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Background: During anaesthetic induction with a facemask, the inconsistent inspiratory flow with manual ventilation (MV) raises the peak airway pressure (PAP), which can be significantly higher than PAP during pressure-controlled ventilation (PCV). In this study, PAP was compared between MV and PCV at the same tidal volume of 8-10 ml/kg during facemask ventilation for anaesthetic induction in children. The occurrence of gastric insufflation (GI) was evaluated with ultrasonography and stethoscopic auscultation.Methods: Forty-eight children, aged 0.5-7 years, undergoing elective urologic surgery were randomly allocated into either Group MV or Group PCV. Under light sedation with thiopental iv., ultrasonography (US) was performed and the gastric antrum was identified. After additional thiopental and rocuronium administration, facemask ventilation with a tidal volume of 8-10 ml/kg was performed for 3 min, whereas respiratory parameters were recorded at 1 min intervals. Real-time US and stethoscopic auscultation were performed for evaluation of GI.Results: In the MV group, PAP was higher at all the time points compared with the PCV group (14 vs. 9.5, 15 vs. 10 and 15 vs. 9 cmH2 O, all P < 0.05). However, there was no difference in the GI occurrence between Group MV and Group PCV (7 vs. 3, P = 0.284). There was no difference between PAP in patients with GI and without GI (P > 0.05). Ultrasonography was more sensitive in detecting GI than the stethoscopic auscultation (10 vs. 5). Gastric antral area was expanded after facemask ventilation in both groups, but there were no intergroup differences.Conclusion: Although PCV provided lower PAP than MV at the same tidal volume, the risk of GI may not be eliminated during facemask ventilation in paralysed small children. [ABSTRACT FROM AUTHOR]

This study aimed to assess the association between caudal block and postoperative complications after tubularised incised plate urethroplasty. The medical records of 388 paediatric patients who underwent urethroplasty at a tertiary medical centre were analysed retrospectively. Among the 342 patients included, 216 patients received a caudal block and 72 (21.1%) patients suffered surgical complications. The number of patients having surgical complications was significantly greater among patients who received a caudal block than among patients who did not receive a caudal block (53 (24.5%) versus 19 (15.1%), respectively, p = 0.04). Based on multivariate logistic regression analysis, duration of surgery, caudal block and hypospadias types were independent risk factors for the surgical complications. Patients with caudal block had an odds ratio of 2.1 (95% CI, 1.14-3.81, p = 0.018) for the development of postoperative complications compared with patients without caudal block. This analysis demonstrates that caudal block is associated with surgical complications after tubularised incised plate urethroplasty. [ABSTRACT FROM AUTHOR]

Background The appropriate endotracheal tube ( ETT) size is commonly determined using age-based formula; ETT size determination based on ultrasound ( US) measurement of subglottic diameter ( SD), the narrowest portion of the paediatric upper airway, may provide a better method for accurate fit. We aimed to validate ETT size determination using US measures of SD before intubation to establish an empirical formula for ETT fitting based on SD and biographic parameters. Methods We included 215 children aged 1-72 months undergoing general anaesthesia. US was performed on the anterior neck to measure SD during mask ventilation under anaesthesia. Endotracheal intubation was performed with a cuffed ETT selected by age-based recommendation; the transverse outer diameter ( OD) of the ETT within the trachea at the subglottis level ( OD-ETT at SD) was measured. Results The OD-ETT at SD was correlated with the actual OD-ETT outside the trachea ( R2 = 0.635), showing the validity of ultrasonographic measurement; moreover, the US-measured SD revealed strong correlation with the actual OD-ETT ( R2 = 0.834). US-measured SD and biographic data (age, height and weight) showed little correlation in children less than 12 months but good correlation (age, height) in children older than 12 months ( P < 0.01). Conclusions US-measured OD-ETT at SD was in good agreement with the actual OD-ETT, suggesting that US-measured SD helps in choosing the appropriate ETT diameter for children. In children older than 12 months, the equation ' OD (mm) = 0.01 × age (months) + 0.02 × height (cm) + 3.3' may help select the appropriate ETT. [ABSTRACT FROM AUTHOR]

