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We report the case of a 3-year-old boy, who received long-term parent-controlled analgesia after traumatic amputation of one leg. He underwent surgery 17 times for a period of 25 days. Parent-controlled analgesia was started four days after admission because analgesia with non-opioid analgetics (acetaminophen) proved to be insufficient. The pump was set to a bolus-dose of 23 micrograms kg-1 piritramide (dipidolor) and a lockout interval of 10 minutes. Permitted maximum cumulative dose in four hours was 5 mg piritramide. There was no continuous infusion of opioid. PCA and possible adverse effects were explained to the mother. A monitoring regimen was used to assess efficacy (pain intensity estimated by the mother), adverse effects (sedation score, occurrence of nausea and vomiting) and piritramide consumption. For fear of side effects opioid administration was insufficient in the beginning. After three days the mother used the PCA effectively and no additional analgesic medication was required. Nausea or other side effects were not observed. After seven days opioid consumption nearly doubled. Apart from tolerance, this might have resulted from the mother's caution in the first days. After 17 days the PCA was discontinued. Oral analgetics (tramadol) controlled the pain adequately. Management of postoperative pain in children is difficult and too often insufficient. PCA is a safe and effective method of providing postoperative pain relief. Feasibility was shown in adolescents and, more recently, in children aged five years and over. Only few reports are available describing long term use of PCA in children younger than five years. Our case suggests that PCA may also be used effectively and safely in children younger than five years, if experienced staff, a monitoring regimen and cooperative and well instructed parents are available.

We are reporting a case of an acute thromboembolic obstruction of the aortic bifurcation in a 66-year-old patient undergoing coronary artery bypass grafting with extracorporeal circulation. After declamping of the aorta, the arterial pressure measured in the femoral artery suddenly dropped, whereas the pressure measured in the aortic cannula and in both radial arteries stayed normal. Transoesophageal echocardiography was performed to exclude an acute aortic dissection. While the patient always had a constant sinus rhythm, an angiography following the end of surgery, showed a complete obstruction of the abdominal aorta. Subsequent embolectomy through bifemoral arteriotomies was performed and a histologically fresh embolus (6,5 g in weight) was extracted. Neither the pre- and intraoperative echocardiography, nor the preoperative ventriculography showed signs of an intracardiac thrombus. Insufficient anticoagulation and a lack of inhibitor potential were almost excluded. Considering the histological findings, we assumed that the embolus was formed intraoperatively. Without further complications the patient left our department on the 8th postoperative day.

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