Regional analgesia in Italy: A survey of current practice

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European Journal of Pain Supplements 4 (2010) 219–225

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Regional analgesia in Italy: A survey of current practice Massimo Allegri a,⇑, Thekla Niebel a,b, Dario Bugada c, Flaminia Coluzzi d, Marco Baciarello e, Marco Berti e, Carmine Tinelli f, Battista Borghi g, Paolo Grossi h, RICALOR Group Investigators 1 a

Pain Therapy Service, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy Department of Surgical Science, University of Pavia, Pavia, Italy c Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy d Department of Anesthesia, Intensive Care and Pain Therapy, ‘‘La Sapienza” University of Rome, ICOT-Polo Pontino, Rome, Italy e Anesthesiology and Reanimation, Ospedale Maggiore di Parma, University of Parma, Parma, Italy f Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy g Department of Surgery and Anaesthesiology Sciences, University of Bologna Research Unit of Anesthesia, Istituto Ortopedico Rizzoli Bologna, Italy h Department of Regional Anesthesia and Pain Therapy, IRCCS Policlinico San Donato, San Donato Milanese (MI), Italy b

a r t i c l e

i n f o

Keywords: Postoperative pain Regional anesthesia Regional analgesia Acute pain service Peripheral nerve block Epidural block

a b s t r a c t Two decades of attention have focused on regional anesthesia, both central neuraxial blockades as well as peripheral blocks. Though there are a considerable number of recent publications on the topic, the complex issues around the effect of regional anesthesia on outcome have not been completely resolved, possibly because the data are often not procedure-specific. In this survey, we tried to focus on current Italian practice and therapeutical criteria in the management of postoperative pain. We also evaluated how the clinical practice of the respondents follows the international and national guidelines for postoperative pain. A questionnaire was mailed to 64 anesthesiologists who had been identified from a database kept by the RICALOR Group (Registro Italiano Complicanze Anestesia LOcoRegionale – Italian Registry of Complications during Locoregional Anesthesia). The survey requested information regarding demographic data and general management, postoperative pain management and guidelines, and specific questions on epidural analgesia and on peripheral blocks. Only 35 of the 64 anesthesiologists answered the questionnaire and sended it back for analysis. Basing on these 35 returns, data from 51 surgical units (some respondent referred data of more surgical units) leading to 135 departments (surgical units may be constituted by more departments) were analyzed. A total of 245,382 surgical procedures were analyzed. Regional analgesia was used in 46.71% of the procedures. In university and teaching-hospitals, protocols concerning regional anesthesia were attended and shared with the whole staff more often than in non-teaching hospitals (P = 0.0001). For postoperative pain management 31.48% of responders used <10% of regional analgesia, 20.37% used 10–30%, 25.93% used 30–50%, 14.81% used 50–75% and 7.41% used >75% of regional analgesia. We identified a huge variety of responses regarding therapeutical protocols but the majority of responders used the drugs with the best safety/efficacy profile. In conclusion, we demonstrated an improvement in the management of postoperative pain compared to previous studies, but still efforts should be made to standardize daily practice in order to avoid complications and improve safety. Ó 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.

1. Introduction

⇑ Corresponding author. Address: Anesthesia Intensive Care I and Pain Service, Fondazione IRCCS Policlinico San Matteo, V.le Golgi, 27100 Pavia, Italy. Tel.: +39 0382 502627; fax: +39 0382 502226. E-mail address: m.allegri@smatteo.pv.it (M. Allegri). 1 The members of RICALOR Group Investigators are listed after conclusion.