This study evaluated ulnar and radial artery blood flow after radial artery cannulation during general anaesthesia using Doppler ultrasound. A total of 80 patients were randomly assigned to receive radial artery cannulation with either a 20-G or 22-G cannula. Arterial diameter, peak systolic velocity, end-diastolic velocity, resistance index and mean volume flow were measured at four time points in both arteries: before anaesthesia; 5 min after intubation; immediately after cannulation; and 5 min after cannulation. After radial artery cannulation, ulnar diameters and blood flow were significantly increased, and persisted until 5 min after cannulation. Radial blood flow was decreased immediately after cannulation and recovered to pre-cannulation values 5 min after cannulation. There were no statistical differences between groups at each time point. Radial artery cannulation causes compensatory increase in ulnar artery blood flow, and the difference in cannula size has minimal effect on this change. [ABSTRACT FROM AUTHOR]

Background Lower spinal dysraphism is frequently reported in anorectal anomaly combined with urogenital anomalies. The prevalence of the spinal dysraphism has not been comprehensively studied in children with simple urogenital anomalies. We evaluated the prevalence of the spinal dysraphism using ultrasound data of the lumbosacral area in children with urogenital anomalies. Methods Lumbosacral ultrasound images of 259 children who underwent urological surgery with simple urogenital anomalies were reviewed by an ultrasound-specialized radiologist. The primary outcome measures were the conus medullaris ( CM) level and the thickness of the filum terminale. The spinal ultrasonographic findings that were assessed in children showed abnormal spinal findings compared with the other children having normal findings. Two years later, the follow-up telephone interviews were made with the parents of the children with abnormal findings. Results Eighteen children were differentiated as the abnormal finding group. They were suspected of spinal cord tethering. The level of CM was lower, and the filum terminale was thicker compared to the normal group [ L2lower (L) vs. L1L, 2.2 mm vs. 0.8 mm]. Of eighteen children, four were confirmed as tethered spinal cord with lipoma on magnetic resonance imaging by the time of surgery, and two were strongly suspected of occult spinal dysraphism ( OSD) based on ultrasound findings and follow-up interviews. Conclusions The prevalence of OSD in children under 24 months of age with simple urogenital anomaly was higher than what was reported for the general population. Ultrasound examination of spinal structures before caudal block in children with urogenital anomaly should be considered. [ABSTRACT FROM AUTHOR]

Background Spinal block induces hyperkinetic change in lower extremity blood flow. We compared the venous flow dynamic responses to spinal block in normotensive and hypertensive elderly patients. Methods Following spinal block using 10 mg 0.5% (w/v) bupivacaine, we measured changes in blood pressure, heart rate, and venous flow dynamics of the popliteal vein by duplex ultrasonography in 20 normotensive ( NBP group) and 18 hypertensive ( HIBP group) patients. Results Spinal block caused significant decreases in blood pressure in both groups; similar rates of hypotension were observed. At baseline, peak velocity, time-averaged maximum velocity, and time-averaged mean velocity were higher in the HIBP than in the NBP group. During spinal block, peak velocity increased in both groups, and the between-group differences were no longer significant. At baseline, volume flow in the two groups was similar and increased by 141.5% in the NBP and 131.7% in the HIBP group during spinal block. Conclusions Blood pressure and flow dynamics in the popliteal vein showed similar changes during spinal anaesthesia in elderly patients taking antihypertensive medication and normotensive patients, despite differences in baseline values. [ABSTRACT FROM AUTHOR]

