SummaryA rrrndonzised double-blind study was conducted to compare the influence on postoperative pain of equal volumes of one of two conim.ntru[ions of bupivacaine (0.25Y0, 0.5%), or saline 0.9?0, injected into the knee joint after arthroscopy. The results showed tha/ intra-uriiculur bupivucuine hud no significant analgesic eflect in either concentration. Plasma bupivacaine concentrations were measured 20 minutes after injection in order to determine the extent of' systemic absorption.

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SummarySixty-two children undergoing cardiac surgery were surveyed for the presence of external jugular veins. When present, these were used as a route for central venous catheterisation using a 'J' wire Seldinger technique. Only 54% of attempted insertions were successful but the results support greater efJacy in older children. Key wordsVeins; jugular, external, cannulationThe external jugular vein (EJV) provides a safe and reliable route for central venous access in adults especially where a 'J' wire technique is employed [1,2]. A lower success rate was reported in a small series of children and showed no correlation with patient size [3]. We aimed to assess the suitability of this approach in children in a larger paediatric series. MethodThe presence of EJVs was determined in children presenting for cardiac surgery. After induction of anaesthesia, the child was tilted 15" head down and the EJV was cannulated with a 20 G Abbocath cannula, using full aseptic technique. A J-shaped guidewire (radius of curvature of J = 3 mm) was then inserted into the cannula and manoeuvred into a central vein. Finally, after removal of the short cannula, a 22 G hydromer-coated polyurethane catheter was advanced over the guidewire and secured in place. Satisfactory placement was ascertained initially by aspiration of blood through the catheter and after the procedure was confirmed by chest radiography. Duration in situ and any complications were noted. All central line tips were sent after removal for bacterial culture. ResultsThe children's range of age and weight are illustrated in Figures 1 and 2. The mean age was 41 months and mean 7n " , . , . , , , , . . weight was 13.9 kg. Twenty-nine subjects were male and 33 were female. Fifty-eight of the 62 subjects (93.5%) had one or more visible EJV and initial cannulation was successful in 50 children (80.6%). Only 33 'J' wires (53.2%) were successfully manipulated into a central vein. Catheters passed easily over the 'J' wires, but two were subsequently found to be malpositioned. In both of these cases the catheters had passed in a cephalad direction along the internal jugular vein, one ipsilaterally, the other contralaterally. The ages, in years, of the successes and failures are shown in Fig. 3, and suggest increased success with age. This was confirmed when the ages in months were compared by calculating the Spearman Rank Correlation Coefficient (r, = 0.84) which showed that age had a statistically significant effect (p < 0.001) upon success. This result is more easily appreciated by comparing the success rate in those subjects less than 3 years old (37%) and those above this age (71%). Despite all cannulations being performed by the same anaesthetist, the success rate did not improve with greater experience of the technique over the course of the study. No pneumothorax or carotid puncture occurred. Staphyloccoccus albus was cultured from three of the catheter tips, but none of the children had evidence of systemic sepsis. The duration that successful cannulations remained in s...

SummaryThree children who received patient-controlled analgesia ,for periods of up to 41 days are described. In each casi> putientcontrolled analgesia allow,ed pain control to be achieved in dificult situations. No patient developed tolerance or clinical signs of dependence. This use qf long-term patient-controlled analgesia warrants ,further evaluation. Key wordsAnalgesia; postoperative, patient-controlled. Surgery; paediatric.Patient-controlled analgesia (PCA) is becoming well accepted in the management of acute pain in adults,' and was described in adolescent',' and pre-ad~lescent~.~ children. However, the reports in children describe only its shortterm use, typically for the management of postoperative pain. Over 300 children aged as young as 5 years have received PCA in our hospital, with encouraging results. Three patients have received 'long-term' PCA.Our method of prescribing PCA has already been described.' We use the Graseby PCAS device with a 60-ml syringe attached to an intravenous line which incorporates a one-way valve. Morphine 1 .0 mg/kg (maximum 60 mg) is made up to 60 ml with saline 0.9%. Initially, demand doses of 1.0 ml are given, with a 5-minute lockout interval. This regimen i s often supplemented with a background infusion of 1.0 ml/hour. The volume of drug used, the quality of analgesia, and any sedation or nausea are assessed each hour by the ward nursing staff. A member of the acute pain service sees the patient at least once daily, and is also available 'on-call' for any after-hours problems. Case histories Case IA previously healthy 12-year-old girl (weight 40 kg) presented at another hospital with a large ischiorectal abscess. After incision and drainage, a large cavity remained that needed frequent packing and dressing changes. She was referred to our hospital 7 days after surgery because inadequate analgesia had made these dressing changes impossible. Analgesia was initially with intravenous pethidine by bolus, but morphine syrup was used subsequently. Neither regimen produced acceptable pain relief; morphine also caused nausea and vomiting.She was taken to the operating theatre after admission for examination under general anaesthesia. This demonstrated an abscess cavity that was slow to heal. PCA was started postoperatively using pethidine, since this had not caused nausea previously. Bolus doses of 10-mg were prescribed, with a 3-minute lockout interval and no background infusion. It was anticipated that this regimen would allow the patient to achieve adequate analgesia rapidly (because of the short lockout interval). Figure 1 shows the pethidine doses administered over successive 4-hour periods before and during 14 successive dressings, over a 9-day period. Severe pain was not reported on any occasion. Nausea was reported on only four out of a total of 216 hourly observations. She presented for further curettage of the abscess cavity 5 months later. She requested PCA, which was provided, and analgesia was excellent for a period of one week while further dressings were applied. ...

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