Regional anesthesia (RA) encompasses both central neuraxial blockade and peripheral nerve block techniques that can use effective and safe drugs such as local anesthetics, opioids, and other adjuvants (Ilfeld et al., 2008; Allegri et al., 2009). These techniques can be used as the sole anesthetic technique or in conjunction with general anesthesia or sedation (Ballantyne et al., 2005), and in

1754-3207/$36.00 Ó 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.eujps.2010.09.007

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recent years the continuous (epidural and peripheral) blocks have been used for postoperative pain (POP) management. Metanalyses have shown that RA guarantees better postoperative analgesia than systemic drugs (Rodgers et al., 2000; Beattie et al., 2001; Rigg et al., 2002), with a reduced percentage of side effects compared to intravenous opioid administration (Park et al., 2001; Ballantyne, 2004), particularly in elderly people (Mann et al., 2003). SpeciďŹ c outcomes in speciďŹ c types of surgery, however, such as bowel recovery after abdominal surgery (Werawatganon and Charuluxanun, 2005), can be improved by neuraxial blockade, which also remains the technique of choice for obstetric analgesia and anesthesia (Bloom et al., 2005). In recent years, there has been an increase of the use of peripheral nerve blocks; in fact, they can guarantee the same results as neuraxial ones with less risk of side effects (Brull et al., 2007) and/or they can be used with an optimal outcome when epidurals blocks cannot be used (Davies et al., 2006). Moreover, the use of continuous peripheral nerve catheters allows for extension of the block for analgesic purposes to all the postoperative period (Ilfeld et al., 2010). Monitoring of close relationship between needle and nerve must be afforded using peripheral nerve stimulator (PNS) and ultrasonography. This is true for needles but is still limited for catheters more in relation with ultrasonography (material limitations) than for PNS. Security of the methods depends on the operator and in fact more intraneural injections have been produced and/or reported since ultrasonography is available and in practice. Otherwise the tendency in reducing the dose of local anesthetic and the choice of safer ones is helping in reducing the risk of neurological damage (Abrahams et al., 2009; Grossi et al., 2010). Even if the incidence of severe side effects is rare, it is very important that we approach this technique with full knowledge of the risks in order to improve the outcome of patients (Allegri et al., 2008; Gerner, 2009). Despite these data, the results about morbidity and mortality are far less consistent (Kehlet and Holte, 2001; Rigg et al., 2002; Wu et al., 2005; Capdevila et al., 2008) and all authors stress the importance of adopting speciďŹ c protocols and of choosing the right technique for the right patient and procedure, also considering the context in which the technique is performed (Tziavrangos and Schug, 2006; Fanelli et al., 2008). Nevertheless all these improvements and the guidelines published (American Society of Anesthesiologists Task Force, 2004; SFAR Committees, 2008), recent surveys, evaluating postoperative pain management in hospitals, have identiďŹ ed major deďŹ ciencies (Benhamou et al., 2008; Coluzzi et al., 2009) due to difďŹ culties both in organization and in adopting speciďŹ c postoperative protocols. Independently of literature data, it has become even more important to evaluate how the ‘‘newâ€? techniques and drugs are used in clinical practice and how Italian hospitals are organized in the management of POP. The purpose of this survey is to evaluate how frequently RA is used in postoperative treatments, identify which techniques and drugs are preferred, and consider whether the protocols and anesthesiologists follow a continuous educational program.