Background Dexmedetomidine (DMT) has been shown to prolong spinal anaesthesia. We evaluated the effects of intravenous DMT on low-dose bupivacaine spinal anaesthesia in elderly patients. Methods Fifty-one elderly patients undergoing transurethral resection of the prostate were randomized into two groups receiving either 1.0 μg/kg DMT ( DMT group, n = 26) or normal saline (control group n = 25) intravenously prior to spinal anaesthesia with 1.2 ml of bupivacaine, 5 mg/ml. Results The mean time to two-segment regression (39 min vs. 78 min for cold, 41 min vs. 61 min for pinprick) and that to motor regression (23 min vs. 46 min) were longer in the DMT group than in the control group. The atropine-requiring bradycardia was more frequent in the DMT group than in the control group (24.0% vs. 3.8%). The median sedation scores (ranges) during surgery were 4 (2-6) in the DMT group and 2 (1-3) in the control group ( P < 0.001). Two patients in the DMT group showed oxygen desaturation (peripheral oxygen saturation < 90%) during surgery. The duration of post-operative care unit stay was longer in the DMT group than in the control group (58 min vs. 96 min). Post-operative pain intensity was lower and the mean time to first request for post-operative analgesia was longer in the DMT group compared to the control group (6.6 h vs. 2.1 h). Conclusion Intravenous DMT prolonged the duration of spinal anaesthesia and improved post-operative analgesia. However, more profound sedation with desaturation was observed with more frequent bradycardia, and delayed recovery should be considered in elderly patients. [ABSTRACT FROM AUTHOR]

This study was designed to determine the optimal dose of propofol for excellent intubating conditions in children without neuromuscular blockade at various alveolar concentrations of sevoflurane. Sixty-three children, aged 0.5-5 years, were randomized to three groups of end-tidal sevoflurane concentration (ET) 3%, 3.5%, and 4%. Inhalation anesthesia was started with sevoflurane 7% in 100% oxygen. When the patients became unconscious, inspired concentration was adjusted to obtain the target ET for each group. When ET reached the target concentration, a predetermined dose of propofol was given and tracheal intubation was performed. The proper dose of propofol was determined using the 'up-and-down' method. The median dose (95% confidence intervals) of propofol for excellent tracheal intubating conditions in 50% of children were 1.25 mg/kg (0.84-1.75) at ET of 3%, 0.76 mg/kg (0.35-1.21) at 3.5%, and 0.47 mg/kg (0.26-1.09) at 4%. The frequency of adverse effects was not different between groups during induction and recovery. Propofol 1.5-2 mg/kg provides excellent intubating conditions at 3-4% ET in children without using any neuromuscular blocking agent. [ABSTRACT FROM AUTHOR]

The effects of an epidural opioid and a local anesthetic on the perioperative stress responses have not been fully investigated in elderly patients undergoing cancer surgery. We hypothesized that the stress response after a radical retropubic prostatectomy (RRP) would be attenuated by epidural ropivacaine and sufentanil. In this randomized, double-blinded study, we included patients above 65 years of age who were scheduled for a RRP. In addition to general anesthesia, they received either epidural saline continuously (5 ml/h) (C group, n=20); 0.3% ropivacaine (R group, n=20); or 0.3% ropivacaine combined with 1 μg/ml sufentanil (RS group; n=20). We determined the concentrations of glucose, insulin, cortisol, epinephrine, norepinephrine, and prolactin before, during, and up to 48 h after surgery. The concentrations of glucose and insulin increased in all the groups. The cortisol level increased in the C group while it decreased significantly in the RS group. Epinephrine and norepinephrine concentrations increased significantly after surgery in the C group, but not in the R and RS groups. The prolactin concentration increased in all the groups, and was higher in the RS group than in the other groups ( P=0.002). Post-operative pain scores and analgesic requirement were lower in the R and RS groups. Epidural ropivacaine blunted the perioperative stress responses in elderly patients undergoing a RRP. The combination of epidural ropivacaine and sufentanil was associated with the most pronounced attenuation of the stress response. ClinicalTrial.gov registration number: NCT01086956. [ABSTRACT FROM AUTHOR]

