postoperative analgesia in thoracic surgery a comparison between continuous paravertebral nerve block and continuous incisional infusion with onq pain relief system

Objectives: Thoracotomy is one of the most painful surgical stimuli and inadequate management of postthoracotomy pain is often associated with pulmonary and cardiac complications. The aim of this prospective, randomized, double-blinded study was to compare continuous paravertebral block versus continuous incisional infusion with OnQ Pain Relief System. Methods: Forty eight patients, undergoing thoracotomy for elective lobectomy, were randomized to receive a continuous paravertebral infusion of bupivacaine 0.25% through an elastomeric pump which delivers 0.1 mL/Kg/h (group A) or a continuous incisional infusion of bupivacaine 0.25% at an infusion rate of 4 mL/h with OnQ Pain Relief System (group B). Both infusions were started before wound closure, and continued for 48 postoperative hours. General anaesthesia was standardized. In the recovery room, patients were provided with intravenous morphine patient-controlled analgesia (PCA). Visual analogue scale at rest (VASr) and when coughing (VASi), rescue patientcontrolled analgesia morphine consumption, hemodynamic, time to ambulation and side-effects were evaluated within 48 h. Results: The two groups were comparable regarding to patients' number and characteristics, type of surgery, time to ambulation and side-effects; postoperative hemodynamic profile was stable in all the patients. Absolute pain scores were low in both groups; patients in group A reported significant lower VASr and VASi values during the postoperative 48 hours compared with group B (p<0.001). Total morphine consumption and PCA requests number were significantly lower in group A than in group B (p= 0.05 and p< 0.01). Conclusions: Continuous incisional infusion of local anesthetic is not as effective as paravertebral analgesia after thoracotomy

Unintetional tracheal extubation during prone position: what is the best rescue airway device?

