Epidural infusions (0.2-0.4 mg.kg(-1).h(-1) ropivacaine) provided satisfactory pain relief in neonates and infants under 1 year. As plasma concentrations of unbound ropivacaine were not influenced by the duration of the infusion, ropivacaine can be safely used for postoperative epidural infusion for 48-72 h. Levels of unbound ropivacaine were higher in the neonates than in the infants, but were below threshold concentrations for CNS toxicity in adults (> or =0.35 mg.l(-1)). This should not preclude the use of ropivacaine infusions in neonates but suggests a need for caution during the first weeks of life.

The findings support this six-graded faces pain scale as a useful and valid instrument for measuring pain in the postoperative period in children aged 4-12 years.

It was concluded that 1 ml x kg(-1) of ropivacaine 2 mg x ml(-1) for caudal block provided satisfactory postoperative pain relief after inguinal surgery in 4-12-year-old children. Ropivacaine 1 mg x ml(-1) showed less efficacy while the use of ropivacaine 3 mg x ml(-1) was associated with a higher incidence of motor block with minimal improvement in postoperative pain relief.

Following single-shot caudal doses of 1-3 mg/kg in children up to 25 kg and aged between 4 and 12 years, plasma levels of free ropivacaine increase in proportion to dose and all were shown to be within safe limits.

SummarySixty-two children were randomly allocated to receive, during inhalational anaesthesia with iso¯urane and nitrous oxide, either 1.0 lg.kg )1 remifentanil (n 33) or saline (n 29) just before the tunnelling phase of ventriculoperitoneal shunt insertion, in a double-blind study. The remifentanil group showed little stress response to tunnelling as indicated by median (interquartile range [range]) change in heart rate )5. ]) min, respectively (p 0.75). There was no difference between the two groups in postoperative analgesic requirements or in blood loss and there were no signi®cant side-effects. We conclude that remifentanil is an appropriate and safe analgesic to provide balanced anaesthesia to cover the tunnelling phase of paediatric ventriculoperitoneal shunt insertion.

SummaryWe compared the efficacy and safety of a remifentanil (0.25 mg.kg 21 .min 21)-based balanced anaesthetic technique with a bupivacaine-based regional anaesthetic technique in an open label, multicentre study in 271 ASA physical status 1 or 2 children aged 1±12 years. Subjects requiring major intra-abdominal, urological or orthopaedic surgery were randomly allocated to receive either intravenous remifentanil (group R; n 185) or epidural bupivacaine (group B; n 86) with isoflurane/nitrous oxide for their anaesthesia. The majority of children in both groups (85% in group R, 78% in group B) showed no defined response to skin incision, and although the mean increase in systolic blood pressure (111 mmHg) was significantly greater in group R than in group B, this change did not represent a serious haemodynamic disturbance. More children in group R (31%) required interventions to treat hypotension and/or bradycardia than those in group B (12%), but these were easily managed by administration of fluids or anticholinergic drugs. Adverse events, mainly nausea and/or vomiting, occurred in 45% of group R and 42% of group B (NS). The adverse event profile of remifentanil in this study was typical of a potent m-opioid receptor agonist. Remifentanil was as effective as epidural or caudal block in providing analgesia and suppressing physiological responses to surgical stimuli in children aged between 1 and 12 years undergoing major abdominal, urological, or orthopaedic surgery under isoflurane/nitrous oxide anaesthesia.

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