Children undergoing ureteroneocystostomy suffer from post-operative pain due to the surgical incision and bladder spasm. A single-shot caudal block is a common technique for paediatric analgesia, but a disadvantage is the limitation of a short duration in spite of the additives co-administered. A few clinical trials have shown that ketorolac provides an effective post-operative analgesia and reduces the bladder spasms after ureteral implantation in children. We compared the efficacy of a continuous infusion of ketorolac and fentanyl in post-operative analgesia and bladder spasm in children who underwent ureteroneocystostomy. Fifty-two children were allocated to the ketorolac group (Group K, n=26) and fentanyl group (Group F, n=26). After general anaesthesia, a caudal block was performed with 1.5 ml/kg of 0.15% ropivacaine. At the beginning of surgery, an infusion was started after the bolus injection of ketorolac 0.5 mg/kg or fentanyl 1 μg/kg. An infusion device was programmed to deliver ketorolac 83.3 μg/kg/h or fentanyl 0.17 μg/kg/h for 48 h. Two of Group F and three of Group K were excluded from the study. Post-operative pain scores were similar between the two groups. One of Group K (4%) and seven of Group F (30.4%) experienced bladder spasms. The rescue analgesic requirements were significantly less in Group K. A Continuous infusion of ketorolac provided effective analgesia after operation in children who underwent ureteroneocystostomy as well as a low dosage of fentanyl. Ketorolac was more effective in reducing the frequency of bladder spasms and rescue analgesic requirements. [ABSTRACT FROM AUTHOR]

Background: Caudal block is the most common regional technique to provide post-operative analgesia in pediatric infra-umbilical surgery. This study was designed to define how many spinal segments would be covered by the weight-based dosage of caudally administered 0.2% ropivacaine in children using the fluoroscopic method. Methods: After an approval from the institutional human research review board, in 83 ASA I boys undergoing day-case urological surgery, the distribution of ropivacaine mixed with a radioactive dye in relation to the volume injected caudally was studied. Three groups were studied: for perineal surgery 0.5 ml/kg ( group C0.5), for inguinal hernia repair 1 ml/kg ( group C1.0), and for orchiopexy 1.25 ml/kg ( group C1.25). The dose of 0.2% ropivacaine containing radiopaque dye at a ratio of 1 : 4 was injected at a rate of 1 ml 3 s−1. Fluoroscopic examination was performed immediately to define the level of the drug spread within the extradural space. Results: The highest spinal levels [median with ranges] of spread were L2 [L4-T12] in group C0.5, T12 [L1-T8] in group C1.0, and T10 [L2-T7] in group C1.25. Analysis by age distribution (infants: <12 months; toddlers: 12–36 months; and children: >36 months) revealed a larger spread in younger patients. Conclusions: Based on the fluoroscopic findings, the weight-based doses for caudally administered 0.2% bupivacaine suggested by Armitage are also useful for ropivacaine to block the spinal level required for the different types of surgeries studied. [ABSTRACT FROM AUTHOR]

Background: Ilioinguinal nerve (IIN) and iliohypogastric nerve (IHN) blocks provide good perioperative pain relief for children undergoing inguinal procedures such as inguinal hernia repair, orchiopexy, and hydrocelectomy. The aim of this ultrasound imaging study is to compare the relative anatomical positions of IIN and IHN in different age groups of pediatrics. Methods: Two-hundred children (aged 1–82 months, ASA I or II) undergoing day-case surgery were consecutively included in this study. Following the induction of general anesthesia, an ultrasonographic exam was performed using a high-frequency linear probe that was placed on an imaginary line connecting the anterior superior iliac spine (ASIS) to the umbilicus. Results: There were significant differences in ASIS–IIN (distance from ASIS to IIN), ASIS–IHN (distance from the ASIS to the IHN), and IIN–IHN (distance between IIN and IHN) between the age groups: <12 months ( n=84), 12–36 months ( n=80), and >37 months ( n=36). However, IIN–Peritoneum (distances from IIN to peritoneum), skin–IIN, and skin–IHN (depth of IIN and IHN relative to skin) were similar in three groups. ASIS–IIN and ASIS–IHN showed significantly positive correlations with age. Conclusions: Age should be considered when placing a needle in landmark techniques for pediatric II/IH nerve blocks. However, needle depth should be confirmed by the fascial click due to the lack of predictable physiologic factors. [ABSTRACT FROM AUTHOR]

