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Introduction: Mastocytosis is a rare heterogeneous disease of bone marrow origin which arises as a consequence of abnormal growth and/or accumulation of clonal mast cells in one or more organs. Sixty-five percent of patients with mastocytosis are children in whom it usually regresses around puberty. Adult patients with mastocytosis have been identified as at high risk of widespread mast cell degranulation in the perioperative period, this finding has not been reported in pediatric patients. This information has been repeated in mastocytosis websites where it has the potential to cause disproportionate alarm in parents., Methods: We considered our experience of six children with mastocytosis together with a review of the literature to examine other reports of anesthesia in children with mastocytosis. Our literature search found 57 general anesthetics in 39 children with mastocytosis. In addition, we searched for information about current consensus in diagnosis, classification and treatment of mastocytosis and in vitro and in vivo studies looking at mast cell behavior in response to drugs commonly used during anesthesia., Discussion: The literature search revealed that general anesthesia has precipitated life threatening complications in adult patients with systemic mastocytosis (SM) but no such complications have been described in children with mastocytosis. Our own experience with children with mastocytosis is of uneventful anesthesia. Advances in the understanding of the genetic basis of mastocytosis suggest that pediatric cutaneous mastocytosis (CM) and SM are different entities. SM in children is extremely rare and is associated with elevated baseline serum tryptase. There are few reports of anesthesia in this group., Conclusion: The risks for most pediatric patients are overstated by mastocytosis websites. Most pediatric patients with CM do not appear to be at risk of widespread mast cell degranulation during anesthesia but because of the small number of cases reported, the risk cannot be ascertained with confidence. Children with SM and a high baseline serum tryptase (marker of mast cell burden) may merit extra precautions but experience in this subgroup is even more limited. Drugs which cause minimal histamine release can be selected from the range of drugs available in most pediatric centers without compromise to technique.

Objectives: When introduced, suction coagulation was initially utilised for haemorrhage control following curettage of the adenoid pad. More recently the whole procedure has been performed using the technique. This study aims to report post-operative haemorrhage rates and risk of recurrence in adenoidectomy performed solely by suction diathermy in children., Methods: A retrospective study of 1411 consecutive paediatric patients. Surgery was performed using suction diathermy. No patients were excluded. All patients were followed up., Results: There were no cases of post-operative haemorrhage. 1.7% of patients remained symptomatic and underwent revision adenoidectomy. None required a third procedure., Conclusions: Re-growth of adenoid tissue may occur despite visualisation of the nasopharynx at the time of surgery. The incidence of re-growth is similar to that reported in patients undergoing conventional adenoidectomy by curettage. Post-operative haemorrhage was not encountered in children having adenoidectomy by suction diathermy. The authors suggest suction diathermy as the most appropriate method for adenoidectomy in children.

Objectives: Obstructive sleep apnoea is a common childhood disorder. Adenotonsillar enlargement is most commonly implicated, with adenotonsillectomy representing an effective treatment in the majority of cases. Such children may develop respiratory compromise post-operatively, sometimes necessitating admission to the intensive care unit. We describe insertion of a nasopharyngeal "prong" airway and evaluate its benefits after adenotonsillectomy for obstructive sleep apnoea and milder forms of sleep-disordered breathing., Methods: The prong is easily fashioned from a paediatric endotracheal tube. It is inserted once surgery is complete, remaining in situ overnight. We retrospectively examine its elective use over an 18-month period in selected children considered to be at high risk of post-operative respiratory compromise. Existing practice over the preceding 18-month period is also examined, by way of comparison., Results: Forty-three children underwent adenotonsillectomy for sleep-disordered breathing/OSAS in the 18 months prior to introduction of the prong. Ten were considered "high risk" cases: post-operative intensive care beds were pre-booked for these, but none were eventually required. During the subsequent 18 months, 60 children underwent adenotonsillectomy for the same indication. Seventeen "high risk" cases received the prong post-operatively. No intensive care beds were pre-booked and all children were managed safely on the ENT ward, with minimal intervention., Conclusions: Use of a nasopharyngeal prong significantly improves the post-operative course of selected children who are at high risk of respiratory compromise after adenotonsillectomy. This largely avoids the need for medical intervention and intensive care admission.