is currently investigating the incidence of side effects of regional anesthesia techniques. Non-responders were sent the questionnaire again. The questionnaire was constructed around the topics of the regional analgesia promoted by ESRA Italian Chapter. The questionnaire was developed in accordance with published guidelines on the design of questionnaire surveys (Bruce and Chambers, 2002) and following the STROBE statement (Von Elm et al., 2007). Then, the questionnaire was modiďŹ ed following a pilot study carried out within the Acute–Chronic Pain Department of San Matteo Policlinico – Pavia, and discussion with the audit subcommittee of ESRA Italian Chapter. We divided the questionnaire into four sections related to: Demographic data of the responders: the Italian regions were grouped into three districts: north, center, and south and islands. With regard to their roles, anesthesiologists were classiďŹ ed according to the Italian system, i.e. as resident, ďŹ rst level assistant, Unit Head, or Department Director. Hospitals were classiďŹ ed as university-afďŹ liated, teaching, public, or private hospitals. Postoperative pain management and guidelines: we analyzed whether the hospital followed a standard protocol in POP management, how they chose it, and how RA was used in the management of POP. Finally we analyzed if the hospital provided educational courses about POP management. SpeciďŹ c questions on epidural analgesia: we analyzed the drugs used in local anesthetics, opioids and adjuvants (all the responders completed a questionnaire for every kind of surgery present in their department). SpeciďŹ c questions on peripheral blocks: we analyzed the drugs used in local anesthetics, opioids and adjuvants (all the responders completed a questionnaire for every kind of surgery present in their department). All the answers provided on the returned questionnaires were transcribed onto an EXCEL spreadsheet (Microsoft Corporation, USA) for analysis. 2.1. Statistical analysis The collected data were analyzed using descriptive statistics. They were represented as mean values, calculated on the basis of total answers. Results were analyzed and compared by dividing the samples into different subcategories, namely geographic area, physician’s role and type of structure. For each sub-analysis, results were compared with the mean data of the whole sample using the v2 test or Fisher’s exact test for a sample size below ďŹ ve items. Study was not a priori powered since the participating units were not sampled, but rather they constituted the whole population under study. All tests were two-sided. Data analysis was performed with STATA statistical package (release 10.0, 2009, Stata Corporation, College Station, Texas, USA). Results were adjusted for multiple testing. The P value was calculated vis-Ă -vis the national average. Differences were considered signiďŹ cant at P 6 0.05. 3. Results

2. Methods Data were collected from a 19-item questionnaire (Appendix A) sent, in April 2010, to the anesthetists in 64 units including thoracic, abdominal, urological, gynecological, orthopedic, pediatric and vascular departments in Italy. The units and individuals responsible were identiďŹ ed from a database kept by centers who participate in the RICALOR (‘‘Registro Italiano Complicanze Anestesia LOco-Regionaleâ€? – Italian Registry of Complications during Locoregional Anesthesia) Study, a 3-year prospective study that

The questionnaire was mailed to 64 lead anesthetists. A total of 36 (15 responding to the ďŹ rst appeal and 21 to the second) replies were received, indicating a response rate of 56.25%. Data were complete in all questionnaires. One of these was discarded because one unit had disappeared through mergers. The remaining 35 returns were suitable for analysis, giving an overall response rate of 54.69%. Basing on these 35 returns, data from 51 surgical units (some respondent referred data of more surgical units) leading to 135

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departments (surgical units may be constituted by more departments) were analyzed. A total of 245,382 surgical procedures were analyzed. Regional analgesia was used in 46.71% of the procedures. The regional distribution of responders showed a representative sample among the different geographic groups, 82.86% in the north, 11.43% in the center, and 5.71% in the south and islands of the country. 3.1. Demographic data and general management Ten (28.57%) of the hospitals were university-affiliated, six (17.14%) were teaching-hospitals, 17 (48.57%) were public and two (5.72%) were private. For the low sample size we distinguished only between teaching and non-teaching hospitals for further analysis. Of the 35 investigators, 15 (42.86%) were female and 20 (57.14%) were male. Six (17.14%) were residents, 16 (45.71%) were first level assistants, nine (25.71%) were Simple Operating Unit managers, and four (11.43%) were Complex Operating Unit managers. Data from 51 surgical units were available for analysis, showing a total of 245,382 surgical procedures performed during 2009. Regional analgesia was used in 101,174 procedures, which means a percentage of 46.71% (SD ±19.79). We received questionnaire from six mono-departmental and 29 pluri-departmental units for a total of 135 departments. Through the 26 abdominal departments the mean average was 30% (0.1–79.1%) in using RA. The three urological departments showed a mean percentage of 50% (30–74.9%) in utilizing RA. The application of RA was 30% (0.03–80%) in the 19 gynecological departments, but increased to 40.5% (0.01–99%) in the 14 obstetric departments. The eighteen thoracic surgeries showed a 50% (0– 100%) mean average in using RA. In the 29 orthopedic departments the average utilization of RA was 70% (0.07–100%). The 14 vascular departments showed a mean percentage of 27.5% (0–97%) in using RA. Finally, the average rate for the 12 pediatric departments was 40% (0–100%) (Fig. 1). 3.2. General questions concerning postoperative pain management and guidelines To the question concerning the utilization of protocols for the postoperative treatment (Fig. 2), five responders replied with ‘‘no”, and all of these came from non-teaching hospitals (P = 0.043). Seventeen responders shared the protocols with a few colleagues only. Fifteen replies of those arrived from nonteaching hospitals acquiring a statistical significance (P = 0.002). Furthermore, 17 teaching versus six non-teaching hospitals