Unintentional tracheal extubation during surgery is a dramatic situation and may be a life-threatening event if it is not followed by a rapid reintubation. This is particularly true in patients with difficult airways or in patients whose airways are difficult to access such as patients undergoing facial surgery or in prone position. The patient prone is a problem for the anesthesiologist because accidental tracheal extubation in this setting could be a catastrophic event often treated by turning the patient supine for ventilation and tracheal re intubation. However, patient's rotation in supine position is not always achievable and requires time, the support of personnel not necessarily immediately available, and it may contaminate the sterile surgical field with serious postoperative complications.[1] In the last years, several reports have been published to describe the anesthesiological management after unexpected intraoperative tracheal extubation particularly focusing on devices more often used.[2,3] The laryngeal mask airway (LMA) has become the most used device in the catastrophic situation \u201ccannot intubate, cannot ventilate\u201d and in literature, it has been described its insertion as rescue airway management in patients with unintentional tracheal extubation during general anesthesia in prone position.[4] In 1993, McCaughey and Bhanumurthy have inserted for the 1st time a supraglottic airway device (SAD) following the induction in prone position and from that time several studies have been performed to valuate the facility and the security of insertion in this position. In fact, it has been shown that prone insertion may be easy as in the supine because the tongue falls anteriorly and creates an open space for the placement of LMA device (LMAD), whose seal is improved by the cephalic displacement of the larynx. Moreover, the risk of aspiration is reduced because regurgitant fluid for the gravity will be drained from the airway.[5] In the issue of \u201cJournal of Emergencies, Trauma, and Shock\u201d Gupta et al. describe an observational study that they conducted to test the feasibility of SAD insertion for ensure airway ventilation in prone position and fixed head as in neurosurgical patients during accidental extubation.[6] Forty partecipanting anesthesia residents were asked to place to airway trainer (Laerdal) manikin in the prone position three SADs; i-gel, LMA Proseal\u2122 (PLMA), and LMA Classic\u2122 (CLMA). The authors found that despite all three SADs were successful as rescue devices during accidental extubation in prone position, however, the ease of insertion was maximum with i-gel followed by CLMA and PLMA, in fact, i-gel was characterized by fewer time taken for insertion, least resistance in insertion, no maneuvers required for optimal positioning and bronchoscopic view and insertion score was significantly higher with i-gel as compared to CLMA and PLMA. Therefore, the authors compared three different SADs of which CLMA belongs to the first generation of LMA, whereas PLMA and i-gel to second generation of LMA. Second generation LMA was born to reduce the problems associated to the first generation LMA such as the difficult in positioning, the relatively low airway pressures with the risk of aspiration, and dislodgment. The second generation LMADs like proseal have a gastric channel allowing the passage of a tube for gastric decompression. i-gel is a more recent SAD with a non-inflatable cuff made of a thermoplastic elastomer, able to provide a seal by conforming to differently shaped throats. Several studies have compared the i-gel with various types of LMADs regarding to efficacy and ease of insertion. In a systematic review and meta-analysis performed by de Montblanc et al., i-gel was superior regarding first generation LMAD in terms of time of insertion and leak pressure despite this superiority was not for i-gel compared to the second generation LMADs. The main clinical advantage of the i-gel was the less frequent sore throat.[7] Furthermore, in the study of Gupta et al. i-gel seems to have better quality of insertion. The novelty of this manuscript is that the authors' aim was to compare the insertion of different SADs in prone position during emergency situations such as accidental extubation and nowadays the evidence is lacking regarding the feasibility of SADs insertion in prone position in emergency situations because all the data were derived from elective setting or observational studies and case reports and translation of experience of elective cases into emergent situations could be misleading. It is not ethic to conduct randomized clinical trials to test the best rescue airway device for emergency airway management. Therefore, the authors have tried to get around this limit by performing a manikins study. In recent years, it became very difficult to conduct clinical research and obtain ethical approval. Therefore, it was born a research based on manikin studies. For these studies, the approval ethic committee is usually easily obtained, there are no adverse effects, and the studies can be fastly completed. However, manikins are not like real patients for their hard plastic and lack of secretions so the results cannot be simply extrapolated and extended to humans. Howes et al. have evaluated the insertion of LMA supreme first in a manikin and then in patients. All partecipants have inserted successfully the device at the first attempt in the manikin phase of the study. In the patient phase of the study, insertion was successful in only 86% of cases on the first attempt.[8] Rai and Popat have attributed this difference to population diversity that could not be simulated and that is clinically challenging.[9] The studies evaluating the feasibility of insertion of SADs in elective prone position after induction of anesthesia have stressed that the anesthesiologist should have considerable experience with the use of supraglottic airways in the prone position and that for these techniques low-risk patients should be selected. Moreover, the frequent endpoints of the studies regarding positioning of SADs in prone position evaluate the simplicity of insertion, the reduction of complications, and the insertion speed but probably the most important issue in this situation is the most appropriate SAD in terms of successful of insertion, adequate ventilation, utility for intubation through laryngeal mask, and the best position of the operator to insert the device. In fact, for the insertion in prone position different techniques have been described. Some authors describe the insertion of the SAD by the anesthesiologist while an assistant opens the patient's mouth by extending the tip of the patient's chin while in the Stevens and Mehta technique the assistant extends and turns the patient's head to the side.[10,11] However, the condition of insertion of SAD is quite different in an emergency situation, and the expertise of the operator is very important to position the LMA. The insertion of SAD is not elective, and the head cannot be turned. The evenience of an unaspected extubation during surgery in the operating room is not paragonable with the scenario described by authors. Therefore, it is not possible to extrapolate the experiences from the elective to the emergent situation since the insertion of SADs in prone position and emergency situations is not like the insertion in elective series where preoxygenation is often performed and a second bed is positioned alongside the operating table. Furthermore, the assistance of another operating room nurse or anesthesia assistant is often required to open the patient's mouth during the SAD insertion.[10] In conclusion, more prospective randomized studies are needed to investigate the best management for airway management in patient in prone position. Many questions exist regarding to the best device to be used for the feasibility of insertion and the patient's security and currently, the first recommendation for the anesthesiologists involved in surgical procedures with the patient in prone position is to firmly anchor the endotracheal tube to avoid an accidental extubation because the question regarding which SAD is the best choice is still unresolved

