The pharmacokinetics and pharmacodynamics of paracetamol differ substantially in neonates and infants from those in older children and adults; hence, dosing should be adjusted accordingly.

The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Guidelines Working Group on Thromboprophylaxis in Children has reviewed the literature and where possible provided advice on the care of children in the perioperative period. Areas reviewed include the incidence of perioperative venous thromboembolism (VTE), risk factors, evidence for mechanical and chemical prophylaxis, and complications. Safe practice of regional anesthesia with anticoagulant prophylaxis is detailed. In summary, there are few areas of strong evidence. Routine prophylaxis cannot be recommended for young children. Postpubertal adolescents (approximately 13 years and over) are at a slightly increased risk of VTE and should be assessed for prophylaxis and may warrant intervention if other risk factors are present. However, the incidence of VTE is significantly lower than in the adult population. This special interest review presents a summary and discussion of the key recommendations, a decision-making algorithm and a risk assessment chart. For the full guideline, go to www.apagbi.org.uk/publications/apa-guidelines.

We report the case of a two and a half year-old girl who developed fulminant hepatic failure following 5 days of regular oral ingestion of paracetamol, approximately 90 mg x kg-1 x day-1. She presented with the typical findings of hepatomegaly, encephalopathy, high ammonia levels, high transaminases, hypoglycaemia and lactic acidosis. After stabilization, she was transferred to a specialist paediatric liver failure unit and fortunately she made a full recovery with intensive medical management.

The only significant difference was in glucose in the postbypass time periods. Although statistically significant, this difference is insufficient evidence of increased stress in the remifentanil group. The results show that in the patients studied there was no clinically important difference between the two techniques.

Explain the risk factors for venous thromboembolism (VTE) in children. Describe the presentation and investigation of VTE. Assess when prophylaxis is required and implement anticoagulation appropriately. Identify when it is safe to perform regional anaesthesia.Venous thromboembolism (VTE) is a condition where a blood clot forms in the deep veins of the arm, groin or leg (deep vein thrombosis [DVT]), which can subsequently travel through the circulation and occlude the pulmonary vasculature (pulmonary embolism [PE]). Cerebral venous thrombosis makes up a small number of VTE in children, but is not covered in this article.VTE is a recognised cause of morbidity and mortality in the hospitalised adult. It is preventable, and there are national guidelines on recognising risk factors and when to initiate prophylaxis. 1 The incidence of VTE in paediatrics is considerably lower than in adults, but it is still identified in the hospitalised child, particularly in tertiary care facilities. Most children diagnosed with VTE have a number of identifiable risk factors. EpidemiologyThe estimated annual incidence of VTE in general paediatrics ranges from 0.14 to 0.21 per 10,000 children. 2 In hospitalised children, the incidence of VTE is five to eight cases per 10,000 hospital admissions. 3 The actual incidence could be significantly higher as the majority of VTE is asymptomatic. VTE can either be provoked (i.e. resulting from underlying conditions or identifiable risk factors) or unprovoked. In hospitalised children, 80% of VTE is provoked, occurring in patients with more than one risk factor. Only 2e8.5% of VTE occurs in children with no risk factorsdmost of them occur later in childhood and adolescence. This is in contrast to the hospitalised adult, where up to 50% of VTE occurs in the absence of risk factors. 4 There are two peaks in the overall incidence: one in infants less than 2 yrs old and the other in adolescence. 4 In adolescents, the risk factors of smoking, obesity, pregnancy and the combined oral contraceptive pill are relevant and need to be incorporated into risk assessments. Adolescent females are twice as likely to develop VTE than males. 5 Stephanie Jinks FRCA is a locum consultant anaesthetist at Great Ormond Street Hospital for Children NHS Foundation Trust. She has special interests in medical education and quality improvement. Amaia Arana FRCA is a consultant paediatric anaesthetist at Leeds Teaching Hospitals NHS Trust with a specialist interest in pain management. She was a member of the Association of Paediatric Anaesthetists Guidelines Development Group for the prevention of perioperative venous thromboembolism in children. Key pointsEighty per cent of venous thromboembolism (VTE) in paediatrics occurs in those with identifiable risk factors. VTE is associated most commonly with central venous catheters. Adolescents are at an increased risk of VTE, and this risk should be assessed. Prophylaxis can be mechanical and pharmacological. Low-molecular-weight heparin is used for treatment and prophylaxis. Ne...