Fig. 1. Mean average percentages of RA used for analgesia in each surgical department.

Fig. 2. Differences between teaching and non-teaching hospitals in answering to question A: ‘‘do you use protocols for postoperative treatment in your department?”.

(P = 0.0001), confirmed that protocols were used by the whole staff of anesthesiologists. Sixteen affirmed that the protocols were approved by sanitary direction. There was no statistical difference between the two groups of hospitals (P = 0.623). The second question concerned protocols or guidelines for RA management (Fig. 3). Thirteen hospitals used international and 11 used national protocols or guidelines for RA management. Forty-two confirmed that their protocols and guidelines were taken from literature and adapted to local use. Only one used no protocols for RA management. No statistical difference could be revealed regarding the two types of hospitals (P > 0.1). All responders (100%) mentioned rescue dose beside RA in their protocol. The drugs mentioned as rescue doses were acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids (tramadol, codeine, morphine, oxycodon, buprenofine, and sufentanil) and local anesthetics for continuous RA (levobupivacaine, ropivacaine and mepivacaine). The responses concerning drugs and dosages were so heterogeneous that it was not possible to analyze the data. The next question looked at the kinds of devices and endovenous analgesia used habitually for severe postoperative pain. Twenty centers used patient controlled analgesia, 11 used continuous infusion of tramadol, 10 used continuous infusion of morphine with an electronic pump, and 29 used continuous infusion of morphine with an elastomeric pump. Concerning the use of PCA the distribution between teaching (14) and non-teaching hospitals (6) was statistically significant (P = 0.002). A total of 31.48% of respondents used <10% of RA, 20.37% used 10–30%, 25.93% used 30–50%, 14.81% used 50–75% and 7.41% used >75% of RA for postoperative pain management in 2009. We could not reveal any statistical difference between the subgroups in relation to RA during pain management (Fig. 4).

Fig. 3. Differences between teaching and non-teaching hospitals in answering to question B: ‘‘do you use protocols or guidelines for RA management?”.

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Fig. 4. Percentages of RA used for postoperative pain management, divided into teaching and non-teaching hospitals.

In 2009, 4.26% of the anesthetists used bolus, continuous infusion and PCEA for epidurals, 10.64% used bolus and continuous infusion, and 2.13% used bolus and PCEA. Furthermore 6.38% used only bolus for epidural analgesia, 72.34% used only continuous infusion, and 4.26% used only PCEA. In the same period, four responders utilized bolus for paravertebral analgesia, two used continuous paravertebral infusion and three responders used both. Also during the same period, 12 responders utilized bolus for perinervous analgesia, 12 used continuous perinervous infusion and 12 responders used both. Concerning wound infiltration, 25 anesthesiologists gave boluses, one gave only continuous, and one gave both. Regarding continuous epidural analgesia or peripheral nerve block duration, nine stated 24 h, six stated 30 h, 34 stated 48 h, five stated 50 h, and 12 affirmed longer periods. Twelve responders mentioned duration of 1 h, and one declared 6 h. More than 79% of the responders had attended more than one educational program on RA management in the last 2 years, and 13% had attended once. Only 7% of the anesthesiologists had not attended any refresher courses in the last 2 years. There were no statistical differences between teaching and non-teaching hospitals. 3.3. Questions on epidural analgesia The question of whether they used test dose during epidurals was answered by 93.18% positively and negated by the remaining 6.82%. Lidocaine 0.5–2%, levobupivacaine 0.5–1.25%, ropivacaine 0.1–2% and mepivacaine 1–2% were mentioned. About 1–5 ml was habitually administered, but the majority declared 2 ml. For the full dose during epidural analgesia, levobupivacaine 0.1–0.15% and ropivacaine 0.05–0.75% were declared, while lidocaine was mentioned once. Seventeen (32.08%) of the participants always used opioids in RA, 15 (28.30%) used them often, nine (16.98%) sometimes, two (3.77%) seldom, and 10 (18.87%) never used them. During epidurals the investigated anesthetists used morphine in 30% (18 replies) (with 2–3 mg epidurally and 0.1 mg spinally), fentanyl in 23.33% (14 replies) (0.2–1 lg/ml epidurally), and sufentanil in 46.66% (28 replies) (with 0.1–0.75 lg/ml epidurally and 2.5 lg spinally). As adjuvants for RA, 12 respondents used clonidine, four used ketamine and one used epinephrine. No other adjuvants were mentioned. 3.4. Questions on peripheral blocks All the 44 responders utilized auxiliary techniques for peripheral blocks; 21 used neurostimulators, one used ultrasound, and the