Effect of remifentanil and fentanyl on postoperative cognitive function and cytokines level in elderly patients undergoing major abdominal surgery

Purpose Postoperative cognitive dysfunction is a frequent complication occurring in geriatric patients. Type of anesthesia and the patient's inflammatory response may contribute to postoperative cognitive dysfunction (POCD). In this prospective randomized double-blinded controlled study we hypothesized that intraoperative remifentanil may reduce immediate and early POCD compared to fentanyl and evaluated if there is a correlation between cognitive status and postoperative inflammatory cytokines level. Methods Six hundred twenty-two patients older than 60 years undergoing major abdominal surgery were randomly assigned to two groups and treated with different opioids during surgery: continuous infusion of remifentanil or fentanyl boluses. Twenty-five patients per group were randomly selected for the quantitative determination of serum interleukin (IL)-1β, IL-6, and IL-10 to return to the ward and to the seventh postoperative day. Results Cognitive status and its correlation with cytokines levels were assessed. The groups were comparable regarding to POCD incidence; however, IL-6 levels were lower the seventh day after surgery for remifentanil group (P= .04). No correlation was found between POCD and cytokine levels. Conclusions The use of remifentanil does not reduce POCD

Ultrasound Assisted Spinal Anesthesia: A Safety Procedure or a Lost of Time?

The role of ultrasound (US) in central neuraxial blocks has often been underestimated, partly due to the relative efficacy of blind ...

A year in review in Minerva Anestesiologica 2014

Year in revie

Is sedation for endoscopy as safe as you think?

