitable also for the use in younger patients without incurring an unacceptable risk of PDPH. However, serious neurological complications such as cauda equina syndrome after CSA performed with microcatheters were described by Rigler et al. in 1991 (6); additional cases after CSA administered through microcatheters resulted in a safety alert of the Food and Drug Administration in 1992. Spinal micro catheters thinner than 24 gauge inteded for the use in CSA were banned from the US-market. Furthermore, manufacturers of local anaesthetics declared that their products were not indicated for the use with CSA. In all, approximately 12 cases of cauda equina syndrome after CSA with microcatheters have been reported (7). This reinforced the misconception that CSA was a dangerous technique. However, with experiences gained from more than 3000 patients in the course of five years, CSA appears in a totally different light to me - namely as an effective and safe technique when performed correctly. Therefore, I give a brief update on the present status and possible future directions for CSA. CSA offers the attractive possibility of extending the block during surgery when needed. It provides an easy technique to reach an adequate level and duration of anaesthesia with small intermittent doses of local anaesthetic, which also minimizes the risk of possible cardiovascular and respiratory disturbances. Several studies have shown that haemodynamic stability is greater with CSA than with continuous epidural anaesthesia (CEA). For example, Sutter et al. (8) retrospectively compared more than 700 patients who underwent lower limb orthopaedic surgery either with CSA or with CEA. Although the patients in the CSA group were at a higher anaesthetic risk, the incidence of failures was lower and fewer patients showed a decrease in the mean arterial pressure. CSA thus was more reliable and provided better cardiovascular stability for elderly and high-risk patients. Such results can be attributed to the fact that CSA allows administration of small incremental doses of local anaesthetics at different concentrations and baricity according to the need of the individual patient, whatever surgical procedure and position are required. The better cardiovascular stability observed in CSA patients seems to be a result of the more easily controlled sympathetic blockade (9). Other advantages of CSA compared with CEA are a more complete muscular blockade and smaller dosage of local anaesthetic to obtain adequate anaesthesia, without any risks of systemic toxic effects due to absorption. The large dose of local anaesthetics administered with epidural anaesthesia means that elderly patients are at greater risk of intoxication because of their reduced clearance for local anaesthetics and their reduced cardiac output and liver blood flow (10). Since the elderly population is increasing, and since these patients often have concomitant medical problems and reduced physiologic adaptation capacities, CSA might be the anaesthetic technique of choice for such patients, especially when haemodynamic stability is critical (11, 12, 13, 14). By contrast to the question of intraoperative anaesthesia with CSA, there are only few studies published on the use of spinal catheters for postoperative analgesia (15, 16, 17). There is general agreement about the major goals of postoperative pain treatment such as minimizing the patient’s discomfort, facilitating the recovery process and avoiding side effects. Nevertheless, unrelieved postoperative pain is still reported to be a rather common clinical problem (18, 19). There is increasing evidence in the literature that especially for major orthopaedic surgery techniques using regional anaesthesia provide a pronounced inhibitory effect on the stress response and have beneficial effects on outcome variables (20). Finally, the fact that morbidity and hospital stay decrease with the use of such techniques implies economic aspects that should not be underrated nowadays (21, 22). Postoperative pain relief using CSA was first described by Ansbro et al. (23). Concerning the question whether to prefer CSA or CEA for postopertive pain control, Niemi et al. (24) randomized 55 patients who underwent hip arthroplasty under spinal anaesthesia to receive postoperative analgesia either using an intrathecal or an epidural catheter. Spinal catheter failures were found to present a significant disadvantage of CSA. However, Standl et al. (25) presented 100 patients undergoing lower limb orthopaedic surgery who received CSA using a 28 gauge catheter inserted through a 22 gauge needle and 0.25% bupivacaine titrated as bolus injections in the postoperative period. Their data suggest that CSA provides good postoperative analgesia, associated with a low incidence of complications and a high acceptance of CSA reported from the patients. In our research group, we found in a randomized, prospective study with 102 patients that both techniques result in adequate postoperative pain relief (26). In both groups, the level of pain was gauged from verbal rating score and from a visual analogue scale. In the CSA-group 90.2% reported complete analgesia on the verbal rating score, but only 21.6% of the CEA-group did so. Throughout the study period of 72 postoperative hours, the visual analogue scores given by the CSA-group were significantly lower than those of the CEA-group. It can be concluded that CSA and CEA proved to be effective and safe, but CSA provided faster onset of pain relief, ensured better analgesia and produced more satisfied patients. As the incidence of side effects such as motor blockade, nausea and vomiting was comparable in both groups, CSA