remaining 22 used both. Nobody performed peripheral blocks without auxiliary techniques. The question regarding the use of test dose during peripheral blocks was answered only by 11 anesthesiologists. The others did not answer. Lidocaine, levobupivacaine, ropivacaine and mepivacaine were mentioned. Data about dosage and administration route were incomplete, so no analysis was possible. For the full dose during peripheral blocks for regional analgesia, lidocaine 1%, levobupivacaine 0.125–0.5%, ropivacaine 0.2–0.75% and mepivacaine 1.5% were mentioned. A dose of 6–40 ml was administered during the procedure. Thirty-six never used opioids during peripheral blocks, two participants do use them ever and one anesthetist each answered often, sometimes and seldom. One responder added morphine, two added fentanyl and one chose sufentanil for his blocks. Ten respondents confirmed clonidine and a single one confirmed ketamine as adjuvants during peripheral blocks. No other adjuvants were declared.

4. Discussion An important European survey (Benhamou et al., 2008), evaluating POP management in European hospitals, identified four topics as major deficiencies in postoperative pain management: professionals’ education, patient information, evaluation of pain, and protocols. In addition, results from a recently conducted national survey (Coluzzi et al., 2009) suggest that postoperative pain continues to be under-managed in Italy, showing that pain services and analgesic techniques chosen by Italian anesthesiologists are well below the European standards. Both surveys showed a difference between the ‘‘ideal” POP management represented by the literature and the clinical current practice in all hospitals. In our survey, we tried to evaluate how RA is actually used in the POP management and how POP protocols are chosen in different hospitals. In our study, we confirmed that there is still a need to improve our POP management as demonstrated due by the fact that only 51% of responders regularly attended protocols, 38% used protocols shared randomly and only 11% still used no protocol. We noted an improvement compared to the previous surveys, but we can still do better. It is important to notice that there is a significant correlation between the types of hospital, teaching and non-teaching. It is important to underline that only 28.5% used national or international guidelines for RA management. The majority (68.6%) used local adapted guidelines and the remaining 2.9% did not use any. Nevertheless almost all responders stated that they prescribed a rescue dose routinely even though there was great heterogeneity in the choice of the drugs. It is very important to underline this data because in the Benhamou’s work (Benhamou et al., 2008) they report that only 40% of responders had a ‘‘red flag” pain score that determine the administration of rescue therapy. Otherwise the majority of responders prolonged the POP management for more than 24 h (even if only 15.2% for 72 h). We observed that a high percentage (93%) of the participants attended educational programs about POP management (without any difference between teaching and non-teaching hospital). Also this data is higher than those reported in previous studies and it could indicate that ‘‘postoperative pain treatment” is becoming an educational topic in all types of hospital. Another significant finding of the data is that, although in literature, PCA is the most effective technique among protocols, we observed that the majority of hospitals still used elastomeric pumps, while PCA and electronic pumps were not common. Also, in this case there was a statistical difference between the types of hospitals (PCA was almost exclusively used in teaching-hospitals).