Background: Propofol is the popular intravenous (i.v.) anaesthetic for paediatric sedation because of its rapid onset and recovery. We compared the efficacy and safety of a single dose and conventional infusion of propofol for sedation in children who underwent magnetic resonance imaging (MRI). Methods: This was a double-blind, randomized-controlled study. One hundred and sixty children were assigned to group I (single dose) or II (infusion). Sedation was induced with i.v. propofol 2 mg/kg, and supplemental doses of propofol 0.5 mg/kg were administered until adequate sedation was achieved. After the induction of sedation, we treated patients with a continuous infusion of normal saline at a rate of 0.3 ml/kg/h in group I and the same volume of propofol in group II. In case of inadequate sedation, additional propofol 0.5 mg/kg was administered and the infusion rate was increased by 0.05 ml/kg/h. Induction time, sedation time, recovery time, additional sedation and adverse events were recorded. Results: Recovery time was significantly shorter in group I compared with group II [0 (0–3) vs. 1 (0–3), respectively, P<0.001]. Group I (single dose) had significantly more patients with recovery time 0 compared with group II (infusion) (65/80 vs. 36/80, respectively, P<0.001). Induction and sedation times were not significantly different between groups. There was no significant difference in the frequency of additional sedation and adverse events between groups. Conclusion: A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min. [ABSTRACT FROM AUTHOR]

Although the anatomy of the spinal cord and its associated structures have been well defined, the effects of body position relevant to neuraxial blockade have not been elucidated. This study was designed to determine the effect of body position on the end of the dural sac in children. After induction of anaesthesia, ultrasound examination was performed to evaluate the location of the dural sac end in the lateral position with a straight back and knee, and in the lateral position with the knees, legs, and neck flexed. The level of the end of the dural sac was determined in relation to the vertebrae. Our data demonstrate that the dural sac shifts significantly cephalad in the lateral flexed position used for neuraxial blockade (p < 0.001). These results suggest that the safety margin to avoid dural puncture during hiatal or S2-3 approach for caudal block can be increased in younger children. [ABSTRACT FROM AUTHOR]

Background: Epidural opioids are frequently combined with local anaesthetics for an additive antinociceptive effect. We investigated the efficacy of epidural fentanyl to 1.25 or 1.5 mg/ml ropivacaine for post-operative epidural analgesia in children. Methods: One hundred and eight children undergoing hypospadias repair were randomized to receive 1.25 mg/ml ropivacaine (R1.25 group), 1.25 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.25F group), 1.5 mg/ml ropivacaine (R1.5 group) or 1.5 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.5F group) for post-operative epidural analgesia. The epidural catheter was threaded caudally through the L4-5 interspace. The face, legs, activity, cry, consolability (FLACC) score was assessed at every hour and at FLACC score >4, an epidural bolus of 0.5 ml/kg of ropivacaine 1.5 mg/ml was given as the rescue analgesia. The incidence of side effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was recorded. Results: The need for rescue analgesia was higher in the R1.25 group compared with that in the other three groups (all P<0.05). The incidence of side effects was higher in the R1.5F group compared with that in the R1.25 and R1.5 groups (both P=0.010). Conclusion: The addition of 0.2 mcg/kg/h fentanyl to 1.5 mg/ml ropivacaine increased the incidence of side effects without improvement of analgesia in infants and children undergoing hypospadias repair. The use of plain 1.25 mg/ml ropivacaine increased the need for rescue analgesia and this could be compensated by addition of fentanyl. [ABSTRACT FROM AUTHOR]

Seventy elderly males received lumbar epidural anaesthesia with 12 ml of 2% lidocaine containing fentanyl 50 μg. At the end of transurethral surgery, the washout group ( n = 33) received an epidural bolus of 30 ml saline while the control group ( n = 34) did not. Mean (SD) times to 1-grade (17.2 (11.9) vs 32.7 (11.3) min) and 2-grade regression (23.8 (12.2) vs 56.0 (23.9) min) of motor block, 3-dermatomal sensory regression (31.4 (11.6) vs 42.2 (14.4) min for cold and 30.8 (15.6) vs 40.6 (14.2) min for pinprick), and regression to S1 (57.7 (16.1) vs 76.2 (20.2) min for cold and 56.8 (17.3) vs 69.2 (16.2) min for pinprick) were significantly shorter in the washout group than the control group. There were no differences in postoperative pain scores and side effects between the two groups. We concluded that epidural washout facilitates regression of both motor and sensory block following epidural anaesthesia without reducing the postoperative analgesic benefit. [ABSTRACT FROM AUTHOR]

