Summary This study compares the quality and duration of analgesia in two groups of patients aged between I and Key wordsPain; postoperative. Anaesthetic techniques, regionah caudal, iliohypogastric and ilio-inguinal block.Conventional postoperative analgesia for paediatric surgery involves the administration of either opioid injections or oral analgesics. However, repeated intramuscular injections are unpopular with children and also often cause nausea, vomiting and unwanted sedation; furthermore, the administration of such injections requires trained nursing staff and hospitalisation prevents early discharge home. The selective use of regional anaesthetics administered during general anaesthesia is able to provide pain-free recovery which, with the use of the longeracting local anaesthetic agents, can last well into the postoperative period and reduce the need for either conventional intramuscular injections or oral analgesics.Both caudal anaesthesia and an iliohypogastric and ilio-inguinal nerve block using plain bupivacaine 0.25% have been used to provide postoperative analgesia in children who undergo orchidopexy.' In the present study, caudal anaesthesia using plain bupivacaine 0.25% was compared with an iliohypogastric and ilioinguinal nerve block augmented by skin infiltration of the incisional site using bupivacaine with adrenaline. The investigation monitored the duration and quality of the postoperative analgesia provided by the two techniques, following hcrniotomy and orchidopexy in children. MethodForty-one patients between the ages of 1 and 13 years about to undergo either herniotomy or orchidopexy, were randomly allocated to receive either an iliohypogastric and ilio-inguinal nerve block with skin infiltration, or caudal anaesthesia. Patients with spinal cord defects, bleeding diathesis or infection at the site of injection were not studied. The children were premedieated with papaveretum 0.3 mg/kg and hyoscine 0.006 mg/kg given one hour pre-operatively. Anaes-

A collaborative project between a district hospital and a local university resulted in a senior lecturer being seconded 2 days per week to facilitate the continued improvement in pain management. The rationale for this collaboration was to explore the utilization of innovative teaching methods to deliver education in practice and to develop further research in relation to pain management. An interprofessional pain steering group (IPSG) was established with representation from several services (acute pain, chronic pain, palliative care, physiotherapy, etc.). This group identified several objectives, one of which related to the improvement of pain management through interprofessional education based on the findings from previous audit work. This paper reports on the provision of interprofessional education in pain management and on the evaluation of the impact of this on patient outcomes and practitioner learning. The successes and challenges of this endeavour are discussed.

We have assessed in vitro the viability of eight species of micro-organism suspended as aerosols and passed through a soda-lime absorber rebreathing system. As had been predicted, the soda-lime exerted a potent cidal effect on non-sporing organisms, all of which were rendered non-viable. One percent of the spore bearing organism, Bacillus subtilis, was still viable after 30 min contact. Although Bacillus subtilis is an organism of low pathogenicity, spores may be more resistant to the alkaline medium of the soda-lime. The micro-organisms were observed to lodge in all components of the breathing system, with the greatest concentration being recovered from the corrugated tubing. We recommend that disposable components of the circle breathing system should be changed, and the non-disposable parts sterilized or disinfected, daily. Soda-lime cannisters should be sterilized or disinfected when changing the soda-lime.

SummaryThis re-survey of neurosurgical centres was conducted to determine whether the publication of management guidelines has resulted in changes in the intensive care management of severely headinjured patients (defined as Glasgow Coma Score , 9) in the UK and Ireland. Results were compared with data collected from a similar survey conducted 2 years earlier. Almost 75% of centres monitor intracranial pressure in the majority of patients and 80% now set a target cerebral perfusion pressure of . 70 mmHg. The use of prolonged hyperventilation (. 12 h) is declining and the target P a co 2 is now most commonly . 4 kPa. More centres maintain core temperature , 36.5 8C. Although wide variations in the management of severely head-injured patients still exist, we found evidence of practice changing to comply with published guidelines. In surveys carried out 2 years ago, we highlighted the wide variation in the intensive care management of severely head-injured patients [defined as Glasgow Coma Score (GCS) , 9] in neurosurgical centres throughout the UK and Ireland [1, 2]. Since these initial surveys, two expert bodies have produced guidelines for the management of severe head injury [3, 4]. We surveyed neurosurgical centres to examine whether the management of severely head-injured patients had changed following publication of these guidelines. MethodsThe directors of 44 neurosurgical centres in the UK and Ireland were asked to complete a questionnaire identical to that used 2 years earlier. After 4 weeks, a copy of the questionnaire was sent to all non-responders with a covering letter urging them to reply. The data collected in this survey were compared with results obtained 2 years ago using a Chi-squared test. The significance level was set at 0.05 and statistical analysis was performed using statview 4.0 (Abacus Concepts Inc., Berkeley, CA, USA). ResultsAll 44 centres replied, but four of these did not treat severely head-injured patients and so were not analysed further. Compared with 1996, a greater proportion of units had dedicated junior staff (87 vs. 66%; Chisquared 13, d.f. 1, p , 0.05) and identifiable high-dependency unit (HDU) facilities (68 vs. 43%; Chi-squared 17, d.f. 1, p , 0.05). Only 54% of units had a written protocol for the management of raised intracranial pressure. The changes in management that we observed between the two survey periods are listed in Tables 1±3. DiscussionRecent guidelines [3, 4] suggest monitoring intracranial pressure (ICP) in all patients with a GCS , 9 or an abnormal computed tomography scan. Mean arterial pressure (MAP) should be maintained . 90 mmHg and cerebral perfusion pressure (CPP) . 70 mmHg. Intracranial hypertension should be treated when ICP is . 25 mmHg. The guidelines advise against severe or prolonged hyperventilation and found no evidence to support the use of steroids in head injury. The availability of these guidelines appears to have altered ICU care for severely head-injured patients.Organisational changes in admission practice, unit staffing and HDU bed...

One hundred female patients undergoing major reconstructive plastic or gynaecological surgery were randomized to either receive subcutaneous patient-controlled analgesia (PCA) (bolus dose 2.5 mg diamorphine in 1 ml with a 20-minute lockout) or intravenous PCA (bolus dose 0.5 mg diamorphine in 1 ml with a 5-minute lockout). Data were collected by questionnaire and interview to evaluate the intervention on pain scores, quality of sleep on the first postoperative night, postoperative nausea and vomiting (PONV) and overall patient acceptability. The subcutaneous PCA group experienced less 'worse pain' (P < 0.01) and less sleep disturbance due to pain (P < 0.001). Subcutaneous PCA would appear to offer patients a safe and effective means of analgesia and may offer significant advantages over the intravenous route of administration.