Using the database of our pain management team, we examined the records of 254 patients weighing between 4.5 kg and 10 kg who received an epidural for postoperative analgesia. We looked at the incidence of catheter related problems in two groups of patients in whom either a 21-G (18-G short Tuohy needle) or a 23-G catheter (19-G short Tuohy needle) was used. There was a significantly higher incidence of difficulty in threading the catheter, kinking and occlusion in the 23-G catheter group. There were more leaks in the 21-G catheter group but the difference was not significant and both groups had a comparable incidence of clinically relevant leakages. No dural tap or difficulty in using either needle were reported.

Laboratory data, economic pressures, and the wish for humane treatment have been some of the driving forces behind improvements in paediatric pain management. Within the space of 10 years, there have been dramatic changes in the quality of treatment received by children undergoing surgical operations. Moreover, those receiving medical treatment, for example, sickle cell disease, have also benefited from increased experience in pain management. Children receiving care in specialised centres can now expect to benefit from up-to-date techniques of pain management, such as patient-controlled analgesia, nurse-controlled analgesia, and epidural infusions. They will be managed by ward nurses experienced and trained in paediatric pain relief, they will be attended by nurses whose special interest and training is the management of children's pain, and they will be provided with the techniques of analgesia by competent, trained anaesthetic staff. Improved care, with close attention to pain relief, is not only humane, but improves the patient turnaround by enhancing rapid discharge. Further education is required to spread these benefits to children being managed outside highly specialised centres. Not only education, but investment, is needed also to ensure that all children receive a standard of care second to none.

Objective: To determine whether, in the treatment of major depression in primary care, a brief psychological treatment (problem solving) was (a) as effective as antidepressant drugs and more effective than placebo; (b) feasible in practice; and (c) acceptable to patients., Design: Randomised controlled trial of problem solving treatment, amitriptyline plus standard clinical management, and drug placebo plus standard clinical management. Each treatment was delivered in six sessions over 12 weeks., Setting: Primary care in Oxfordshire., Subjects: 91 patients in primary care who had major depression., Main Outcome Measures: Observer and self reported measures of severity of depression, self reported measure of social outcome, and observer measure of psychological symptoms at six and 12 weeks; self reported measure of patient satisfaction at 12 weeks. Numbers of patients recovered at six and 12 weeks., Results: At six and 12 weeks the difference in score on the Hamilton rating scale for depression between problem solving and placebo treatments was significant (5.3 (95% confidence interval 1.6 to 9.0) and 4.7 (0.4 to 9.0) respectively), but the difference between problem solving and amitriptyline was not significant (1.8 (-1.8 to 5.5) and 0.9 (-3.3 to 5.2) respectively). At 12 weeks 60% (18/30) of patients given problem solving treatment had recovered on the Hamilton scale compared with 52% (16/31) given amitriptyline and 27% (8/30) given placebo. Patients were satisfied with problem solving treatment; all patients who completed treatment (28/30) rated the treatment as helpful or very helpful. The six sessions of problem solving treatment totalled a mean therapy time of 3 1/2 hours., Conclusions: As a treatment for major depression in primary care, problem solving treatment is effective, feasible, and acceptable to patients.

We have studied the depth of epidural space in 586 children who had lumbar epidural block as part of their anaesthetic management. The mean depth of epidural space in neonates was 1 cm (SD 0.2, range 0.4-1.5 cm). The depth of epidural space in older infants and children correlated significantly with age and weight with regression equations of depth (cm) = 1 + 0.15 x age (years) and depth (cm) = 0.8 + 0.05 x weight (kg) respectively.

One hundred and fifty extradural infusions of diamorphine and bupivacaine after major surgery in children were audited over a 15 month period. The majority of the children (69%) were less than 5 years of age. Analgesia was assessed or self-rated as 'very good' in over 75% of patients. Urinary retention was seen in 11% of patients and pruritus in 10%. Respiratory depression requiring intervention was only seen in one patient--a premature infant of 39 weeks post-conceptual age. Technical complications resulted in the early loss of 16.7% of the infusions. Although analgesia was good the complexity of the extradural infusion technique demanded significant medical and nursing time especially to overcome technical problems.