Background: This prospective, randomized, double-blind study aimed to determine whether caudal midazolam combined with ropivacaine affects anesthetic requirements, recovery profiles, and post-operative analgesia compared with ropivacaine alone in pediatric day-case hernioplasty. Methods: Sixty boys (2–5 years old) received caudal injections of 0.2% ropivacaine 1 ml/kg and epinephrine 1 : 200,000 with (RM group) or without (R group) 50 μg/kg of midazolam under sevoflurane anesthesia. The sevoflurane requirement was determined by adjusting to a bispectral index score=50. Results: Concentrations of end-tidal sevoflurane (ETsevo%) after induction were similar in both groups. After caudal block, ETsevo% before and after surgical stimuli did not show significant intra- or intergroup differences. Recovery characteristics, including post-operative sedations, were similar in both groups. Post-operative pain scores were significantly lower in the RM group than the R group. Conclusions: Caudal midazolam (50 μg/kg) added to 2% ropivacaine did not influence sevoflurane requirement or recovery but improved post-operative analgesia compared with ropivacaine alone in pediatric day-case hernioplasty. [ABSTRACT FROM AUTHOR]

Background: Studies comparing epidural fentanyl and sufentanil in adults reported a similar analgesic effect with variable side effects. We hypothesized that epidural fentanyl and sufentanil will have a similar analgesic effect in children undergoing urological surgery. Methods: Sixty-four children undergoing urological surgery were randomized into two groups: fentanyl in ropivacaine (fentanyl group, n=32) and sufentanil in ropivacaine (sufentanil group, n=32). After anaesthesia, an epidural catheter was inserted at the L2–3, L3–4 or L4–5 interspace. For post-operative pain relief, a solution consisting of fentanyl 0.1 mcg/kg/ml or sufentanil 0.015 mcg/kg/ml in 1.5 mg/ml ropivacaine was infused at a rate of 2 ml/h. To assess post-operative pain, the faces pain scale and the face, legs, activity, cry, consolability score were recorded at 1, 6, 24, 48 and 72 h after surgery. The incidence of adverse effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was also evaluated. Results: Pain scores demonstrated no significant difference between the groups. The need for rescue analgesia during 24–72 h was higher in the fentanyl group than in the sufentanil group (6/32 vs. 0/32, P=0.012). The incidence of pruritus was higher in the sufentanil group compared with that in the fentanyl group (5/32 vs. 0/32). Conclusions: Epidural sufentanil provides better analgesia from 24 h after surgery compared with epidural fentanyl in infants and children undergoing urological surgery. The incidence of pruritus in the sufentanil group was higher than that in the fentanyl group. [ABSTRACT FROM AUTHOR]

Using ultrasound imaging, the optimal angle for needle insertion during caudal epidural injection in children was estimated. After general anaesthesia, ultrasonography was performed at the sacral hiatus in 130 children aged 2–84 months positioned in the lateral position. The median [range] values for the intercornual, caudal space depth and the distance from skin to the posterior sacral bony surface were 17.0 [9.6–24] mm, 3.5 [1–8] mm and 21.0 [10–39] mm, respectively. The optimal angle showed no significant correlation with age, weight, height or body surface area. The median [range] calculated optimal angle for the needle was 21.0 [10–38]°. We conclude that the needle should be inserted at about 20° to the skin to avoid puncture of the bone and potential intra-osseous injection. [ABSTRACT FROM AUTHOR]