1118 Minerva Anestesiologica N November 2017 I n this issue of Minerva Anestesiologica, Brumby et al.8 report an observational pilot study assessing the incidence of failure to recover at day 1 and in subsequent days and weeks after either colonoscopy, gastroscopy, or both procedures combined in 102 patients of over the age of 18 years. Recovery was evaluated not only using physiologic endpoints but also evaluating other aspects such as nociception, emotion, activities of daily living (ADL), and cognition on the following day as well as over a 1-month follow-up period using the multidimensional Postoperative Quality of Recovery Scale (PostopQRS ). All the patients received total intravenous anesthesia with propofol alone or in combination with opioids. Some participants received midazolam or opioids in the pre-operative period. The authors have seen that incomplete recovery is common after colonoscopy, gastroscopy or both procedures. Failure to recover was mainly due to failure in nociceptive and cognitive recovery at day 1 with modest but clinically important differences in early quality of recovery between the procedures. C orrectly, the authors underline that recovery after endoscopic procedures should be defined by a multidimensional tool able to assess emotive, functional and cognitive domains. T his is particularly important because the patients must be discharged as soon as possible and should return to preoperative levels of independency in activities of daily living. Anesthesia demand for colonoscopy and gastroscopy is increasing each year and this is due to need of diagnostic or screening programs and therapeutic management of acute pathologies or neoplastic diseases. Because of the air or CO 2 insufflation for adequate distention and visualization of the gastrointestinal lumen, the endoscopic procedures are associated with significant pain and discomfort, therefore sedation is often required to improve patient tolerance and safety.1, 2 Propofol alone or combined with midazolam and opioids is commonly used for sedation although drugs as etomidate and dexmedetomidine have been introduced.3, 4 Usually, the procedures are ambulatory and the patients must be discharged soon after the endoscopy. Adverse events during sedation for endoscopy are very low and anesthetic techniques are performed to provide sedation minimizing hemodynamic changes and allowing faster emergence and patient\u2019s discharge. Patients can return to their daily lives safely and promptly as soon as have recovered to pre-procedural baseline physical performance.5 However, optimal recovery after sedation for endoscopy is not always observed. C ommonly, a patient\u2019s discharge is related to recovery time, adverse events and physiological parameters such as level of consciousness and stability of vital signs.6, 7 EDITORIAL I s sedation for endoscopy as safe as you think? Germano DE COS MO 1 *, Elisabetta CONGEDO 2 1Department of Anesthesia and Intensive Care, Sacro Cuore Catholic University, Rome, Italy; 2Department of Anesthesia and Intensive Care, Antonio Perrino Hospital, Brindisi, Italy *Corresponding author: Germano De Cosmo, Department of Anesthesia and Intensive Care, Sacro Cuore Catholic University, via G. Moscati 31, 00168 Rome, Italy. E-mail: [email protected] C omment on p. 1161. Minerva Anestesiologica 2017 November;83(11):1118-20 DOI : 10.23736/S0375-9393.17.12260-1 \ua9 2017 EDIZIONI MINERVA INERVAINERVA MEDICA O nline version at http://www.minervamedica.it COPYRIGHT\ua9 2017 EDIZIONI MINERVA MEDICA This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. SA FET Y OF SE DATIONATION FOR EN DOSCO PY DE COS MO V ol. 83 - No. 11 Minerva Anestesiologica 1119sedated with propofol or remifentanil.14 Allen et al. have shown that the incidence of post-procedural cognitive impairment was similar in patients randomized to light versus deep sedation. In addition, the authors have not considered pain an important risk factor for post procedural cognitive dysfunction, especially if the endoscopic procedure is diagnostic and not operative.16 S harma et al. have investigated cognitive function in 108 patients with cirrhosis undergoing endoscopy under sedation with propofol. Before and two hours after endoscopy psychometric tests have been administered to evaluate cognitive function. The authors have not found a worsening of the psychometric tests after the endoscopy.17 T hese differences can be due to several factors: the type and sensitivity of the psychometric tests used, the variation also in the healthy subjects\u2019 performance at a few days away, the too small simple size. There is a wide confidence interval of evaluated parameters that indicates that there is a great variation of response in the various subjects, due to a small simple size.18-20 I n conclusion, thousands of endoscopic procedures are performed daily and the main question that this article raises is to understand what means recovery from a procedure: an adequate recovering goes beyond vital functions. Incomplete recovery can last up to one month and is mainly due to nociceptive and cognitive impairment that could also occur in young people undergoing minor procedures. Therefore, subsequent studies might need to investigate if and how a low impact procedure can induce cognitive impairment and the main parameters that should be assessed to consider a patient overall recovered utilizing appropriate tests that can identify the most vulnerable patients. References 1. A Allen ML. Safety of deep sedation in the endoscopy suite. Curr Opin Anaesthesiol 2017;30:501-6. 