A patient suffered cardiovascular collapse and died during surgery for prolapsed intervertebral disc. At postmortem a tear was found in the abdominal aorta.

SummaryMore than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.

These findings have implications for the safe same-day discharge of children following tonsillectomy.

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catheter was placed and rectal paracetamol 20 mgAEkg )1 given for postoperative pain relief. An esophageal temperature probe was placed and a warming mattress was used to prevent hypothermia. The TissueLink device was used for left heminephrectomy for a total time of 30 min. During this time esophageal temperature rose from 36.3 to 38.5°C despite the mattress being turned off at 37.5°C. Vital signs remained stable apart from a slight increase in heart rate. As soon as surgery with TissueLink was finished, the temperature slowly normalized. Emergence from anesthesia was uneventful and the baby was transferred to the ward with a tympanic temperature of 37.1°C.Intraoperative elevation of body temperature is uncommon during surgery especially in neonates and young infants: exposure of the relatively large body surface and internal organs to room temperature, the inhibitory effects of general anesthesia on temperature regulation and redistribution of heat from core to periphery because of vasodilation and a relatively high cardiac output predispose children to hypothermia rather than pyrexia during surgery.The most threatening cause of fever during anesthesia is malignant hyperthermia (MH). The classic presentation of MH includes tachycardia, increased endtidal CO 2 , rise in body endtidal temperature, arrythmias, acidosis and hyperkalemia (4). Such a situation could be ruled out in our two cases as these features were not present. Other potential causes of increased body temperature are excessive covers or ambient temperature, malfunction of heating devices and inaccurate temperature monitors. As mentioned above heating devices were turned off as body temperature started to rise and pyrexia was confirmed in both cases with a tympanic thermometer. Excessive heat production by the patients can also be ruled out as they had no thyrotoxicosis, pheochromocytoma, osteogenesis imperfecta and had no signs of infection or sepsis. A transfusion reaction can lead to fever (5); however, in our first case transfusion of blood and FFP were commenced when body temperature was already abnormally high.We postulate that in our two cases intraoperative fever was due to warming caused by the thermal effect of the TissueLink device. Elevation of body temperature has not been described in adult practice with this device, although some surgeons report a local heating effect of the affected organ (6). Radiofrequency energy is delivered to organ tissues, the heat is transferred to the flowing blood by conduction and passes into the systemic circulation (7). The transmitted thermal energy indexed to body mass is relatively high in the child compared with the adult; furthermore, the high cardiac output in the child favors heat absorption. This effect may have accounted for the intraoperative increase in body temperature in our pediatric patients. We recommend close temperature monitoring in children when using the TissueLink device. Maurizio Pas sariello Ni cole Almenrader B r u n o C o cc e t ti A et al. Hepatic resections using water-cooled,...