Ultrasonography is a useful aid to verify epidural placement of local anaesthetic agents and epidural catheters in children. Advantages include a reduction in bone contacts, faster epidural placement, direct visualization of neuraxial structures and the spread of local anaesthetic inside the epidural space. Ultrasound guidance requires additional training and good manual skills, and should only be used once experience in ultrasound-guided techniques of regional anaesthesia has been acquired.

SummaryEach year millions of children undergo surgery in the developing world with inadequate facilities, equipment and drugs. In many hospitals, anaesthesia is largely dependent on the availability of ketamine. Application of well-established clinical techniques, particularly for postoperative pain control, would relieve unnecessary suffering in children. Improvements in peri-operative care are required by investment in health systems and training.

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Defining anatomical landmarks may be difficult in the growing child. With the aid of a peripheral nerve stimulator, the path of many superficial peripheral nerves can be 'mapped' prior to skin penetration by stimulating the motor component of the peripheral nerve percutaneously with a 2-3.5 mA output. The required current will vary and is dependent upon the depth of the nerve and the moistness of the overlying skin. This 'nerve mapping technique' has proved particularly useful for brachial plexus, axillary, ulna and median nerve blocks in the upper limb and femoral and popliteal nerve blocks in the lower limb. It is a useful teaching tool and improves the success rate of peripheral nerve blocks in children of all ages.

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CASE REPORTA 4-year-old female, weighing 12kg, presented for ENT and dental examination under anaesthesia. Nasal intubation was requested to facilitate the dental examination. On examination she had the distinctive facial features of Wolf-Hirschhorn syndrome that included hyperteleorism, prominent glabella, short "beaked" nose, short philtrum, mild micrognathia and microsomia, but she had no cleft lip or palate, nor iris coloboma. She had generalised hypotonia. She initially failed to thrive because of feeding difficulty, recurrent infections and aspiration pneumonia, requiring numerous hospital admissions. She is developmentally delayed and has a history of convulsions that are controlled with levetiracetam 750mg and lamotrigine 25mg. The PDA noted at birth had closed by 3 months and there was no other cardiac abnormality. She had intra-uterine growth retardation (IUGR) and was delivered prematurely at 34 weeks by emergency Caesarean section to a 34-year old primigravida.At 8 months she underwent an anti-reflux procedure for recurrent aspiration. A feeding gastrostomy was placed at the same time, in view of her difficulty with swallowing and refusal to eat. The Nissen fundoplication was made difficult by a small diaphragmatic hernia. Intubation at that time was noted to be difficult, but not impossible, using a Miller 1 laryngoscope blade. Anaesthesia was uneventful and consisted of a sevoflurane induction, maintenance with isoflurane and a thoracic epidural for peri-operative pain management. There was no suggestion of malignant hyperthermia.On this occasion she required no sedative premedication. On arrival in theatre, she was asleep in her father's arms and a "steal induction" using sevoflurane was performed. After ascertaining that the larynx could be visualised, albeit with some difficulty, a nasal RAE endotracheal tube was softened in hot water to facilitate passage through the more patent left nostril. A smaller ET tube (4mm) than expected for her age (5mm) was placed atraumatically without muscle relaxants. A throat pack was inserted to prevent potential soiling of the airway. Anaesthesia, lasting 2 hours, was uneventful and she remained normothermic. A paracetamol suppository (250mg), placed prior to surgery, provided adequate postoperative analgesia.

fied, but the liver and spleen were normally situated. X-ray of the lower limbs showed a normal looking pelvis, femurs, tibiae and fibulae, and abnormal feet. Full blood count, urea and electrolytes were normal.Neither the paediatric surgeon nor anaesthesiologist had prior experience of this clinical problem and on a Sunday, access to a reference library was not possible. A colostomy, and if possible a stoma for urinary drainage, was planned.Anaesthesia was induced with halothane and intubation achieved without muscle relaxants. In view of the easily palpable sacral hiatus, a caudal block using 2.5ml 0.25% bupivacaine was performed. A block to the level of T8 was achieved.Laparotomy revealed bilateral renal agenesis, an absent urinary collecting system and no bladder. The rudimentary kidneys seen on ultrasound were in fact the adrenal glands. In view of hopelessness of these findings further surgery was abandoned. The gravity of the situation was explained to the mother. The infant was kept comfortable and discharged at mother's request to die at home.A second case of sirenomelia was admitted to the paediatric surgical unit at King Edward VIII Hospital a year later. In view of the hopeless prognosis, no surgery was offered. SynopsisA 2.4kg one day old, the product of a 36-week monozygotic twin pregnancy born to a 24 yr old primigravida by C-section for foetal distress, presented for laparotomy. The child's mother had attended antenatal clinic once during her otherwise uneventful pregnancy. No antenatal investigations were performed. The monozygotic twin sibling, a male weighing 2.65kg, was completely normal.On examination of the abnormal twin, the most striking feature was the complete fusion of the lower limbs from buttock with no perineum to the heels, and a single 5th toe (sympus); there were also no external genitalia or urogenital orifice, and an imperforate anus. The feet were inverted, the popliteal region was dimpled and the sole of the feet faced forward. The feet were fused along the lateral border and resembled a flipper (dipus) (Figure1 and 2). The rest of the examination, from the umbilicus upwards, was completely normal.Preoperative ultrasound of the abdomen revealed what was thought to be rudimentary kidneys. No bladder could be identi-A Bösenberg Figure 1. Monozygotic male twins. The typical features of sirenomelia are present in one -fused lower limbs (dipus) with flipper like feet, absence of external genitalia, imperforate anus and normal upper torso. Features of Potter's facies are not present. Figure 2. Lateral and posterior views of the sirenomelia. The sacral hiatus was easily palpable despite the abnormal buttock. The feet are rotated inwards and fused along their lateral borders with a single 5th toe.