We have used sequential measurements of median nerve somatosensory evoked potentials (mnSSEP) in 10 children to estimate the equilibration time of an inhalation anaesthetic agent between alveolar gas, arterial blood and brain. MnSSEP were obtained sequentially every 90-180 s. After control measurements in the absence of isoflurane, the end-tidal concentration was increased stepwise (0.25, 0.5 and 0.75 MAC). Each isoflurane concentration was maintained for 15 min. The point at which the N20 latency reached stability was determined; the mean time between reaching a stable end-tidal isoflurane concentration and this point varied between 5 min 16 s and 7 min 37 s. This technique may be useful in circumstances in which a "steady state" of anaesthesia is important, such as in the determination of MAC or during intraoperative monitoring of evoked potentials.

Evoked potentials are used to determine the integrity of neural pathways during neurosurgical and orthopaedic procedures, but the extent to which they may be altered by anaesthetic agents has not been studied systematically in children. In this study we have recorded median nerve somatosensory evoked potentials (mnSSEP) in children during isoflurane anaesthesia to determine if there are changes similar to those seen in adults. We studied 10 patients using standardized anaesthetic and clinical neurophysiological techniques. Control mnSSEP were obtained with 70% nitrous oxide in oxygen and isoflurane was then administered at 0.25, 0.50 and 0.75 MAC. The latencies and amplitudes of the mnSSEP were subjected to repeated measures analysis of the variance (ANOVA) and linear regression. There were statistically significant increases in N20, P22 latencies and central conduction time (P < 0.001) and reductions in amplitude of the N20-P22 complex (P < 0.03) with increasing end-tidal isoflurane concentrations. These results are similar to the findings in adults.

Interest in the management and study of pain in children has increased in recent years. A range of techniques appropriate to children with different developmental levels is now available for the assessment of various aspects of childhood pain. A management plan can be developed depending on the cause of pain and choosing from a range of therapeutic techniques. It should take into account both the physical and psychological aspects of pain. Drugs from the mainstay of treatment of pain with a clear physiological cause. Suitable drugs are now available but inexperience and myths may still result in reluctance to use appropriate strong analgesics in children. Postoperative pain control and the analgesic needs of neonates have been particularly neglected areas. Management can be dramatically improved by increasing staff sensitivity and the use of an integrated programme of drugs, physical techniques and psychological approaches.

We report the effect of cyclopropane used for induction of anaesthesia in children on the subsequent measurement of maintenance volatile anaesthetic agents with the single wavelength infrared absorption technique. After using cyclopropane to induce anaesthesia we have observed that falsely high readings of the expired maintenance agent occur for up to 60 minutes when using the Datex Capnomac. This is because of the effect of low concentrations of cyclopropane expired from the patient.

We studied EEG and brainstem auditory evoked potentials (BAEP) during routine surgery at various concentrations of isoflurane (12 patients) or halothane (11 patients) or during prolonged (mean 2.5 h, range 1.9-3.5 h) administration of 1% isoflurane (five patients). Recording and analysis was performed with the cerebral function analysing monitor (CFAM). At equivalent MAC, the two agents exhibited distinctive neurophysiological profiles. Increasing concentrations of isoflurane produced a clear sequence of EEG changes (decreasing fast and increasing slow components) then burst suppression activity suggesting cortical depression. With halothane, changes in EEG amplitude were less pronounced and those in frequency content less systematic, with no periods of suppression. Simultaneous BAEP showed greater latency increase with halothane than with isoflurane. Prolonged administration of 1% isoflurane was associated with a stable EEG (no periods of suppression) and BAEP.

We have studied the EEG analysed with the cerebral function analysing monitor (CFAM) during trimetaphan (TMP)-induced hypotension to a mean arterial pressure (MAP) of 40 mm Hg in 20 normocapnic patients anaesthetized with either 1% end-tidal isoflurane or 0.5% halothane. During the acute reduction in MAP, the average reduction in mean EEG amplitude with halothane was 14%, two patients showing short periods of EEG suppression; the decline in EEG amplitude correlated with declining MAP in four patients. In contrast, the average reduction in mean EEG amplitude with isoflurane was only 0.3% and there were neither periods of suppression nor any correlation between EEG amplitude and MAP. No significant changes in EEG frequency occurred in either group. Isoflurane prevented EEG amplitude depression during TMP-induced hypotension.

