There is no high-level evidence supporting an optimal top-up solution to convert labour epidural analgesia to surgical anaesthesia for Caesarean section. The aim of this meta-analysis was to identify the best epidural solutions for emergency Caesarean section anaesthesia, with respect to rapid onset and low supplementation of intraoperative block. Eleven randomized controlled trials, involving 779 parturients, were identified for inclusion after a systematic literature search and risk of bias assessment. 'Top-up' boluses were classified into three groups: 0.5% bupivacaine or levobupivacaine (Bup/Levo); lidocaine and epinephrine, with or without fentanyl (LE ± F); and 0.75% ropivacaine (Ropi). Pooled analysis using the fixed-effects method was used to calculate the mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes. Lidocaine and epinephrine, with or without fentanyl, resulted in a significantly faster onset of sensory block [MD -4.51 min, 95% confidence interval (CI) -5.89 to -3.13 min, P < 0.00001]. Bup/Levo was associated with a significantly increased risk of intraoperative supplementation compared with the other groups (RR 2.03; 95% CI 1.22-3.39; P = 0.007), especially compared with Ropi (RR 3.24, 95% CI 1.26-8.33, P=0.01). Adding fentanyl to a local anaesthetic resulted in a significantly faster onset but did not affect the need for intraoperative supplementation. Bupivacaine or levobupivacaine 0.5% was the least effective solution. If the speed of onset is important, then a lidocaine and epinephrine solution, with or without fentanyl, appears optimal. If the quality of epidural block is paramount, then 0.75% ropivacaine is suggested.

extensively investigated, leading to different recommendations. Ginosar et al 6 determined that the 95% effective dose was 11 mg of hyperbaric bupivacaine 0.75% when combined with fentanyl 10 mg and morphine 200 mg and injected as part of a CSE technique in the sitting position. Interestingly, they demonstrated no rescue analgesic supplementation when the dose was above 10 mg. Finally, this current study by Loubert et al reflects one of the principles of the sequential CSE technique, in which an initial dermatomal spread is obtained through the spinal component and additional epidural top-ups are required to achieve a dermatomal level for surgical anesthesia. 7 In summary, the clinical implication of administering in the sitting position a dose of hyperbaric bupivacaine that is lower than the evidence-based recommendation implies the mandatory use of a CSE technique to guarantee surgical anesthesia. Comment by Cristian Arzola, MD, MSc REFERENCES 1. Russell IF. Routine use of the sitting position for spinal anaesthesia should be abandoned in obstetric practice. Int J Obstet Anesth. 2008;17:343-347. 2. Dresner M. Controversy. Routine use of the sitting position for spinal anaesthesia should be abandoned in obstetric practice. Int J Obstet Anesth. 2008;17:347-349. 3. Hallworth SP, Fernando R, Columb MO, et al. The effect of posture and baricity on the spread of intrathecal bupivacaine for elective cesarean delivery. Anesth Analg. 2005;100:1159-1165. 4. El-Hakeem EEA, Kaki AM, Almazrooa AA, et al. Effects of sitting up for five minutes versus immediately lying down after spinal anesthesia for Cesarean delivery on fluid and ephedrine requirement; a randomized trial. Can J Anesth/J Can Anesth. 2011;58:1083-1089. 5. Køhler F, Sørensen JF, Helbo-Hansen HS. Effect of delayed supine positioning after induction of spinal anaesthesia for caesarean section. Acta Anaesthesiol Scand. 2002;46:441-446. 6. Ginosar Y, Mirikatani E, Drover DR, et al. ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery.

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Aims Undergraduate paediatric attachments are typically 5-9 weeks long. As a result of changes in service delivery, it is an increasing challenge to expose students to the process of healthcare delivery and practical management of the unwell child. We sought to develop, use and evaluate a web-based tool to mimic aspects of a daily ward round, so that students could see how a child is assessed and managed over the course of an admission in an interactive and supportive environment. Methods A virtual ward round (VWR), written in html, was delivered through a web browser by a facilitator.1 The VWR consisted of daily 30 minute sessions during the first week of a 4th year paediatric attachment. Participants were shown a virtual ward, and jointly conducted a ward round of 4 patients. Led by the facilitator, groups perused clinical information, discussed investigation results, considered disease processes and planned management. Developments were reviewed the following day. If patients were discharged, a new patient occupying the same bed would be introduced. Feedback was collected at the end of 6 separate attachments. Students rated sessions for content and presentation on a Likert scale from 1-5, chose appropriate adjectives and gave free text comments. Results 28 VWR sessions were delivered over 6 attachments to a total of 221 students. The VWR mean content score was higher than the course mean (4.52 v 4.42). VWR presentation was rated higher than course mean: (4.41 v 4.17). The commonest adjectives chosen for VWR sessions were Interactive, Interesting, Engaging, Useful and Fun. Free text comments indicated that many students found the VWR the most valuable part of the week, and highlighted its breadth, realism and interactivity. Conclusions The VWR successfully introduced students to paediatric clinical decision making, was well received and deemed particularly valuable. A web-based VWR enables students to experience common ward scenarios and is an effective adjunct to the teaching of clinical medicine.