should be regarded as an attractive technique for a flexible postoperative pain therapy. Asked about their main point of fear, most critics of CSA mention two complications: neurological damage and cerebrospinal fluid infection. Unfortunately, only few prospective studies have formally investigated the real incidence of neurological complications (27). That is why we tried in our research group to evaluate the frequency of permanent neurologic sequelae after CSA in a standardized pre- and postoperative investigation (28). A preoperative neurological status was gained from 150 patients who underwent hip arthroplasty with CSA technique, and the same neurological status was gained by the same anaesthetist ten days after surgery. At the occasion of this examination, no patient had noticed any remarkable differerence on his own; nevertheless, in four patients who suffered from Diabetes mellitus II a decrease of the quadriceps-femoris reflex was found. No differences in physical power were found and no cauda equina syndrome arose. All patients reported complete satisfaction with anaesthesia and postoperative shape and no serious complications were found - thus CSA should no longer be just condemned as a „risky technique", but more prospective clinical studies on this question are mandatory in the future. In order to research on the risk of infection when performing CSA in the postoperative period, in 144 patients, who successfully underwent CSA for surgery, CSF was sampled both immediately after positioning and before removing the catheter (29). Leukocytes, proteins and glucose concentration were determined, meninigsm and infection parameters were compared preoperatively and by removal. The catheter was removed under aseptic conditions, the tip was cut and washed with saline. CSF, tip and saline were cultured to find microbiological contamination. In five cases bacteria were found in CSF, the catheter tip was contaminated in eight cases and saline in one case. Statistically significant positive correlation with the indwelling catheter time was found. Signs of local infection at the insertion side appeared in three cases with CSA lasting longer than 90 hours. However, no patient showed evidence of local or systemic infection with CSA for up to 200 hours. Taking into consideration that a meticulous technique of insertion and handling the catheter is mandatory, as well as a daily inspection of the insertion site, we conclude from our results that fear of infection should no longer lead to restrictions in the use of CSA in the postoperative period(, even when performed for 200 hours). In conclusion, CSA is an established anaesthetic technique that has advantages over CEA especially in elderly or high-risk patients. Correctly used, CSA is an effective and safe technique - not only for intraoperative anaesthesia but also for an up-to-date postoperative pain treatment. Former doubts about its safety can be regarded as eliminated by clinical studies published over the last years that should encourage the more frequent use of this technique in the future.References: 1. Dean HP. Discussion on the relative value of inhalational and injection methods of inducing anaesthesia. Br Med J 1907: 5: 869-877 2. Lemmon WT. A method for continuous spinal anaesthesia. Ann Surg 1940: 111: 141-144 3. Tuohy EB. Continuous spinal anaesthesia: Its usefulness and technique involved. Anesthesia 1944: 5: 142-148 4. Holst D, Möllmann M, Ebel C, Hausmann R, Wendt M. In vitro investigation of cerebrospinal fluid leakage after dural puncture with various spinal needles. Anesth Analg 1998: 87: 1331-1335 5. Hurley RJ, Lambert DH. Continuous spinal anaesthesia with a micro catheter technique: the experience in obstetrics and general surgery. Reg Anesth 1989: 14: 3-8 6. Rigler ML, Drasner K, Krejcie TC et al. Cauda equina syndrome after continuous spinal anaesthesia. Anesth Analg 1991: 72: 275-281 7. Denny NM, Selander DE. Continuous spinal anaesthesia. Br J Anaesth 1998: 81: 590-597 8. Sutter PA, Gamulin Z, Forster A. Comparison of continuous spinal and continuous epidural anaesthesia for lower limb surgery in elderly patients - A retrospective study. Anaesthesia 1989: 44: 47-50 9. Standl T, Eckert S, Rundshage I, Schulte am Esch J. A directional needle improves effectiveness and reduces complications of microcatheter continuous spinal anaesthesia. Can J Anaesth 1995: 42: 701-705 10.Greenblatt DJ, Sellers EM, Shader RI. Drug disposition in old age. N Engl J Med 1982: 306: 1081-8 11.Covert CR, Fox GS. Anaesthesia for hip surgery in the elderly. Can J Anaesth 1989: 36: 311-319 12.Carpenter RL, Caplan RA, Brown DL, et al. Incidence and risk factors for side effects of spinal anesthesia. Anesthesiology 1992: 76: 906-916 13.Favarel-Garrigues JF, Sztark F, Petitjean ME, Thicoipé M, et al. Hemodynamic Effects of spinal anesthesia in the elderly: Single dose versus titration through a catheter. Anesth Analg 1996: 82: 312-316 14.Holst D, Möllmann M, Karmann S, Wendt M. Kreislaufverhalten unter Spinalanästhesie. Anaesth 1997: 46: 38-42 15.Bachmann M, Laakso E, Niemi L, Rosenberg PH, et al. Intrathecal infusion of bupivacaine with or without morphine for postoperative analgesia after hip and knee arthroplasty. Br J Anaesth 1997: 78: 666-670 16.Niemi L, Pitkanen M, Dunkel P, Laakso E, Rosenberg PH. Evaluation of the usefulness of intrathecal bupivacaine infusion for analgesia after hip and knee arthroplasty. Br J Anaesth 1996: 77: 544-545 17.Burchett KR, Denny NM. Initial experience of continuous subarachnoid diamorphine infusion for postoperative pain relief. Reg Anesth 1991: 16: 253-256 18.Kehlet H. Postoperative pain relief - what is the issue? - Editorial. Br J Anaesth 1994: 72: 375-378 19.Dahl JB, Kehlet H. The value of pre-emptive analgesia in the treatment of postoperative pain. Br J Anaesth 1993: 70: 434-439 20.Kehlet H. General vs regional anaesthesia. In: Rogers M, Tinker J, Covino B, Longnecker DE, eds. Principals and Practice of Anesthesiology. St Louis: C.V. Mosby, 1993: 1218-1234 21.Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation and duration of hospitalization in total knee arthroplasty. Clin Orthop 1990: 260: 30-37 22.Schug SA. Continuous regional anaesthesia in comparison with intravenous opioid administration for routine postoperative pain control. Anaesth 1994: 49: 528-523 23.Ansbro FP, Latteri FS, Blundell AE et al. Prolonged spinal anaesthesia. Anesthesiology 1954: 15: 569-571 24.Niemi L, Pitkänen M, Tuominen M, Rosenberg P. Technical problems and side effects associated with continuous intrathecal or epidural post-operative analgesia in patients undergoing hip arthroplasty. Eur J Anaesth 1944: 11: 469-474 25.Standl T, Eckert S, Schulte am Esch J. Microcatheter continuous spinal anaesthesia in the post-operative period: a prospective study of its effectiveness and complications. Eur J Anaesth 1995: 12: 273-279 26.Möllmann M, Cord S, Holst D, Auf der Landwehr U. Continuous spinal anaesthesia or continuous epidural anaesthesia for postoperative pain control after hip replacement? Eur J Anaesth 1999: 16: 454-461 27.Horlocker TT, McGregor DG, Matsushige DK, et al. Neurologic Complications of 603 Consecutive Continuous Spinal Anesthetics Using Macrocatheter and Microcatheter Techniques. Anesth Analg 1997: 84: 1063-1070 28.Möllmann M, Cord S, Mayweg S, Frerker K. The Risk of Permanent Neurologic Sequelae after Continuous Spinal Anesthesia. Reg Anaesth Pain Med 1999 (Suppl 1): 24: 22 29.Santamaria M, Möllmann M, Röttger T, Auf der Landwehr U. Continuous spinal anaesthesia: is there a risk of infection? Br J Anaesth (Suppl 1) 1998: 80: 116  _______________________________________________________ ESRA 2002 Italian Chapter - Relazioni 3 - Safety and outcome in the practice of peripheral nerve blocks Jose De Andrés - Associate Professor of Anesthesia. Director Multidisciplinary Pain Management Center. Department of Anesthesia  Valencia University General Hospital Avda. Tres Cruces s/n, 46014-Valencia (Spain)INTRODUCTION With the increase in popularity and consequently amount in the practice of regional anesthesia, an emphasis has been placed on its risks and outcomes. Regional anesthesia is now more than ever part of a multi-modal approach to perioperative pain management that not only cover surgical procedure but also expedites patient recovery and discharge (1). Certainly regional anesthesia, with all its advances and modifications, has met many of its challenges. Now in the time of "evidence based medicine", clinicans are responsible for working to provide not only relief of pain in the short term during the postoperative period, with a shortening of hospital stay and a lessening of health care costs, but also in the long run by preventing post-injury sequelae and subsequent development of long-term pain syndromes.IMPLICATIONS OF REGIONAL ANAESTHESIA IN OUTCOME The implication of regional anaesthesia techniques in outcome has been mainly related to its importance in the segmentary block of the nociceptive impulse and its direct repercussions upon endocrine-metabolic, cardiac, respiratory and gastrointestinal functions. These effects have mainly been studied in relation to spinal conduction block (2). Regional anaesthesia techniques produce their effect by blocking the production of afferent peripheral nociceptive stimuli. The absence of information at spinal level impedes the development of the so-called "wind-up" phenomenon in the neurons of the dorsal horn, and hence their hypersensitivity - which causes an increased response to the stimulus that triggers enhanced sensitivity to pain. Although both general and regional anaesthesia are able to block nociception, they do so through different mechanisms, involving different neuronal pathways and/or receptor systems. In being inhalatory, general anaesthesia lacks the capacity to block the spinal hyper-excitability phenomenon (3). At the same time, regional anaesthesia is able to block the afferent stimulus, inhibiting the sympathetic response to impede the stress response to surgical stimulus, and interrupting the reflex circuit that contributes to postoperative morbidity.  However, the true role of regional anaesthesia in surgical outcome remains to be established, for although its qualitative importance is clear, in quantitative terms its utility is influenced by other surgical and patient-dependent parameters (4).IMPORTANCE OF NERVE LOCATION METHOD IN SAFETY AND OUTCOME Plexus anesthesia undoubtedly offers its best performance when objective and atraumatic techniques for nerve localization secure success and morbidity rates in inverse proportion - the best expression of such performance being patient satisfaction with the technique.The classical nerve location methods are subjective and in some cases cause patient discomfort and can give rise to severe nerve injury as a result of direct damage to the nerve structure (5). Once produced nerve parestesia, the injury will be variable and independent of the used technique and more will be related to the type of bevel and diameter of the used needle and the skill of the anesthesiologists. In agreement with the intensity of the contact and the penetration of the needle in the thickness of the nerve a nervous injury of variable degree will take place, being minimum if a superficial contact only takes place 6 . Using the transarterial