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Aim: Define pathophysiology, epidemiology, diagnosis and therapy in case of spinal bleeding after central neural blockade (CNB)., Methods: Spinal epidural hematoma (SEH) following CNB may occur due to vascular trauma from needle/catheter placement and can occur in subdural and epidural spaces. Epidural artery bleeding seems the source of SEH: the damage mechanism depends on compression and neural vascular ischemia of cord, nerve roots, ganglion and toxicity from blood cell lysis products. Incidence varies (1:150.000 - 1:500.000) but SEH may be asymptomatic., Conclusions: SEH starts with acute severe low back and/or radicular pain and neurologic signs that may progress to paraparesis, sensory loss and sphincter disturbances. After CNB, the only sign of SEH may be an unusually prolonged motor and sensory block. Symptoms may start even 96 hours after CNB and/or removal of the epidural catheter. Neurological recovery is related to severity and speed of preoperative deficits development and surgical decompression. MR imaging features (diagnostic tool of choice), including degree of cord compression, are useful to establish or confirm the diagnosis of SEH but do not influence the management or predict outcome. Hematoma resolution and severity of neurologic impairment has the greatest impact on management and outcome. Preoperative MRI information and intraoperative evidence of subarachnoid hemorrhage (SAH) and CSF leakage is important: SAH worsens outcome for its negative effect on spinal cord and cauda equina. Conservative therapy may be successful in cases with minimal neurologic deficits, despite cord compression.

The Health Services, not only the Italian one, is under pressure because of request for improving treatment quality and the financial need for reorganization and cost-saving. It's required a rationalization of intervention, together with a careful choice of the best and cheapest techniques and the demonstration of their efficacy. The anaesthesia service activity, in a period of cost rationalization and funds restriction should be aimed to appropriate outcome measures corrected by both patient's risk factors and surgical-anaesthesiological case-mix. The development of a complete strategy for surgical pain management might run into two phases. The first phase, internal and mono-specialistic, should develop like the creation of an Acute Pain Team. The main processes are: focusing the problem (charge of the care), training, information, teaching methodology (timing, methods, drugs, techniques, etc.) and the audit (before and after changes). The main aims are the evaluation of the level of analgesia and pain relief or patient's satisfaction which are partial endpoints useful to demonstrate the improvement and the efficacy of the new pain management strategies. The second phase, multidisciplinary, is directed toward the creation of a Postoperative Evaluation Team. The main objective is to set up a collaborative clinical group able to identify the criteria for quality, efficacy and safety. The major purpose is the evaluation of major outcome measures: surgical outcome, morbidity, mortality and length of hospitalization. The improvement in the quality of postoperative pain treatment goes through a better organization and a progressive increase of the already available therapy. The achievement of the result and the quality projects depend on the interaction among staff members with different behaviours and settings. Internal teaching and training, continuous education for doctors and nurses, and external information, marketing and improvement of attractive capability of Institution, are the procedures of a growing integrated program for postoperative pain treatment. The organizational processes should interact effectively with a plan of education, updating, revision and information in a definite development timing. It should be emphasized a collaborative, interdisciplinary approach to pain control, assessment and treatment, including all the members of the health care team, with an input from the patient and a protective collaboration from the Institution. The development of a postoperative care team must be considered as part of the largest project for "a Painfree Hospital". It represents a keystone of a Institutional Quality Assurance Plan for health care providers, patients (customs) and Institution.

Objective: To determine the reliability on spontaneous ventilation of small continuously associated doses of ketamine and propofol during yag-laser therapy for upper airways neoplastic obstructions., Design: Prospective description of blood gas analysis variation throughout the intervention and in the early postoperative period., Setting: Operating theatre and postoperative Intensive Care Unit of the National Institute for Cancer Research., Patients: A hundred consecutive cancer patients referred to our Institution for upper airways tumoral progressive obstruction., Intervention: Yag-laser firing., Measurements and Main Results: Pre-intra and postoperative blood gas analysis, BP, HR, Sat O2 have been registered every 10'. Mean intraoperative pCO2 rose to 47.3 mmHg (30-60), but within 2 to 3.20 hrs returned close to preoperative value (38.3 mmHg) allowing early patient discharge., Conclusions: The i.v. association of 0.7-1.0 mg/kg Ketamine and 1 mg/kg propofol, followed by 5 micrograms/kg/h and 3 mg/kg/h respectively, turned out to be satisfactory for both patients and anaesthetists in terms of anaesthesia and spontaneous breathing maintenance during yag-laser firing for obstructive upper airways cancer patients.