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In this case all these observations identify that we are still quite far from the gold standard suggested by Benhamou et al. (2008). A positive element of the data was that, in accordance with literature suggestions, a relatively high percentage of procedures used regional anesthesia/analgesia in Italian hospitals (46.71%) with a peak of 70% in orthopedic and 50% in thoracic surgery, where regional anesthesia has been proved to be the best choice for POP management. As discussed by Fanelli et al. (2008) it could be important to note that the increasing in the use of RA should be contextually followed by the increase of the quality level of POP management. In fact, the absence of adequate monitoring, equipment, motivation and coordination, even the best techniques may fail to show an improvement of patient outcome. Analgesic efďŹ cacy should always be balanced against safety and the ability to monitor patients in order to reduce complications that may actually impair recovery. Analyzing the data on the neuraxial technique we can observe that all of responders used safer local anesthetics such as levobupivacaine or ropivacaine, and none used bupivacaine anymore, as it has been shown to be more toxic than previously thought. All responders indicated a great variety of concentrations and volumes. The mostly used opioid was sufentanil (46.7%). Quite a large percentage of responders also used adjuvants, mainly clonidine. Analyzing the data on peripheral techniques we can observe that also in this case the majority of responders used safer local anesthetics (levobupivacaine and ropivacaine). A small proportion of responders (12%) also used opioid or adjuvants (clonidine was the most frequently chosen). Responders indicated a great variety of concentrations and volumes. It is interesting to note that all participants used ultrasound or electric guidance for their peripheral nerve blocks and 50% used both. Unlike other previous surveys, we succeeded in underlining that the heterogeneity of therapeutical practice (different drugs as rescue doses and various concentrations and volumes of RA drugs) could be a signiďŹ cant problem and a source of complications and behavioral errors. We should make the effort to implement uniform daily practice using evidence-based protocols in order to avoid complications and improve the safety of our treatment. We cannot evaluate if the improvements noted are homogenously distributed in our country. Coluzzi et al. (2009) in a precedent survey underlined the differences in the standard level between north and south. The present study has potential limitations. Firstly, it has a bias due to the non homogeneous distribution of responders (mostly located in the north of Italy). Besides this, the high percentage of use of the RA technique (46.71% in our study versus 21% in POPSI study) could be justiďŹ ed also by the fact that the centers that participated in this study may have been more interested in this topic since they were enrolled by ESRA Italian chapter and are participating in a prospective study about side effects in RA.

5. Conclusion This survey on Italian hospitals provided evidence that there are some areas in which we have to improve (mainly to standardize our clinical practice to that suggested by the literature), but at the same time it showed how neuraxial and peripheral techniques are widely used in POP management, offering the choice of the best drugs and techniques. The differences between teaching-hospitals and other hospitals could signal that we also have to improve in our scientiďŹ c continuous education (Schwinn and Baiser, 2006; BrĂśking and Waurick, 2006). Finally, it is obvious that with the increasing use of these techniques it is even more important to perform a prospective study to identify the real incidence of side effects in order to understand the real proďŹ le of risk/beneďŹ t of RA.

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5.1. Funding source On behalf of my co-authors, I state that The work and my Department has been founded by a grant of ScientiďŹ c Direction of Fondazione IRCCS Policlinico San Matteo, The work have not received any other source of grant including gifts, contracts, equity interest, stock option(s), direct or indirect salary support, consultant fee(s), lecture/travel fees or honoraria received within a period of 3 years of the date of submission of the manuscript from any source (including nonproďŹ t foundations) which has or had ďŹ nancial interest in subject matter, materials, equipment or devices discusses. Any author or participant have not any ďŹ nancial interest (patent, patent licensing arrangement(s), stock, equity interest or any other arrangement which may be of actual or potential ďŹ nancial beneďŹ t to any author or participant) in the subject matter, materials or equipment discussed or incompeting materials

