SummaryInvestigators from Bristol described a fentanyl-and diclofenac-based analgesic technique for tonsillectomy with low postoperative nausea and vomiting rates and low pain scores. This study compared the effectiveness of a modified Bristol technique with a codeine-based regimen with respect to PONV and analgesia. Sixty-five children, ASA 1-2, were randomly assigned to either the Bristol group (fentanyl 1-2 lg.kg )1 and diclofenac 1-2 mg.kg) or codeine group (codeine 1.5 mg.kg). All children received paracetamol 15 mg.kg )1 and dexamethasone 0.1 mg.kg. Postoperative nausea and vomiting and pain scores were recorded hourly, and fitness for discharge was assessed at 4 h. The overall incidence of postoperative nausea and vomiting was 21% with no difference between groups (Bristol group 8 ⁄ 30, codeine group 5 ⁄ 32, p = 0.29). Children in the Bristol group required analgesia earlier than those in the codeine group (p < 0.005), but maximum pain scores were not different (Bristol group median (IQR [range) 4.5 (3-5 [0-5]), codeine group 4.0 (2-5 [1-5]), p = 0.15). Twenty-three per cent of children were assessed as not fit for discharge at 4 h. The codeine-based regimen may have a small advantage over the Bristol regimen, but neither technique seems ideally suited for a day-case service without a longer period of observation.

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IntroductionThere are multiple reports of the use of vasopressin with phaeochromocytoma resections in adults. Support for vasopressin in the paediatric patient, however, is not quite as substantiated. We report such a case to add to the limited evidence for its use in a young child. Case reportA 6-year-old boy, weighing 21 kg, was admitted to a local District General Hospital with severe headaches not responding to simple analgesics. His initial blood pressure was recorded as 166/91 mmHg. This was persistently elevated and, subsequently, he developed vomiting, photophobia and bilateral papilloedema. He was referred to our institution for further investigation and treatment. Tests showed raised urinary levels of catecholamine metabolites over 24 h and a subsequent computed tomography (CT) scan confirmed a left-sided adrenal phaeochromocytoma. He was started on gradually increasing doses of phenoxybenzamine and atenolol, and a laparoscopic adrenalectomy was planned for within 6 weeks. In the meantime, his blood pressure was controlled with phenoxybenzamine, 20 mg twice daily, and atenolol, 30 mg once daily. Cardiac workup included electrocardiography and echocardiography, which were both normal. PreoperativeThe boy was admitted to our hospital 48 h before surgery when he was noted to have an increased BP of 140/80 mmHg. In addition to the phenoxybenzamine and atenolol, he was started on hydralazine 10 mg three times daily; all three of which were continued until the morning of surgery. As a premedication, he was given midazolam (0.5 mg kg À1 orally) 30 min prior to coming to theatre. The BP before induction of anaesthesia was 105/68 mmHg. Induction of anaesthesiaAnaesthesia was induced with intravenous propofol (4 mg kg À1 ) and fentanyl (slowly titrated up to 5 mg kg À1 ), and he was paralysed with rocuronium (1 mg kg À1 ). After endotracheal intubation, large bore peripheral intravenous catheters, an arterial line, a central venous line and an epidural catheter (L1/2) were inserted. The epidural was dosed with 10 ml of 0.25% ropivacaine over a period of 30 min. The patient remained normotensive with blood pressure readings around 100/50 mmHg. Anaesthesia was maintained with oxygen, air and isoflurane. Operative procedureThe operation was performed in the right lateral position via a laparoscopic retroperitoneal route, using three 5 mm operative ports and gas insufflation with CO 2 . The ventilation was adjusted to maintain normocapnia throughout. Dissection of the adrenal gland was kept to an absolute minimum until its blood vessels were identified. It was clear that any contact with the adrenal gland did cause major spikes in blood pressure. As soon as these vessels were clearly identified, the adrenal vein was double clipped and divided, the remaining vessels were then divided. The adrenal gland was removed intact with no damage to the surrounding structures, and there was no significant bleeding or breach of the peritoneum.During the operation, sodium chloride 0.9% was infused at a rate of 10 ml kg À1 h À1 for...