Single dose-response curves were determined for suxamethonium in neonates, infants and children during thiopentone-fentanyl-nitrous oxide anaesthesia. During onset of neuromuscular block, suxamethonium produced an increase in muscle tone which was greatest in neonates and infants. The dose-response curves for the three groups were parallel. The effective doses producing 90% depression of twitch height were significantly greater in neonates and infants compared with children (517 and 608 v. 352 micrograms kg-1). These values were greater than those obtained in a comparable study in adults. In view of their higher ED values compared with adults and a marked individual variability in response to small doses of suxamethonium, we recommend an intubating dose of 3 mg kg-1 for neonates and infants and 2 mg kg-1 for children. These doses are 50-100% greater than those previously recommended for paediatric patients.

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Outreach critical care is not the solution I read with interest the editorial on the Acute Pain Service as a model for outreach critical care (Counsel. Anaesthesia 2001; 56: 925±6). In our hospital, the Acute Pain Service detected two cases of severe postoperative complications within the last 4 months while reviewing the patient's analgesia, prompting their return to theatre the same day.However, intensive care nursing resources are already stretched to their limits, and therefore outreach critical care is not the appropriate solution to the problem of inadequate or late initiation of appropriate intensive medical treatment at ward level. From my experience in medicine, surgery and Intensive Care, it appears to me that the problems are: doctors are not trained in caring for the critically ill; their consultants are often not familiar with critical care issues; their patients are scattered across the hospital; monitoring equipment is in short supply on the wards; and nursing staff skilled in monitoring and caring for the acutely ill patient on the ward are in very short supply.As a professional group we should address these issues ®rst. A ®rst step could be to assign doctors to work on a speci®c ward rather than with a ®rm. This would make it easier to literally ÔseeÕ the patients, hourly or more often if necessary. Second, training in Acute ¤ Intensive Care should be compulsory in all acute specialities at SHO level with an introduction to the subject for all House Of®cers. Monitoring equipment and nurses skilled in caring for patients who are unwell should not just be available in the Critical Care areas. However, most important is strong leadership from the top. Each and every Consultant should encourage his ¤ her juniors to acquire the knowledge and the skills needed to work with acutely ill patients in any acute speciality, and give the same positive feedback for caring for an acutely ill patient as for a successful operation or the diagnosis of an uncommon disease.

Obesity is becoming a critical problem in the developed world and is associated with an increased incidence of osteoarthritis of the hip. The Oxford Hip Score was used to determine if Body Mass Index (BMI) is an independent factor in determining patient outcome following primary total hip arthroplasty (THA). Using data from 353 operations we found that patients with BMI ≥ 30 had an absolute score that was lower preoperatively and postoperatively compared to those with a BMI < 30. There was no difference in pre-and postoperative point score change within each group; Kendall's rank correlation was 0.00047 (95% CI, −0.073 to 0.074 ( = 0.99)) and demonstrated no trend. There was no statistically significant difference in change between those with BMI ≥ 30 and < 30 ( = 0.65). We suggest that those with a higher BMI be considered for THA as they can expect the same degree of improvement as those with a lower BMI. Given the on-going increase in obesity these findings could be significant for the future of THA.