The sedation of 50 children aged 6 months to 9 years who had undergone open heart surgery was studied. During artificial ventilation a midazolam infusion was used in conjunction with the administration of morphine (and tubocurarine). Sedation for patients breathing spontaneously with positive airway pressure was continued with midazolam alone. The duration of the midazolam infusion (2-6 micrograms kg-1 min-1) ranged from 12 to 197 h. Forty-seven of the children were sedated uneventfully; the remaining three children needed small doses of other sedative agents. In 10 of the children, blood samples were taken for serum midazolam assay and a short Synacthen test was performed. There was no clinical evidence of accumulation of midazolam, but midazolam concentrations were so variable that no conclusions could be drawn. All patients in whom they were measured (n = 10) had high basal cortisol concentrations, but displayed normal responses to Synacthen.

Summary Sixty patients scheduled for day case surgery were allocated into two groups in a double Key words.Anaesthesia; outpatient. Hypnotics; benzodiazepines, temazepamExtensive clinical and laboratory studies have shown temazepam (3 -hydroxydiazepam) to be an effective hypnotic'-3. The pharmacokinetic and metabolic studies of temazepam indicate that the recently introduced soft gelatin capsule preparation4x5 (Normison, Wyeth) might be suitable for oral premedication in day case surgery because of the rapid rise in plasma levels, the short half-life and the lack of active metabolites (in clinically significant amounts).A double-blind trial was therefore undertaken to evaluate the potential of temazepam as a prernedicant in day case surgery. MethodSixty patients admitted for elective minor surgery as day cases were studied. The age range was 18-70 years, weight 42-85 kg, ASA I or I1 with no recent history of psychotropic drug therapy. The patients, who gave informed consent, were randomly allocated into two groups to be given either temazepam or the placebo on a doubleblind basis. Temazepam 10 mg capsules and placebo capsules of identical appearance were used; patients who weighed less than 60 kg received 20 mg and those who weighed more than 60 kg took 30 mg.Subjective assessments of sedation and anxiety, using 100 mm visual linear analogues, were performed by the patients immediately before premedication and before the induction of anaesthesia 1 hour later. The extremes of the scale recording sedation were marked 'I feel wide ~

SummaryA case is presen'ted of acute life-threatening haemorrhage caused by laceration of the subclavian artery as a result of attempted cannulation of the internal jugular vein. This sequence of events has not been reported previously, and probably resulted from use of a cannula-over-needle system. Key wordsVeins; jugular, cannulation. Complications; haemorrhage.Percutaneous catheterisation of central veins has become common procedure in the management and monitoring of severely ill patients. The incidence of complications is higher after cannulation of the subclavian vein than the internal jugular'-3 and the latter route is used more commonly. We report a case of near fatal acute haemorrhage after accidental laceration of the subclavian artery during internal jugular catheterisation. Case historyA 56-year-old man with severe triple vessel coronary artery disease presented for bypass graft surgery. Premedication was with oral lorazepam 2.5 mg 2 hours before surgery followed by papaveretum 15 mg and hyoscine 0.3 mg intramuscularly one hour later. The patient arrived in the anaesthetic room breathing oxygen at 4 litres/minute via an MC mask. Peripheral venous and radial arterial lines were inserted under local anaesthesia before induction of general anaesthesia. Anaesthesia was induced and the patient was positioned in a 15" head down tilt for cannulation of the right internal jugular vein using the high technique described by Boulanger et aL4 Two 14-gauge Wallace flexihub cannulae were inserted easily and venous blood was aspirated freely. A third cannula was introduced a little lower at the apex of the triangle formed by the sternal and clavicular heads of the sternomastoid muscle. The 'vessel' was located easily 2-3 cm deep to the skin but blood was noted to be a brighter colour compared with the previous cannulations. Blood could be aspirated easily with a syringe, but there was no pulsatile flow. Consequently, the cannula was advanced cautiously over the needle. However, resistance was encountered after insertion by 1-2 cm and the cannulation attempt was stopped, the needle and cannula withdrawn and firm finger pressure applied over the puncture site.There was a rapid decrease in systolic arterial pressure from 120 mmHg to 50 mmHg and a subsequent decrease to 30 mmHg. This was thought a t first to be due to acute left ventricular over-distension caused by the head down position and the operating table was levelled. Calcium and adrenaline were given without effect. External cardiac massage was applied and the patient was transferred to theatre for immediate sternotomy and institution of cardiopulmonary bypass. There was a massive right haemothorax, although there was no obvious bleeding point. The arterial pressure was restored quickly with rapid infusion of blood and colloid solution before cardiopulmonary bypass. The electrocardiogram showed no changes suggestive of ischaemia during the hypotensive period, and the pupils remained small.Initially, the surgeons were unable to locate the source of haemorrhage ...

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