technique for identifying the perivascular space - perforating the artery included in the plexus- we can obtain sustained succes in achieving the nerve block, but outcome will be conditioned for the possibility of associated thrombosis and/or hematoma and the risk of ischemic compression upon the plexus, dilution of the local anesthetic solution injected, and possible systemic vascular absorption of the latter. Although a 1% rate of transient vascular spasm has been reported, with a 0.2% incidence each of inadvertent intravascular injection and hematomas, in a prospective study of 1000 patients, the possible morbidity caused should serve to largely condition if not discard the use of the technique (7). Neurostimulation (NS) presently affords a high, constant and predictable success rate, with practically negligible morbidity, a very low cost and easy availability in the surgical area; moreover, extensive and contrasted experience with its use has been accumulated (5) . With the idea of increasing succes but also decreasing morbidity, avoiding vascular and nervous puncture, orientation to the depth of the nerve structure to be blocked by means the application of ultrasonography in the performance of plexus anesthesia involving brachial and lumbar approaches, have been presented (8, 9). For the artrhoscopic shouder surgery, interscalene brachial plexus block (ISB), provides excellent intraoperative anaesthesia and muscle relaxation with failure index less than 10% (10) and has demonstrated to show several benefits with fewer side effects and a shorter hospital stay than general anesthesia (11). This surgical technique is characterized by severe postoperative pain that occurs in over 45% of patients, specially during movements being according literature ISB the most appropriate technique to provide efficient postoperative analgesia after shoulder arthroscopy (12) .EFFECTS OF SEGMENTARY ANALGESIA The sequence of physiopathological consequences that follow generation of the nociceptive stimulus has been extensively investigated (13, 14). However, no precise benefit has been established from its preventive treatment by regional anaesthesia techniques in comparison to general anaesthesia, and in terms of implications in the outcome of surgery. The postoperative analgesia obtained through different routes – systemic, intravenous and intramuscular – by means of PCA systems possesses a modulating rather than a blocking capacity of these nociceptive stimuli, both peripherally (NSAIDs) and centrally (opioids and alpha-2 agonists). For this reason, this modality of balanced or multimodal analgesia does not substantially modify the response to stress or significantly change outcome when analyzing the incidence upon days of hospital stay or decreased complications (15). However, segmentary analgesia has been shown to prolong the time of demand for the first analgesic, and presumably it exerts a better control over postoperative pain (15). This improved quality of analgesia is achieved both at rest and during mobility, without secondary effects such as nausea, dizziness, vomiting, and so on. The duration and intensity of the analgesia may be anticipated to surgical aggression (pre-emptive analgesia), and may be sustained for hours or even days. This allows early patient mobilization, with the immediate postoperative implementation of programs for accelerated rehabilitation – the precocity and effectiveness of which would not have been possible without effective analgesia. Among the possible drugs used perineurally for providing segmentary analgesia during peripheral blocks, local anesthetics are the most useful drugs and indeed the first but not the only choice. The pharmacological properties of the local anesthetics, configure their clinical profile, as exert most of their clinical actions by inhibiting the normal function of voltage-sensitive Na + channels. But in addition to this essential mechanism of membrane excitability, other factors can also influence the quality of the clinical regional anesthesia 16,17 . The determination of sufficient dose for producing, and most important maintaining the block if necessary, depends on formulations of volume and concentration as well as adjuvants and pH. Once the solution is injected in the close vicinity of the nerve, few percent of the solution is driving into the nerve, and the rest is taken up by fat surrounding neural structures and removed by the local circulation, and only the epineural local anesthetic concentration the responsible for determining the success of nerve block (17). The relative susceptibility of nociceptive fibers (Ad and C), is dependent of the variable and dynamic presence of different kind of receptors, which are activated by different noxious stimuli, and furthermore blocked by other different drugs as previously demonstrated in humans (18) like: Opioids (19, 20); alfa-2 agonists (21); acetyl cholinesterase inhibitors (22), and other miscellaneous drugs like ketorolac (23) or verapamil (20). Accordingly the presentation of the theoretical benefits related with the application of pre-emptive analgesia, attention has focused both on the CNS and peripheral processes that could be modified pharmacologically to improve analgesia. Kissin made a review of studies comparing preincisional versus postincisional analgesia treatment and found two conditions in the studies important for demonstrating benefits of preemptive analgesia (24):Treatment capable to provide effective suppression of the afferent input and with sufficient durationA therapeutic framework that includes: preemptive treatment, maintenance of the obtained effect and reversal of central