2. L Leslie K, Allen ML, Hessian EC , Peyton PJ, Kasza J, Courtney A, et al. Safety of sedation for gastrointestinal I n literature, the reported incidence of Postoperative Cognitive Dysfunction (POC D) varies from 20% to 60% between 6 weeks to 3 months after surgery and the causes of this variability are related to type of surgery, duration, patient\u2019s age and cultural level.9 T he prevalence of POC D has primarily been studied in elderly patients undergoing cardiac surgery.10 However, its frequency should be very rare after endoscopic procedure especially in young people because stress associated to endoscopic procedures is very low as well as the increase of pro-inflammatory cytokines that play a pivotal role in cognitive dysfunction.11, 12 T he novelty of the study by Brumby et al. is that the people enrolled are young, without risk factors for postoperative cognitive dysfunction, and not undergoing major surgery. S urprisingly, a not negligible percentage of patients had a cognitive impairment not only in the early post-procedural period but until one month and perhaps for a longer time if follow-up period would be prolonged. Patients in the gastroscopy group have a lower frequency of overall recovery. We have to consider that both endoscopic procedures have affected not only cognitive function but also pain. Authors do not report if there is a correlation between POC D and the presence of pain despite they have seen that patients undergoing combined procedures had more pain over the entire 1-month follow-up period and a more cognitive impairment at day 1 than participants having only colonoscopy. However, these results should be observed with caution not only because endoscopic procedures have been considered with little impact on daily physiological activity and on cognitive and nociceptive domain but also because few studies have been performed, and only for few days.13-15 Moreover, the studies performed give different results. T heodorou et al. have demonstrated cognitive impairment up to 120 minutes after propofol/midazolam/fentanyl or nitrous oxide/sevoflurane sedation for colonoscopy.13 Instead, Moerman et al. have not found cognitive dysfunction after 15 min in colonoscopy patients COPYRIGHT\ua9 2017 EDIZIONI MINERVA MEDICA This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher. DE COS MO SA SA FET Y OF SE DATIONATION FOR EN DOSCO PY 1120 Minerva Anestesiologica N November 2017gedo E, De Cosmo G. Cognitive Dysfunction after Surgery: An Emergent Problem. J Alzheimers Dis Parkinsonism 2017;7:1. 13. T Theodorou T, Hales P, Gillespie P, Robertson B. Total intravenous versus inhalational anaesthesia for colonoscopy: a prospective study of clinical recovery and psychomotor function. Anaesth Intensive Care 2001;29:124-36. 14. Moerman ATAT, Foubert LA , Herregods LL , Struys MM, De Wolf DJ, De Looze DA, et al. Propofol versus remifentanil for monitored anaesthesia care during colonoscopy. Eur J Anaesthesiol 2003;20:461-6. 15. Fredman B, Lahav M, Zohar E, Golod M, Paruta I, Jedeikin R. The effect of midazolam premedication on mental and psychomotor recovery in geriatric patients undergoing brief surgical procedures. Anesth Analg 1999;89:1161-6. 16. A Allen M, Leslie K, Hebbard G, Jones I, Mettho T, Maruff P. A randomized controlled trial of ligh versus deep propofol sedation for elective outpatient colonoscopy: recall, procedural condition and recovery. Can J Anesth 2015;62:1169-78. 17. S Sharma P, Singh S, Sharma BC, Kumar M, Garg H, Kumar A, et al. Propofol sedation during endoscopy in patients with cirrhosis, and utility of psychometric tests and critical flicker frequency in assessment of recovery from sedation. Endoscopy 2011;43:400-5. 18. S tark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology 2013; 118:1332-40. 19. Bowyer AJ, Royse CF. Postoperative recovery and outcomes--what are we measuring and for whom? Anaesthesia 2016;71(Suppl 1):72-7. 20. N Newman S, Wilkinson DJ, Royse CF. Assessment of early cognitive recovery after surgery using the Post-operative Quality of Recovery Scale. Acta Anaesthesiol Scand 2014;58:185-91. endoscopy in a group of university-affiliated hospitals: a prospective cohort study. Br J Anaesth 2017;118:90-9. 3. Padmanabhan U, Leslie K. Australian anaesthetists\u2019 practice of sedation for gastrointestinal endoscopy in adult patients. Anaesth Intensive Care 2008;36:436-41. 4. Davy A, Fessler J, Fischler M, le Guen M. Dexmedetomidine and general anesthesia: a narrative literature review of its major indications for use in adults undergoing non-cardiac surgery. Minerva Anestesiol 2017 Jun 22. [Epub ahead of print] 5. L Leung FW. Trend in use of sedation for low-risk endoscopy. Looking beyond monitored anesthesis care. JAMA 2017;317:2006-7. 6. Feldman LS , Lee L, Fiore J Jr. What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS ) pathways? Can J Anaesth 2015;62:120-30. 7. L Lee L, Tran T, Mayo NE , Carli F, Feldman LS . What does it really mean to \u201crecover\u201d from an operation? Surgery 2014;155:211-6. 8. Brumby AM, Heiberg J, Te C, Royse CF. Quality of recovery after gastroscopy, colonoscopy or both endoscopic procedures: an observational pilot study. Minerva Anestesiol 2017;83:1161-8. 9. R Royse CF, Andrews DT, Newman SN , Stygall J, Williams Z, Pang J, et al. The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery. Anaesthesia 2011;66:455-64. 10. N Newman MF, Mathew JP, Grocott HP, Mackensen GB, Monk T, Welsh-Bohmer KA, et al. Central nervous system injury associated with cardiac surgery. Lancet 2006;368:694-703. 11. De Cosmo G, Sessa F, Fiorini F, Congedo E. Effect of remifentanil and fentanyl on postoperative cognitive function and cytokines level in elderly patients undergoing major abdominal surgery. J Clin Anesth 2016;35:40-6. 12. C Canistro G, Levantesi L, Oggiano M, Sicuranza R, ConConflicts of interest.\u2014The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Article first published online: July 12, 2017. - Manuscript accepted: July 5, 2017. - Manuscript received: June 27, 2017. (Cite this article as: De Cosmo G, Congedo E. Is sedation for endoscopy as safe as you think? Minerva Anestesiol 2017;83:1118-20. DOI : 10.23736/S0375-9393.17.12260-1) COPYRIGHT\ua9 2017 EDIZIONI MINERVA MEDICA This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher

Laryngeal mask airway, so many limitations?

We read with great interest the article published by Rossi et al., entitled \u201cSafety aspects of desflurane anesthesia and laryngeal mask airway.\u201d1 We would like to comment on the patient-related factors limiting laryngeal mask airway (LMA) usage. LMA is usually used in children under 15 years of age and is proven to be safe and effective. Actually, there is a growing interest in its use in association with desflurane. Despite desflurane is less commonly used in this range of population, recent studies reported a relative safe use of this halogenated also in children whose airways were supported with laryngeal mask. For example, Lerman et al. report a frequency of airway events with desflurane similar to those with isoflurane after LMA removal with an awake patient.2 Furthermore, the difference in events removing LMA in awake patients or deep anesthesia is similar in desflurane and sevoflurane use.3 Lastly, in our experience, the safe LMA profile together with desflurane pharmacokinetic, permits to perform anesthesia in young patients undergoing orthopedic surgery also in association with loco-regional analgesia. Second-generation supraglottic airway devices have contributed to the increase in LMA use, therefore these show that obesity is not a factor limiting its use. A Cochrane Review published in 2013 reported a failure positioning LMA rate of 3% to 5% in obese patients but also a good oxygenation with this device.4 According to 2011 NAP4, the limitation regarding LMA use in obese patients includes patients whose surgery was performed in the lithotomy position and/or head down position.5 In addition, in a group of \u201ccervical disorder\u201d like neck flexing difficulty, we suppose that, with caution and surgery related possibilities, LMA can prevent difficulties during intubation and also results as ventilation device bridging to the orotracheal intubation when it is mandatory. In conclusion, we want to congratulate the authors for a clear and well written paper. However, in our opinion, LMA could provide more possibilities.

The use of NSAID,s in the postoperative period:advantage and sdisfantages.

NSAIDs are commonly used as single analgesics in minor surgery or as component of multimodal analgesia with opioids or locoregional techniques in the postoperative period to assure a better analgesia and reduce the dose of opioids. The analgesic potency evaluated as number needed to treat (NNT) is not very different between the traditional non selective NSAIDs and the selective cyclo-oxygenase-2-inhibitors (Coxibs). The effectiveness as analgesic is unquestionable also if these drugs are not devoid to risk. There is debate in literature about the possible side effects when administrered in the perioperative period: anastomotic leakage, reduced ossification, bleeding and acute renal failure. Recent data underline ad the Coxibs but also traditional NSAIDs can induce cardiac toxicity even if they are utilizrd for few days. The aim of this review is to provide an overview of the effectiveness and side effects of selectie and nonselective NSAIDs in the perioperative perio