Many pathophysiologic alterations in major burns can cause changes in the distribution of, and perhaps response to, drugs commonly used in anesthesia practice. This study was conducted to assess changes in bispectral index (BIS) caused by increasing the target propofol effect-site concentration during a target-controlled infusion (TCI) in major burns.Eighteen patients, ASA physical status 2 or 3, aged from 20 to 55 years old, weighing 50–70 kg, with major burns, scheduled for elective early escharectomy less than a week after injury were recruited. A further 18 ASA physical status class 1 or 2, non-burns, age, sex- and weight-matched adult patients scheduled for elective surgery under general anesthesia were recruited as controls. During anesthesia induction, target propofol effect-site concentrations were increased by increments of 0.5 µg ml−1 up to 4.5 µg ml−1. The BIS responses to each target concentration using TCI were compared in both groups.In the burns group, significantly greater BIS values relating to increasing propofol TCI were noted at deeper anesthesia when compared with controls; at≥3.5 µg ml−1; mean BIS remained at a plateau of about 50. Patients with burns had higher cardiac indices, and lower hemoglobin and albumin concentrations than the controls. They consumed more vecuronium to maintain the same degree of neuromuscular blockade than the controls.In major burns, the final biphasic BIS responses appeared to be determined by numerous other variables such as BIS algorithm, TCI performance, and altered propofol pharmacokinetics and pharmacodynamics. According to our results the importance of an individually tailored approach, including careful anesthetic titration, based upon the patient's clinical condition and responses can not be overemphasized. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which discusses the connection of occult spinal dysraphism to low spine anomalies and genitourinary structures as well as the use of ultrasonic imaging to diagnose dysraphism in infants.

A response from the author of the article "Venous flow dynamics during spinal block in normotensive and hypertensive elderly patients: a duplex ultrasonographic study" in the 2012 issue is presented.

The title mol-ecule, C(24)H(29)N(3)O(6), has a nearly planar ten-atom C(3)N(3)O(4) core, on account of both N-H groups forming six-membered-ring intra-molecular hydrogen bonds to carbamate carbonyl O atoms. The absolute configuration was determined from resonant scattering of light atoms in Mo Kα radiation, agreeing with the configuration of starting materials.

This study evaluated the effects of the reverse Trendelenburg position and additional inguinal compression on the cross-sectional area of the femoral vein in paediatric patients. Seventy subjects were allocated to two groups: the infants group and the children group. Cross-sectional area of the femoral vein was measured just below the inguinal ligament using ultrasound. Three measurements were obtained for each patient: (i) supine, (ii) reverse Trendelenburg position and (iii) reverse Trendelenburg position with inguinal compression. In the infants group, femoral vein cross-sectional area increased by a mean (SD) of 21.1 (15.2) % in the reverse Trendelenburg position and by 60.7 (30.8) % in the reverse Trendelenburg position with inguinal compression; whereas in the children group, femoral vein cross-sectional area increased by 24.7 (15.8) % in the reverse Trendelenburg position and by 100.3 (50.7) % in the reverse Trendelenburg position with inguinal compression. Inguinal compression in the reverse Trendelenburg position offers a useful means of increasing femoral vein cross-sectional area in paediatric patients.

Objective: To investigate the efficacy and safety of suction-curettage with a combination of two different cannulae for treatment of axillary osmidrosis and hyperhidrosis., Design: Retrospective analysis of patients who underwent surgery from September 2004 to September 2006., Setting: Outpatient clinic for hyperhidrosis at a university-affiliated hospital., Subjects: Sixty-five patients who were treated for axillary malodor and hyperhidrosis., Interventions: Patients were sequentially treated with Fatemi and Cassio cannulae., Main Outcome Measures: Demographic data, severity data (assessment of malodor), degree of satisfaction, sweating, hair growth, scarring, recurrence and complications., Results: Sixty of the 65 patients (96.9%) had excellent to fair results, and only 2 patients (3.1%) had poor results. Complications occurred in 4 patients (6.2%). Recurrence occurred in 3 patients (4.6%)., Conclusions: This simplified and inexpensive method resulted in a high success rate with low complications and high satisfaction with minimal scarring and rapid recovery.