sensitization in case of development. Ringrose et al (25) assessed the effectiveness of femoral nerve block with bupivacaine for knee joint (anterior cruciate) reconstruction surgery. This technique reduced the need for im opioid administration by 80% in the recovery room, and 40% in the first 24 postoperative hours, although supportive of a preemptive effect, the nerve block is a one-time intervention, which limits the possible efficacy to the immediate postoperative period. Rosaeg et al (26), used three different regimens before and after arthroscopic knee ligament repair, including ketorolac 30 mg IV, intra-articular injection of 20 ml ropivacaine 0.25% + morphine 2 mg and epinephrine 1:200000, and femoral nerve block with 20 ml ropivacaine 0.25%. All three preemptive groups had lower pain scores in short term, but no long-term advantage was demonstrated. In a very interesting survey performed by Perkins and Kehlet of the chronic pain as an outcome of surgery, authors concluded that is very common after limb amputation, inguinal hernia surgery, breast surgery, gallbladder surgery and lung surgery (27). A very important conclusion is afforded for the intensity of acute postoperative pain as a predictor of chronic pain development. Regional anesthesia by its segmentary action has the possibility if applied correctly (indication and technical performance) of blocking nociceptive input allowing for better outcome and increased safety in the surgical procedure. REFERENCES 1.-Chan V. Advances in regional anaesthesia and pain management. Can J Anaesth 1998: 45(5): R49-R57. 2.- Liu SS, Carpenter RL, Neal JM. Epidural analgesia and anaesthesia: Their role in postoperative outcome. Anesthesiology 1995; 82: 1474-1506. 3.- Abram SE, Yaksh TL. Morphine but not inhalation anaesthesia , blocks post-injury facilitation. Anesthesiology 1993; 78: 713-721 4.-Myles P. Predicting outcome in anaesthesia: understanding statistical methods. Anaesth Intens Care 1994; 22: 447-453. 5.-De Andrés JA, Sala-Blanch X. Peripheral Nerve stimulation in the practice of brachial plexus anesthesia: A review. Reg Anesth Pain Med 2001; 26:478-483. 6.-Reina MA, Lopez A, Villanueva MC, de Andres JA, Leon GI.. Morphology of peripheral nerves, their sheaths, and their vascularization. Rev Esp Anestesiol Reanim 2000; 47(10):464-475 7.-Stan TC, Krantz MA, Solomon DL et al. The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach. Reg Anesth 1995; 20: 486-492. 8.-De Andres J, Sala-Blanch X: Ultrasound in the practice of brachial plexus anesthesia. Reg Anesth Pain Med 2002; 27: 77-89. 9.-Marhofer P, Schrogendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997; 85:854-847. 10.-D’Alessio, Rosemblum M, Shea K,Freitas D. A retrospective comparison of interscalene block and general anaesthesia for ambulatory surgery shoulder arthroscopy. Reg Anesth 1995; 20:62-68 11.-Brown AR, Weiss R, Greenberg C et al. Interscalene block for shoulder artrhoscopy: comparison with general anesthesia: Artrhoscopy 1993; 9:295-300 12.-Al-Kaisy A, McGuire G, Chan VW, et al.Analgesic effect of interscalene block using low-dose bupivacaine for outpatient arthroscopic shoulder surgery. Reg Anesth Pain Med 1998, 23(5):469-73 13.-Kehlet H. Surgical stress: The role of pain and analgesia. Br J Anaesth 1989; 63: 189-195. 14.-Weissmann C. The metabolic response to stress: an overview and update. Anesthesiology 1990; 73: 308-327. 15.-Ballantyne J. Postoperative patient -controlled analgesia: meta-analyses of initial randomised controlled trials . J Clin Anaesth 1993; 5: 182-193. 16.- Butterworth JF, Strichartz GR. Molecular mechanisms of local anesthesia: A review. Anesthesiology 1990;72:711-734. 17.- Strichartz GR. Pathways and obstacles to local ansthesia , a personal account: The 2000 Gaston Labat Lecture. Reg Anesth Pain Med 2000; 25: 447-451. 18.-Murphy DB, McCartney CJ, Chan VW. Novel analgesic adjuncts for brachial plexus block: a systematic review. Anesth Analg 2000 ;90 (5):1122-1128. 19.-Antonucci S. Adiuvants in the axillary brachial plexus blockade. Comparison between clonidine, sufentanil and tramadol. Minerva Anestesiol 2001 Jan-Feb;67(1-2): 23-27 20.-Reuben SS, Reuben JP.Brachial plexus anesthesia with verapamil and/or morphine. Anesth Analg 2000; 91(2): 379-383 21.-Erlacher W, Schuschnig C, Koinig H, Marhofer P, Melischek M, Mayer N, Kapral S. Clonidine as adjuvant for mepivacaine, ropivacaine and bupivacaine in axillary, perivascular brachial plexus block. Can J Anaesth 2001; 48(6): 522-525. 22.-Bone HG, Van Aken H, Booke M, Burkle H. Enhancement of axillary brachial plexus block anesthesia by coadministration of neostigmine. Reg Anesth Pain Med 1999; 24(5): 405-410 23.-Reinhart DJ, Stagg KS, Walker KG, Wang WP, Parker CM, Jackson HH, Walker EB. Postoperative analgesia after peripheral nerve block for podiatric surgery: Clinical efficacy and chemical stability of lidocaine alone versus lidocaine plus ketorolac. Reg Anesth Pain Med 2000;25:506-513. 24.-Kissin I. Preemptive analgesia . Anesthesiology 2000; 93: 1138-1143. 25.-Ringrose NH, Cross MJ. Femoral nerve block in knee joint surgery. Am J Sports Med 1984; 12:398-402. 26.- Rosaeg OP, Krepski B, Cicutti N, Dennehy KC, Lui ACP, Johnson DH. Effect of preemptive multimodal analgesia for arthroscopy knee ligament repair. Reg Anesth Pain Med 2001; 26: 125-130. 27.-Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. Anesthesiology 2000; 93: 1123-1133.4 - LA QUALITÀ, L’OUTCOME e GLI INDICATORI IN ANESTESIAMassimo Nolli Servizio Anestesia, Rianimazione e Medicina Perioperatoria- Ospedale S.Andrea di La Spezia (Direttore Dr Francesco Nicosia) Cattedra di Anestesia e Rianimazione Università degli Studi di Modena e Reggio Emilia (Direttore Prof. Alberto Pasetto)I. LA QUALITÀ II. GLI STRUMENTI DELLA QUALITÀ III. LE TAPPE IV. CONCLUSIONE I. LA QUALITA’La cultura della qualità è strettamente legata alla regressione del lavoro artigianale e alla rivoluzione industriale: quest’ultima non ha solamente comportato la perdita di contatto diretto tra il produttore e il consumatore ma ha prodotto due eventi principali: una enorme accelerazione delle attività e l’elaborazione di prodotti intermedi ciascuno dei quali con una sua linea di produzione e con le stesse identiche necessità e obblighi. Il risultato della produzione industriale diventa l’outcome (ovvero il risultato) in sanità: la necessità del controllo del prodotto ha un obiettivo principale che è la riduzione degli scarti ovvero, in sanità e nel processo chirurgico in particolare, il raggiungimento del risultato positivo per il paziente. Tanto per l’industria come per la sanità il risultato finale, oltre ad essere la somma di prodotti intermedi, viene giudicato da diversi punti di vista: ciascuno di questi deve giungere a soddisfare il proprio obiettivo in quanto componente del processo, organizzatore dello stesso o paziente (consumatore). Per quanto riguarda il risultato, nel processo chirurgico due sono gli elementi essenziali derivanti da questo modo di vedere:L’apporto di ciascun operatore è divenuto componente essenziale del risultato finale: ovvero il risultato finale diventa evento a cui partecipano tutti gli operatori in grado di incidere sostanzialmente sul risultato finale.L’outcome è costituito dalla somma di più valori che rappresentano il diverso modo di vedere la salute: dalle conseguenze fisiche, psichiche e sociali del soggetto operato, alla soddisfazione degli operatori e del paziente stesso, alle conseguenze economiche dell’impegno erogato.Migliorare la qualità dell’assistenza sanitaria vuol dire aumentare il valore ottenuto con i processi di assistenza. La qualità è diventata qualcosa che si rapporta ai valori che ciascuno di noi sente più importanti e ritiene essenziali nel raggiungimento del proprio obiettivo senza dimenticare che l’outcome diviene il progetto finale comune. L’outcome di un sistema tarato sull’assistenza medica (e chirurgica in particolare) diviene non più solo l’obiettivo ma anche una caratteristica di questo sistema: ovvero diviene caratteristica di quel determinato sistema il produrre buoni o cattivi risultati. E poiché i risultati (il valore) di un sistema dipendono da tutti gli elementi che lo compongono e che contribuiscono ad essi, modificare gli elementi strutturali del processo (organizzazione, allocazione di risorse, interdipendenza, efficienza) significherà modificare gli stessi risultati (Focarile 1998). Per questo all’interno di un procedura chirurgica i risultati (l’outcome) divengono effetti (conseguenze) del miglioramento delle strategie di approccio parziale di ciascun operatore e dell’integrazione di queste attività in un processo globale a cui le varie figure devono concorrere. La definizione del risultato finale è profondamente variato negli ultimi anni anche la professione anestesiologica Divengono espliciti tre concetti:che l’anestesia è in grado di modificare il risultato chirurgico (se un certo tipo di anestesia, qualunque essa sia, rispetto ad una anestesia standard di confronto riesce a modificare il risultato della degenza del paziente chirurgico significa che quell’approccio anestesiologico piuttosto di un altro è in grado di modificare il risultato chirurgico).che l’anestesia otterrà il miglioramento dell’atto chirurgico solo se inserita in una serie di processi in grado di amplifica e mantenere i vantaggi da essa indotti.che l’influenza anestesiologica si estende dagli outcomes a breve o brevissimo termine a quelli più dilazionati che sino ad oggi erano per molti motivi di pura pertinenza chirurgicaChe significa questo per l’anestesista ?Non più mortalità anestesiologica ma bensì mortalità e morbilità perioperatoria. Non più surrogate endpoints ma outcome vero e proprio (Fisher 1994, Fisher 1998). Non possiamo più parlare o trattare solo di mortalità o morbilità dipendente o risultato dei nostri atti anestesiologici intraoperatori e/o di cura intensiva postoperatoria ma ci dovremo occupare di verificare quanto e come il nostro comportamento perioperatorio sia in grado di influire sostanzialmente sui risultati della degenza del nostro paziente. La capacità di preparare e trattare il paziente non deve essere più o solo finalizzata ad evitare l’evento indesiderato intraoperatorio o a programmare la degenza protetta ma a permettere (a favorire) UN RAPIDO RECUPERO POSTOPERATORIO (Nolli e Nicosia 2000). La scelta del tipo di anestesia si deve basare sulla conoscenza acquisite di sicurezza delle varie metodiche non solo per la loro capacità di riduzione del rischio intraoperatorio (rischio anestesiologico e chirurgico) ma anche per la efficienza del recupero postoperatorio. E deve variare o meglio si deve ampliare il campo degli indicatori di performance a cui fare riferimento per capire se i nostri comportamenti si possono considerare validi ed efficienti. I lavori di Capdevilla (1999) e soprattutto la Metanalisi di Rodgers et al (2000) hanno su questo punto definito in modo inequivocabile la nostra prospettiva di lavoro proponendo quella che può sembrare, a secondo del modo di vedere, un minuscolo (un decesso in meno su 100 pazienti) o un meraviglioso enorme risultato (il 33% dei decessi in meno tra AG e blocco nervoso centrale) ma rafforzando i concetti di impegno di una specialità verso un risultato che definisce in modo globale il valore dell’assistenza sanitaria.Per fare questo diviene necessario migliorare