Ninety boys, aged 13-53 months, undergoing repair of hypospadias, were allocated randomly to receive 0.8 ml kg-1 of one of three solutions into the caudal extradural space: group B received bupivacaine 2 mg kg-1, group T received tramadol 2 mg kg-1 in 0.9% saline and group BT a mixture of both. Postoperative pain was assessed hourly for 12 h after injection using a modified TPPPS pain score and additional analgesia was administered to those children whose pain scores were > 3/10. Nine patients (30%) in group T required additional analgesia within 1 h of surgery compared with only two (6.7%) and three (10%) patients in groups B and BT, respectively (P = 0.04). Mean duration before additional analgesia was required in the remaining patients was 9.3 (SD 3.0) h in group B, 10.7 (2.2) h in group T and 10.5 (2.0) h in group BT (P > 0.20). There were no significant differences between the groups in mean ventilatory frequency, sedation scores, incidence of emesis, facial flushing or pruritus. We conclude that caudal tramadol had a slow onset of action and that the addition of tramadol to bupivacaine, when both drugs were administered caudally, did not significantly prolong the duration of action of bupivacaine.

SummaryFive hundred members of the Obstetric Anaesthetists Association were surveyed regarding their technique for identification of the epidural space. Eighty-one per cent of the questionnaires were returned completed. Fifty-nine per cent of respondents first learned a loss of resistance to air technique, 33.4% to saline and 7.4% another technique. Presently, 37.1% and 52.7% use only a loss of resistance to air or saline, respectively. Six per cent use both techniques and 3.2% use other techniques. Twenty-eight per cent taught a loss of resistance to air, 57.2% taught a loss of resistance to saline and 12.9% taught both techniques. Twenty-three per cent changed from a loss of resistance to air, to a saline technique, and 4.2% vice versa. Forty-seven per cent of those using air felt that loss of resistance to air was not associated with a clinically significant difference in the incidence of accidental dural puncture compared with saline.

We describe the anesthesia management of a 12-year-old girl, diagnosed with fibrodysplasia ossificans progressiva (FOP), who presented with a submandibular abscess. FOP is a rare, inherited disorder with heterotopic bone formation and progressive musculoskeletal disability. This disability ultimately confines patients to a wheelchair. Minor trauma following dental treatment may lead to ankylosis of the jaw. Subsequent to this disability, which resulted in poor dental hygiene, our patient developed a dental abscess. This spread along the mandibular margin and under the tongue. She presented with an impending airway compromise in an already difficult situation. The options for airway management in a child with limited mouth opening are discussed.

12 minutes (mean 4.64 and median 4 minutes). The volume of local anaesthetic injected to achieve satisfactory anaesthesia ranged from 8 to 16 ml (mean 10.96, SD 1.95) in the control group and 10 to 18 ml (mean 11.64, SD 2.8) in the hyaluronidase group. A Mann-Whitney test to compare onset times to globe akinesia between groups gave a p value = 0.6 and 95% confidence interval (-1 to 2 minutes). Conclusion-Addition of 25 IU/ml of hyaluronidase to a standard pH unadjusted local anaesthetic mixture does not significantly reduce the time to the onset of satisfactory globe akinesia.

We have examined the effect of profound hypothermia on gut mucosal perfusion in 20 infants, aged 1.4-45 weeks, requiring cardiopulmonary bypass (CPB). After induction of anaesthesia, a laser Doppler probe was inserted 8 cm into the patient's rectum to allow monitoring of rectal mucosal perfusion ("flux") throughout operation. Steady-state observation periods (5 min with no change in temperature or mean arterial pressure (MAP) were achieved after 10 min on CPB at 35 degrees C, after CPB-induced cooling to 15-25 degrees C, immediately before rewarming and after rewarming to 35 degrees C. Throughout these periods flow rate was 100 ml kg-1 min-1, packed cell volume was kept constant and Paco2 maintained at 5.3 +/- 0.5 kPa. No vasoactive drugs were used. Initial warm and rewarm MAP values (46 mm Hg) were significantly lower (P = 0.008) than during the cold CPB periods (63 and 64 mm Hg). Mean flux in the first cold period (152) was significantly lower (P = 0.001) than that in the first warm CPB period (211). Post-rewarm flux (127) was significantly lower than all other CPB flux values (P = 0.004). We conclude that although hypothermia significantly reduced mucosal blood flow, rewarming produced even greater reductions in mucosal perfusion that may prove crucial in the development of mucosal hypoxia.