Midazolam was given, by infusion, for the sedation of 10 children receiving intensive care after cardiac surgery. Plasma concentrations greater than 250 ng ml-1 were required for adequate sedation. Midazolam did not cumulate in eight of the 10 children, and these patients excreted the drug in a fashion similar to that by adults. However, midazolam did accumulate in two children, one with profound hepatic disturbance. In one of these patients recovery was slow following cessation of the infusion.

The sedation of 50 children aged 6 months to 9 years who had undergone open heart surgery was studied. During artificial ventilation a midazolam infusion was used in conjunction with the administration of morphine (and tubocurarine). Sedation for patients breathing spontaneously with positive airway pressure was continued with midazolam alone. The duration of the midazolam infusion (2-6 micrograms kg-1 min-1) ranged from 12 to 197 h. Forty-seven of the children were sedated uneventfully; the remaining three children needed small doses of other sedative agents. In 10 of the children, blood samples were taken for serum midazolam assay and a short Synacthen test was performed. There was no clinical evidence of accumulation of midazolam, but midazolam concentrations were so variable that no conclusions could be drawn. All patients in whom they were measured (n = 10) had high basal cortisol concentrations, but displayed normal responses to Synacthen.

The mortality of patients admitted to intensive care units with haematological malignancy is high. A humane approach to the management of the critically ill as well as efficient use of limited resources requires careful selection of those patients who are most likely to benefit from intensive care. To delineate more accurately the factors influencing outcome in these patients the records of 60 consecutive admissions to the intensive care unit (37 male, 23 female) with haematological malignancy were reviewed retrospectively. Fifty patients were in acute respiratory failure, most commonly (34 patients) with a combination of pneumonia and septicaemic shock. The severity of the acute illness was assessed by the APACHE II (acute physiology and chronic health evaluation II) score and number of organ systems affected. Thirteen patients survived to leave hospital. The mortality of patients with haematological malignancy was consistently higher than predicted from a large validation study of APACHE II in a mixed population of critically ill patients. Moreover, no patient with an APACHE II score of greater than 26 survived. Mortality among the 22 patients with relapsed malignancy (21 deaths), was significantly higher than among the 35 patients at first presentation (26 deaths). On discharge from the intensive care unit all survivors had responded well to chemotherapy and had normal or raised peripheral white cell counts. They included seven patients who had recovered from leucopenia (white cell count less than 0.5 X 10(9)/l). In contrast, 36 of the 47 patients who died were leucopenic at the time of death. The overall mortality of critically ill patients with haematological malignancy is higher than equivalently ill patients without cancer. The dysfunction of an increasing number of organ systems, an APACHE II score of greater than 30, failure of the malignancy to respond to chemotherapy, and persistent leucopenia all point to a poor outcome.

The medical records of 22 consecutive adult admissions to an intensive care unit (ICU) with life-threatening complications of haematological malignancy, or its treatment, are reviewed. Twenty patients (91%) were in acute respiratory failure, and 17 of the 22 patients required intermittent positive pressure ventilation (IPPV). The in-unit mortality was 55%, but only 4 patients (18%) survived to leave the hospital. Although the unit mortality appeared to be related to the acute physiology score (APS), this small series did not demonstrate a clear relationship between the APS and long-term survival (discharge from hospital). There were, however, significant differences in the number of organ systems involved between those who died on the ICU and those who returned to the ward, as well as between those who survived to leave hospital and those who died. No patient with more than three systems involved became a long-term survivor. All long-term survivors had either reasonable peripheral white cell counts throughout or their bone marrow showed significant recovery prior to discharge from the ICU. Unresponsive malignant disease and a failure to recover bone marrow function were major factors in those patients who died shortly after discharge from the ICU. Although long-term survival rates are low and are probably largely determined by the progress of the underlying malignancy, intensive care was life-saving in four patients, three of whom are alive several years after discharge.

A case is presented in which the inhalation of a foreign body caused a respiratory arrest and was subsequently diagnosed and treated as an attack of acute asthma. The presentation, diagnosis, investigation and treatment of this condition is discussed and a review of the literature is presented.

A case is reported in which stridor was the presenting symptom of acute superior vena cava obstruction, after attempted insertion of a Hickman catheter.