il nostro approccio al processo globale e migliorare la nostra conoscenza degli strumenti che dobbiamo utilizzare per questo miglioramento. Oggigiorno gli anestesisti devono conoscere i concetti e gli strumenti della qualità ed essere in grado di applicarli alla loro pratica ed attraverso la loro all’interazione con numerose altre figure professionali, all’insieme del processo di cure. La qualità in anestesia include ovviamente la ricerca della riduzione del rischio di complicanze legate all’anestesia. Secondo l’International Standardization Organization (ISO), la qualità è"l’insieme delle caratteristiche e delle proprietà di un prodotto o servizio che conferiscono allo stesso l’attitudine a soddisfare bisogni impliciti o espliciti". Secondo l’Organizzazione Mondiale della Sanità (OMS) la qualità delle cure è "la capacità di fornire a ciascun paziente tutte le attività diagnostico terapeutiche in grado di assicurare il migliore risultato in termini di salute conformemente allo stato attuale della scienza medica, al miglior costo per lo stesso risultato, ai minori rischi iatrogeni e per la sua più grande soddisfazione in termini di procedure, risultati e contatti all’interno del Sistema di Cura". Queste definizioni hanno in comune il fatto che pongono il cliente/utente/paziente e la considerazioni dei suoi bisogni al centro di tutti gli obiettivi di qualità.II. GLI STRUMENTI DELLA QUALITÀ L’applicazione alle cure sanitarie dei concetti di qualità necessita di strumenti di valutazione della qualità stessa: il metodo di misura in questo contesto, molto di più che in altri, risente delle caratteristiche dell’oggetto della misura stessa. "Ciò che non si misura non si può gestire". Non esiste la ricerca della qualità senza ricorso alla misura. La misura non può essere fine a se stessa, ma deve permettere di mettere in opera modifiche finalizzate al raggiungimento della qualità. La misura della qualità si avvale di specifici strumenti: indicatori, audit clinico, processi, strumenti di analisi dei processi. Un indicatore è un’informazione scelta, associata ad un fenomeno, destinata ad osservarne periodicamente le evoluzioni in rapporto ad obiettivi periodicamente definiti (norma ISO 8402).  L’indicatore è una variabile che ci consente, quindi, di descrivere fenomeni complessi e di prendere decisioni per ottenere e mantenere cambiamenti; nella capacità di descrivere e indicare le decisioni da adottare per migliorare il sistema, risiede la caratteristica fondamentale dell’indicatore. L’indicatore è una misura obiettiva che descrive una situazione dal punto di vista quantitativo e deve essere in grado di evolvere sollevando domande circa le cure cliniche erogate al paziente e le possibili vie alla ricerca del miglioramento: al variazione della misura di un risultato deve riflettere l’impatto potenziale delle misure di correzione adottate. L’utilizzo degli indicatori permette quindi anche il confronto sui risultati. Esistono diversi tipi di indicatori:- indicatori di risultati - indicatori di struttura: risorse umane , materiali, economiche - indicatori di processo (di presa in carico) Quindi, possiamo immaginare di avere a disposizione centinaia di indicatori clinici in grado essere, potenzialmente, utili a professionisti e istituzioni nelle più varie situazioni cliniche e profili di cura. Ciascuno (professionista, governi, pazienti, assicurazioni) utilizzeranno quelli a loro più congeniali: per stimare il livello di eccellenza di un determinato aspetto di cura, valutare la sua performance nella erogazione delle cure cliniche e influenzare la struttura di una eventuale riallocazione delle risorse. L’audit è un metodo di valutazione che permette, a partire da criteri determinati, di confrontare una tecnica o un’attività (medica, di nursing o di un’organizzazione) ad un’insieme di riferimenti predeterminati [6]. L’approccio necessita il censimento dei problemi legati alla qualità delle cure ed alla selezione di uno di essi. Il tema può riguardare problemi identificati o segnalati dai sanitari o dagli utenti.Processo: Il processo è un’insieme di tappe. Ogni tappa a sua volta è costituita da una successione di compiti che fanno intervenire diversi attori. Un processo deve essere considerato come un’operazione che trasforma, con l’apporto di un valore aggiunto, una o più entità, definite "intrants" in una o più entità denominate "extrants". L’apporto di un valore aggiunto è effettuato conformemente ad un metodo, con il ricorso a risorse umane e/o materiali e nel rispetto di alcune"costrizioni" come esigenze regolamentar, ambientali, o etiche riguardo alle condizioni nelle quali la trasformazione deve essere realizzata [7] (figura 1,2).III. LE TAPPE Il miglioramento della qualità viene raggiunto attraverso tappe che si sviluppano in tempi simili ma che hanno strumenti differenti a seconda del criterio e delle dimensioni della qualità da esplorare. Una volta raggiunto il livello minimo accettabile che è legato alla disponibilità di strumenti per la conformità a norme esigibili, il passo successivo è fondato sullo sviluppo di sistemi di raccolta dati, di sintesi e interpretazione delle informazioni. IV. CONCLUSIONE Negli ultimi venti anni abbiamo assistito ad una importante evoluzione della relazione medico-paziente: da paternalista è diventata una relazione tra pari tipo quella Nord americana oppure cliente/fornitore di servizi. L’accreditamento come la certificazione, che riconoscono la conformità di un sistema a determinate norme, rimangono tappe molto importanti ma non costituiscono il motore della garanzia di qualità. L’approccio alla qualità consiste nel soddisfare ed anche anticipare i bisogni dell’utente. Per raggiungere un tale obiettivo, sono indispensabili la responsabilizzazione dell’insieme degli attori della struttura. I rischi legati all’anestesia devono essere analizzati attraverso l’analisi delle tre tappe: pre-, intra- e post-operatorie e tre dimensioni: personale, materiale, organizzazione. La valutazione della qualità delle pratiche deve sfociare in cambiamenti di pratiche o di comportamenti dando la priorità alla gestione dei rischi e privilegiando sempre le soluzioni più motivanti per il maggior numero di persone. I cambiamenti di pratiche sono sostenuti dalla formazione e dai risultati della ricerca clinica.  