provides improved analgesia in a number of settings. Their citation list is impressive, and I would note that systemic betamethasone has also shown promise. 2 Regarding their concerns about neurotoxicity, I agree that it is an unsettled issue. We made no assertions about the safety or recommendations for the use of perineural dexamethasone. One must not, however, be alarmist: a careful reading of one of their citations, an elegant preclinical model of adjuvant neurotoxicity, 3 reveals that, in the paradigm studied, ropivacaine was much more neurotoxic than dexamethasone.One larger question I would like to pose is, 'What is the duration of a nerve block?' Is it the duration of anaesthesia to pinprick? Is it the duration of motor weakness? Or, as I would argue, is it the length of time the patient is comfortable? In a real-world setting, we studied the most easily measured and clinically relevant outcome: how long patients were comfortable enough to not require other analgesics.Yes, systemic administration, if equally effective, would be much preferred. Including systemic administration in our trial would have required a much larger patient sample, as it was already a four-group trial. Consequently, we were forced to leave the question open. It will not, however, remain open for long.

Patients undergoing bi-directional Glenn shunt for various congenital anomalies of the heart will have their superior vena cava (SVC) clamped during the procedure. The duration of the procedure is variable, ranging from five to 30 minutes. This can affect the cerebral perfusion due to raised venous pressure [Cerebral blood flow = Mean arterial pressure-(Intracranial pressure + Central venous pressure)]. Shunting away the SVC blood is a well known technique to counter this problem, but we describe two cases where a novel technique was successfully used to decompress the SVC.

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SUMMARY Volume therapy and maintenance of stable hemodynamics is crucial in children undergoing cardiac surgery on cardiopulmonary bypass (CPB). The clinical use of hydroxyethyl starch (HES) 130/0.4 is limited by the possibility of adverse hemostatic effects which could potentially increase the risk of perioperative bleeding and transfusion requirements. We conducted this study to evaluate the safety and efficacy of HES in comparison with modified succinylated gelatin (MSG). Forty‐nine children were randomly assigned to receive either HES (n = 28) or MSG (n = 21) during the pre‐bypass period. Coagulation was assessed with thromboelastography (TEG) and the transfusion requirements up to the first postoperative day were documented. Both groups were comparable with respect to age, weight, CPB duration as well as hematological and biochemical laboratory investigations. TEG parameters were not deranged up to the first postoperative period in either group and there was a trend of reduced blood loss and transfusion requirements in HES groups although there was no statistically significant difference. Our study shows that HES 130/0.4 is safe and effective for volume replacement in pediatric cardiac surgery patients.