SummaryWe report an ischaemic penile glans following circumcision and a dorsal penile nerve block in a 9-year-old boy. Ischaemia of the glans penis is a rare complication associated independently with both circumcision and dorsal penile nerve blocks. There are a number of pathophysiological mechanisms of this ischaemia and its management is varied and not well recorded. We report the successful management of this complication using a caudal epidural block and also discuss technical aspects of penile nerve blocks. Circumcision is a commonly performed surgical procedure with a low complication rate. Penile ischaemia is a rare complication of circumcision and surgical causes include haematoma, vessel ligation, and an excessively tight suture line.The dorsal penile nerve block is a widely used form of regional anaesthesia, particularly in children [1]. It is a simple, easy and effective block that reduces postoperative pain and analgesic requirements. A number of complications have, however, been reported [1][2][3][4]. Ischaemia of the glans penis is a rare complication associated with this block and may arise via a number of mechanisms [3].We report a case of ischaemic glans penis following circumcision and dorsal penile nerve block in a 9-yearold boy which was managed successfully with a caudal block. Case reportA healthy 9-year-old, 38-kg Caucasian boy presented for an elective circumcision. Following intravenous induction of anaesthesia, with the child spontaneously breathing oxygen and isoflurane through a laryngeal mask airway, a dorsal penile nerve block was performed under sterile conditions with a 22-G blunt-bevel needle. The subpubic approach to the dorsal nerves of the penis was used [5], with the child lying in the supine position and the penis pulled inferiorly. Two symmetrical injections 1 cm lateral to the midline, and just below the lower border of the pubis symphysis, were performed. The needle was inserted almost perpendicularly to the skin with slight caudal and medial angulation. After aspiration, to exclude intravenous placement of the needle, 3 ml 0.5% plain bupivacaine was injected on each side. The block appeared uncomplicated. An uneventful classic circumcision was then performed using bipolar diathermy. However, in recovery, the block appeared ineffective and the child required a total of 6 mg morphine to control significant pain. Examination of the penis at this point showed no evidence of bleeding, haematoma or vascular compromise.Four hours later, nursing staff requested urgent surgical and anaesthetic consultations. The boy had ongoing pain and examination revealed a flaccid penis with a significantly ischaemic, poorly perfused, almost black, glans. Significantly, the penile shaft was well perfused and there was no sign of swelling, haematoma or bruising, either at the site of the penile block or at the glans. An urgent duplex Doppler demonstrated good blood flow in both penile arteries distal to the block site. Surgical opinion was that the viability of the glans was threatened but the...

Children taking stimulant medication for ADHD, and who ingest medication on the day of surgery, do not appear to have altered BIS or depth of anesthesia at 1 MAC of sevoflurane. These results do not support a recommendation for a change in anesthetic practice for children having ingested stimulants up to the day of surgery, either in terms of increasing the amount of anesthetic given or monitoring of depth.

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Long term domiciliary oxygen treatment prolongs survival in patients with hypoxic chronic bronchitis and emphysema' 2 but is expensive.3 A recently developed nasal prong system incorporating a pendant reservoir ("Oxymizer Pendant," Chad Therapeutics Inc, Woodland Hills, California) stores oxygen during expiration and delivers it as a bolus at the onset of the next inspiration. We have compared the oxygen conserving ability of this device with standard nasal prongs and with a commercial system with a moustache reservoir ("Oxymizer," Chad Therapeutics). We have also measured the effect of mouth and nose breathing on oxygen delivery by these devices. Patients and methodsWe studied 12 patients (seven men and five women, aged 44-76 years) with hypoxic chronic bronchitis and emphysema who were in a stable condition (FEV, 0-2-1-2 1; FVC 0 8-3 8 1; arterial oxygen tension (Pao2) 54-8 7 kPa; arterial carbon dioxide tension (Paco2) 5-3-7 4 kPa). Arterial oxygen saturation (Sao2) was measured by HewlettPackard 47201A ear oximeter, and oxygen was delivered by a calibrated rotameter measuring to 0-05 1 min-' (AP6222 flow meter, Rotameter Manufacturing Co Ltd). STUDY 1Each patient breathed oxygen for two periods in random order, with the pendant or with nasal prongs, oxygen being delivered at flow rates of 0-5, 1-0, 1-5, 2-0, and 3 0 1 min -1, with stepwise increases. Oxygen was continued until Sao2 was stable at each flow rate and the flow was then increased to the next level. A stable baseline Sao2 was recorded when the patient had been breathing room air for at least 20 minutes before each period of oxygen delivery. STUDY 2In 11 patients we assessed the effect of nose and of mouth breathing on oxygen delivery by nasal prongs and by the pendant and moustache devices. Oxygen was delivered for two separate periods, one during breathing through the nose (mouth closed) and one during breathing with the mouth open. When a stable baseline Sao2 had been recorded with the patient breathing room air, oxygen was delivered at flows of 1-0 and then 2-0 1 min -1, each rate being continued until Sao2 was stable. Between each oxygen breathing period Address for reprint requests: Dr GA Gould, Rayne Laboratory, Department of Respiratory Medicine, City Hospital, Edinburgh EHIO 5SB.Accepted S February 1986 a stable baseline Sao2 with the patient breathing room air was recorded. The order of use of the devices and the nose and mouth breathing periods were assigned randomly.Statistical comparisons were made by means of Wilcoxon's signed rank test for pair differences and analysis of variance. ResultsStudy 1. Pendant versus nasal prongs The mean Sao2 when the patient was breathing room air was not significantly different for the two devices (85 7% prongs, 85 2% pendant), but at oxygen flow rates of 0 5, 1 0, 1 5, 2 0 and 3 0 1 minm l the mean Sao2 values (%) achieved with nasal prongs were 88-4, 90 7, 92-0, 93 3, and 94 4, and with the pendant 91 2, 93 0, 93-8, 94 6, and 95-5. Thus 33-50% less oxygen was required to achieve a given level of S...

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