I cambiamenti comportamentali sono più difficili da ottenere. È fondamentale che gli anestesisti prendano in mano la gestione della qualità del proprio lavoro prima che quest’ultima venga loro imposta da altri: organismi esterni, associazioni di consumatori, amministrativi, ecc.BIBLIOGRAFIA selezionata Baraghini GF, Trevisani B, Roli L: Le ISO 9000 in sanità, 2002, FrancoAngeli ed. Milano Marty J, Nivoche Y, Petit J: Évaluation de la qualité des soins en anesthésie-réanimation chirurgicale, Masson ed, Paris, 1999 Fourcade A, Ricour L, Garnerin P, Hergon, E, Boelle PY: La démarche qualité dans un établissement de santé, Doin éditeurs/Assistance Publique-hôpitaux de Paris, 1997 Du Cailar J, Biboulet P, D’Athis F: Epidémiologie de la mortalité et de la morbidité en anesthésie, Encycl Méd Chir, Elsevier, Paris, Anesthésie-Réanimation, 36-400-A-05, 1997, 19pReason J: Human Error: models and management, BMJ 2000; 320: 768-70. Anhoury P, Viens G: Gérer la qualità et les risques à l’hôpital; ESF éditeur, Paris, 1994Eagle CJ, Davies JM, Reason J: Accident analysis of large scale technological disasters applied to an anaesthetic complication Can J Anaesth 1992; 39:118-22 Health Service Circular: Series number: HSC 1999/999, 16th June 1999, Review date: 16th December 1999: Improving Quality and Performance in the New NHS: Clinical Indicators and High Level Performance Indicators LL Lau, CT Hung, CK Chan, et al.: Anaesthetic clinical indicators in public hospitals providing anaesthetic care in Hong Kong: prospective study: HKMJ 2001 (7): 3: 251 Focarile F: Indicatori di Qualità nella asssistenza sanitaria: Centro Scientifico Editore 1998  M. Nolli M , Nicosia F: La gestione del dolore postoperatorio. Obiettivi, Identificazione e organizzazione delle procedure di sviluppo di un programma di terapia del dolore acuto postoperatorio;Minerva Anestesiologica 66: 585-601:2000 Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubernovitch J, d'Athis F: Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999; 91:8-15 Informazioni sulla rivista ESIA-Italia EDUCATIONAL SYNOPSES IN ANESTHESIOLOGY and CRITICAL CARE MEDICINE - Italia costituisce la parte Italiana della versione Americana, pubblicata su Internet da Keith J Ruskin, Professore di Anestesia alla Università di Yale. I lavori saranno accettati sia in lingua Italiana che Inglese. In quelli di lingua Italiana un corposo riassunto in Inglese verrà preparato dalla redazione, qualora l'autore non fosse in grado di fornirlo. A cura della redazione sarà inoltre la traduzione in Italiano dei manoscritti inviati in lingua Inglese. La rivista sarà inviata gratuitamente a tutti quelli che ne faranno richiesta, inviando il seguente messaggio "Desidero ricevere ESIA versione italiana" indirizzato a LANZA@UNIPA.IT La rivista pubblica rewiews e lavori originali compiuti nei campi dell'anestesia e della medicina critica. I lavori originali riguardano ricerche cliniche, di laboratorio e la presentazione di casi clinici. Le reviews includono argomenti per l'Educazione Medica Continua (EMC), articoli di revisione generale o riguardanti le attrezzature tecniche. ESIA pubblica le lettere all'Editore contenenti commenti su articoli precedentemente publicati ed anche brevi comunicazioni. La guida per gli autori può essere consultata collegandosi al sito ANESTIT all'indirizzo: http://anestit.unipa.it/ utilizzando la sezione riservata ad ESIA-Italia; oppure può essere richiesta inviando un messaggio a lanza@unipa.it EDUCATIONAL SYNOPSES IN ANESTHESIOLOGY and CRITICAL CARE MEDICINE Sezione Italiana Il numero della rivista è anche ottenibile attraverso World-WideWeb WWW: l'URL per questo numero di ESIA è: http://anestit.unipa.it/esiait/esit0110.txt Il nome della rivista è esitaamm, dove aa è l'anno ed mm il mese (per esempio questo numero è esit0110.txt) LA REDAZIONE DI ESIA ITALIA DIRETTORE: Vincenzo LANZA Primario del Servizio d'Anestesia e Rianimazione Ospedale Buccheri La Ferla Fatebenefratelli Palermo LANZA@UNIPA.IT Terapia Intensiva Antonio Braschi Primario del Servizio d'Anestesia e Rianimazione 1 - Policlinico S. Matteo - IRCCS Pavia Anestesia Cardiovascolare Riccardo Campodonico Responsabile dell'Unità di Terapia Intensiva Cardiochirurgica - Azienda Ospedaliera di Parma ricrob@mbox.vol.it Anestesia e malattie epatiche Andrea De Gasperi Gruppo trapianti epatici / CCM - Ospedale Niguarda - Milano Medicina critica e dell'emergenza Antonio Gullo Professore di Terapia Intensiva - Direttore del Dipartimento di Anestesia e Terapia Intensiva -Università di Trieste Anestesia ed informatica Vincenzo Lanza Primario del Servizio d'Anestesia e Rianimazione - Ospedale Buccheri La Ferla Fatebenefratelli - Palermo Tossicologia Carlo Locatelli Direttore del Centro di Informazione Tossicologica Centro antiveleni di Pavia - Fondazione Scientifica "Salvatore Maugeri Clinica del Lavoro e della Riabilitazione"- Pavia Terapia Antalgica e Cure Palliative Sebastiano Mercadante Aiuto del Servizio d'Anestesia e Rianimazione - Ospedale Buccheri La Ferla Fatebenefratelli - Palermo mercadsa@tin.it