6. Conict of interest None.

7. RICALOR Group Albani A. Department of Anesthesia and Intensive Care, Ospedale Regionale Valle d’Aosta, Aosta, Italy Ambrosoli AL. Department of Anesthesia, Ospedale di Circolo and Fondazione Macchi, Varese, Italy Avallone V. Department of Anesthesia and Reanimation, Azienda Ospedaliera CTO, Torino, Italy Barbaglio C. Department of Regional Anesthesia and Pain Therapy, IRCCS Policlinico San Donato, San Donato Milanese (MI), Italy Baronio M. Department of Anesthesia and Reanimation, Ospedale Sant’Orsola Fatebenefratelli, Brescia, Italy Bonarelli S. Department of Anesthesia and Intensive Care, Istituto Ortopedico Rizzoli, Bologna, Italy Boracchi EM. Department of Anesthesia and Reanimation, Ospedale di Gallarate – Varese, Italy Bosco M. Department of Anesthesia, Complesso Integrato Columbus, Roma, Italy Buffone A. Department of Anesthesia, ICOT Lazio, Latina, Italy Carassiti M. University Policlinic Campus Bio-Medico, Roma, Italy Caristi D. Department of Anesthesia, Reanimation and Pain Therapy, Cattinara University Hospital – Trieste, Italy Ceffa C. Department of Anesthesia and Reanimation, University Hospital ‘‘Maggiore della CaritĂ â€?, Novara, Italy DaviĂ G. Department of Anesthesia and Reanimation, Policlinic Abano Terme, Padova, Italy Delazzo M. Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy Deni F. Department of Anesthesia and Reanimation, IRCCS S. Raffaele, Milano, Italy Dente S. Department of Anesthesia, Reanimation and Pain Therapy, Bolzano General Hospital, Bolzano, Italy Disma N. Department of Anesthesia, IRCCS Gaslini, Genova, Italy Dottore B. Department of Anesthesia and Reanimation, S. Maria della Misericordia Hospital, Udine, Italy Fanzago E. Department of Anesthesia and Reanimation, Cardinal Massaia Hospital, Asti, Italy Fattorini L. Department of Anesthesia and Reanimation, ASUR zona territoriale 5, Jesi, Ancona, Italy Gullotta S. Department of Anesthesia, ‘‘CittĂ di Quartuâ€? Policlinic, Cagliari, Italy

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Manassero A. Department of Anesthesia and Reanimation, ‘‘S. Croce e Carle� Hospital, Cuneo, Italy Marzullo A. Department of Anesthesia and Reanimation, S. Giovanni Battista Hospital, Molinette, Torino, Italy Mazza A. Department of Anesthesia, Santa Corona Hospital, Pietra Ligure, Savona, Italy Mossetti V. Department of Anesthesia and Intensive Care, ‘‘Regina Margherita� Children’s Hospital, Torino, Italy Palermo S. Department of Anesthesia, University of Genova, Genova, Italy Pinciroli RL. Department of Anesthesia, Reanimation and Pain Therapy, Ospedale Civile di Legnano, Milano, Italy Scatto A. Department of Anesthesia and Reanimation, Azienda Ospedaliera Padova, Padova, Italy Seveso M. Department of Anesthesia, S. Carlo Borromeo Hospital, Milano, Italy Taddei S. Department of Anesthesia and Intensive Care, Presidi Ospedalieri Area Nord, Bologna, Italy Ternavasio CG. Department of Anesthesia, Reanimation and Pain Therapy, Sant’Andrea Hospital, Vercelli, Italy Tripi G. Department of Anesthesia and Reanimation, University Hospital ‘‘Santa Maria della Misericordia�, Udine, Italy Vitale G. Department of Anesthesia and Reanimation I, San Gerardo Hospital, Monza, Italy Zadra N. Department of Anesthesia and Reanimation, Azienda Ospedaliera Padova, Italy Zarcone A. Department of Day-Hospital Surgery, ‘‘Gavazzeni� Clinic, Bergamo, Italy

Appendix A The questionnaire sent to all participants.

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