The prescnt investigation differs from these two studics5.6 in two respccts. Firstly, younger children are included, as a pilot study rcvealed that young children could answer questions if sufficient time were taken to win their contidence and care taken to avoid leading questions. Secondly, thc growth in popularity of daycase surgery has increased the number of unpremedicated or lightly premedicated paticnts, and hence the possibility of awarcness.Drcrzniing is defined as any experience (excluding awarcness) which a patient thought occurred between the induction o f anacsthcsia and the first moment of consciousness after anacsthcsia. Children who report dreams cannot say precisely when drcaming occurred; tnany have a postoperative sleep during which dreaming could occur and be indistinguishable from pcranaesthetic dreaming. This problem has becn noted in adults.: Furthermore, the preinduction 'pattcr' in thc anacsthetic room may give rise to hypnagogic phenomena which arc remembered as dreams. Patients and methodsConsecutive patients scheduled to undergo elcctivc daycase surgery at Alder Hey Children's Hospital ovcr a h i o n t h period, and in whom either wxamethonium chloride or atracuriurn bcsylate was used for musclc relaxation, were studied. Patients were cithcr unpremedicated or received a weight-related dose of 'Ponstan Mix' (mefenamic acid, trimcprazine and atropine) one hour before induction of anaesthesia. The 'Liverpool technique' of paediatric anaesthesia was uscd in all cases. This comprised an intravenous induction. the use of a muscle relaxant to allow tracheal intubation, and controlled hand ventilation using an Ayre's T-piece with Jackson-Rees modification. The paticnt's lungs were ventilated with the Jackson-Rccs bag to an end tidal carbon dioxide tension of 4.5-5.0 kPa measured with a Datex infrared carbon dioxide analyser. Anaesthesia was maintained with 70% nitrous oxide in 30% oxygen, and increments of musclc relaxants and andgcsic drugs were given as required peroperatively. Volatile agents were not used.Six anaesthetists were involved in the study. One anaesthetist assessed thc patient's mood with a linear analogue scale which ranged from 0 (very calm) to 100 mm (very agitated). Anaesthesia was then induced with sodium thiopentone 5 mg/kg and the chosen muscle relaxant. Thc choice of either suxamcthonium or atracuriurn depended upon the proposed duration of anaesthesia; intermittent ~-

No abstract

Glycopyrrolate 5 and 7.5 micrograms kg-1 and atropine 10 and 15 micrograms kg-1 were studied in 80 paediatric patients to assess more fully the dose of glycopyrrolate required for adequate prevention of the oculocardiac reflex. A dose-related improvement in protection from this reflex was seen with both drugs, but neither drug prevented reductions in heart rate in every patient. A nodal rhythm was the most common arrhythmia observed with both drugs. In the doses used, no adverse effects were noted and no further anticholinergic treatment was required during muscle traction. Higher doses may be associated with an increase in side-effects with more pronounced dryness of the mouth and tachycardia and, with atropine, a greater likelihood of the production of the "central anticholinergic syndrome".

The presentation and features of Duchenne's progressive muscular dystrophy (Duchenne's PMD) are described and the increased risks associated with anaesthesia are considered. Hazards associated with induction of anaesthesia and immediate postoperative recovery have been stressed in recent case reports, and these are summarized. Features of a hyperpyrexia-like response including cardiac arrest, increased serum creatine phosphokinase concentration, myoglobinuria and metabolic acidosis following suxamethonium or halothane, or both, have been described in patients with Duchenne's PMD. Subsequent in vitro muscle tests have suggested that it is possible that a malignant hyperpyrexia response to general anaesthesia may occur. Six children known to have Duchenne's PMD who developed delayed respiratory insufficiency following anaesthesia and required controlled pulmonary ventilation are reported. In five of the children, cardiac arrest occurred despite apparently adequate respiratory support. Suxamethonium was common to the anaesthetic received by all six patients. In one of these patients subsequent anaesthetics, without suxamethonium, were uneventful and delayed muscle weakness did not occur.

1 3 prospective .mdJ is described of peri-operative dreaming in 144 paediatric patients uged 5-14 years who received suxaniethunium .f.r c h j~ case surgery. No care of awarene.w WNS elicited. One group received pretreatment with 80 niglkg ruhocxrurinc. The incidence of dreaming in the 72 patients who were not pretreated was 16.7% compared with 2.8% in the putienfs pretreated with tubocurarine. This ddermce is statistic~ally sign$cant. The use of an intermittent suxaniethonium techniqiw g i w s m high incidence of dreaming which may be roused by muscle spindle discharge that produce.r cerehral orozrsul. Pretreatnient IcLith u non-depobrising ugent decreases this risk of dreaming. Key wordsC'ouiplicutions; dreaming. Nc~urornii.sciilar reln.xnnts; suxanicthoniuni.There have been marly studies of dreaming and awareness during anaesthesia in adults, but few in children. Hobbs P I ul.' performed a prospective study of 373 children aged 5-16 years who were anaesthetised using the 'Liverpool technique' of paediatric anaesthesia (nitrous oxide/ oxygcn/niusclc relaxant). A much higher incidence of dreaming was observed in day case patients who had received suxamethonium than in any other single group. A large synchronoub afferent stimulus from muscle spindle discharge after suxamethonium administration has been implicated in the production of an arousal-type electroencephalograph (EEG) pattern in adults and children; this pattern can be abolished by prctrcatment with a nondepolarising muscle relaxant.' The purpose of the present study was to detcrminc whcther pretreatment with a nondepolarising relaxant would rcsult in a reduction in the incidence ot' dreaming in children who received suxamc thoni uni . MethodA prospective study was carried out on 144 patients (84 male) agcd 5 14 years. who underwent day case surgery for which suxamcthonium was indicated clinically. The patients received either no preniedication, 'Ponstan Mix' (a mixture o f IrirnepraLine. mefenamic acid and atropine) or pethidine and atropine. They were allocatcd into one of two groups depending on their datc of birth. Patients with an even birth date received prctreatmcnt with 80 pglkg tubocurarinc one minute before induction of anaesthesia; those with an odd birth date received no pretrcatnicnt. A standard anaesthetic was used, which consisted of an induction dose of thiopentone 5 mglkg, atropine 20 pg:'kg, suxamethonium 1.5 ingikg and tracheal intubation. Thc patients' lungs were ventilated manually using an Ayrc's T-piece with the Jackson-Rees modification with a mixture of 70% nitrous oxide and 30% oxygen; increments of suramethonium were given as required during the proccdure. Details of the patient, anaesthetic, opcration, prcSence or absence of fasciculations at induction and degree o f intra-operative movement (none, slight. inoderate) werc rccorded by the anaesthetist.One obscrver (who was unaware of the pretreatment details) interviewed the child on return to the ward. before dischargc. A standard questionnaire ( Table 1 ) modified fi-om Brice...