Greenland Ice Sheet surface melt amplified by snowline migration and bare ice exposure

Greenland Ice Sheet mass loss has recently increased because of enhanced surface melt and runoff. Since melt is critically modulated by surface albedo, understanding the processes and feedbacks that alter albedo is a prerequisite for accurately forecasting mass loss. Using satellite imagery, we demonstrate the importance of Greenland's seasonally fluctuating snowline, which reduces ice sheet albedo and enhances melt by exposing dark bare ice. From 2001 to 2017, this process drove 53% of net shortwave radiation variability in the ablation zone and amplified ice sheet melt five times more than hydrological and biological processes that darken bare ice itself. In a warmer climate, snowline fluctuations will exert an even greater control on melt due to flatter ice sheet topography at higher elevations. Current climate models, however, inaccurately predict snowline elevations during high melt years, portending an unforeseen uncertainty in forecasts of Greenland's runoff contribution to global sea level rise.

“The Anaesthetist” 1933—An Iconic Australian Medical Photograph

Harold Cazneaux was the greatest Australian photographer of the early 20th century. In 1933, he took this image entitled ‘The Anaesthetist’. It is an important documentation of a clinical anaesthetist of the era and was exhibited internationally. Such photographs of specific medical scenarios are rare and valuable. The anaesthetist is Dr Frederick J. Bridges who worked at Royal Prince Alfred and Royal North Shore Hospitals in Sydney. He is using a Clements ether vaporizer which was Australian made. The patient is Cazneaux's daughter. Cazneaux has captured perfectly the care and concern of the anaesthetist for his patient.

Unusual Partnerships: The Corfe–McMurdie Anaesthetic Inhaler of 1918 and the 2nd Australian Casualty Clearing Station

This World War 1 ether/chloroform vaporiser-inhaler was designed by and made for Captain Anstruther John Corfe by Private Eric Aspinall McMurdie, both of the 2nd Australian Casualty Clearing Station (ACCS), Australian Army Medical Corps (AAMC). It has a plaque attached labelled 25 May 1918. It is a perfect example of the ingenuity forced by the realities of war, and is one of the unique pieces in the Harry Daly Museum at the Australian Society of Anaesthetists (ASA) headquarters in Sydney, Australia. While serving in Blendecques, France, Private McMurdie ingeniously fashioned this vaporiser from discarded items he found on the battlefield. These included Horlick's Malted Milk bottles, on which he etched measurements for ether and chloroform, and a spent brass artillery shell, which made the heating component of the inhaler. The 2nd ACCS triaged and operated on thousands of troops, and this inhaler is a reflection of the skills and innovative expertise of the staff of the 2nd ACCS which included X-rays to localise foreign bodies, and locally made splints and apparatus to treat trench foot.

High altitude hypoxia, a mask and a Street. Donation of an aviation BLB oxygen mask apparatus from World War 2

The history of hypoxia prevention is closely inter-related with high altitude mountain and aviation physiology. One pioneering attempt to overcome low inspired oxygen partial pressures in aviation was the BLB mask-named after the three designers-Walter M Boothby, W Randolph Lovelace II and Arthur H Bulbulian. This mask and its variations originated just prior to World War 2 when aircraft were able to fly higher than 10,000 feet and pilot hypoxia affecting performance was an increasing problem. We give a brief description of the mask and its designers and discuss the donation of a model used by the British War Office in October 1940 and donated to the Harry Daly Museum at the Australian Society of Anaesthetists by the family of Dr Fred Street. Dr Street was a pioneering paediatric surgeon in Australia and served as a doctor in the Middle East and New Guinea in World War 2. He received the Military Cross.

Global safe anaesthesia and surgery initiatives: implications for anaesthesia in the Pacific region

In 2015 three major events occurred for global anaesthesia and surgery. In January, the World Bank published Disease Control Priorities 3rd edition (DCP 3rd edition). This volume, Essential Surgery, highlighted the cost effective role of anaesthesia and surgery in global health. In April, the Lancet Commission on Global Surgery released its report "Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development". The report focuses on five key areas to promote change including: access to timely surgery, surgical workforce and procedural capability, surgical volume, data collection such as perioperative mortality rate, and financial protection. In May, the 68th World Health Assembly (WHA) voted in favour of Resolution A68/31: Strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage. The resolution was passed unanimously and it is the first time that surgery and anaesthesia have received such prominence at WHA level. These three events all have profound implications for the provision and access of safe anaesthesia and surgery in the Pacific region in the next 15 years. This article considers some of the regional factors that affect these five key areas, especially with regard to anaesthetic specialist workforce density in different parts of the region. There are many challenges to improve anaesthesia access, safety, and workforce density in the Pacific region. Future efforts, initiatives and support will help address these problems.

Failed intubation and failed oxygenation in a child

A 'can't intubate, can't oxygenate' scenario in a child is fortunately extremely rare. We report a case of this life-threatening event in a four-year-old boy suffering from a rare genetic disorder, fibrodysplasia ossificans progressiva. He presented for manipulation of his dislocated jaw and was identified preoperatively as having a difficult airway. Despite extensive preparation, a catastrophic loss of airway control occurred minutes after induction of general anaesthesia, necessitating a life saving emergency tracheostomy. This report highlights the small evidence base and lack of definitive algorithms relating to how best to rescue a paediatric 'can't intubate, can't oxygenate' situation. Paediatric anatomical factors dictate that immediate procession to a tracheal surgical airway may be the optimal management.

Blood Loss and Replacement for Paediatric Cranioplasty in Australia – A Prospective National Audit

We prospectively audited blood loss and blood replacement in every child less than 24 months of age undergoing cranioplasty for craniosynostosis in Australia during 2008, in order to obtain more accurate data for the discussion of perioperative transfusion risk. A total of 127 cases were performed at seven centres. There were no directed or autologous blood donations. No patient received preoperative erythropoietin. A total of 233 units of homologous red blood cells were transfused. Overall, 83% of patients received a blood transfusion. This included 100% of patients undergoing cranial vault reconstruction (CVR) and 98% of patients undergoing fronto-orbital advancement (FOA), but only 32% of spring cranioplasty patients. Exposure to no more than one donor was achieved in 60% of FOA patients and 36% of CVR patients. Estimated blood volume loss was more than one blood volume in 36% of CVR and 36% of FOA, but only 12% of spring cranioplasty, and more than two blood volumes in 4% of CVR and 11% of FOA. Differences in surgical technique and volume of surgery between different centres appeared to affect transfusion rates. Children with recognised craniofacial syndromes and those undergoing repeat surgery appeared to have greater blood loss and blood product exposure. There were two cases of sudden massive haemorrhage secondary to dural venous sinus tear, but no death or perioperative cardiac arrest. These findings indicate that blood loss requiring blood product replacement is common in patients <24 months of age undergoing cranioplasty for craniosynostosis, particularly in patients undergoing FOA and CVR.

Compartment Syndrome and Patient-Controlled Analgesia in Children – Analgesic Complication or Early Warning System?

We present two cases of children who developed compartment syndrome after upper limb fractures. Morphine patient-controlled analgesia was used in a bolus-only mode for analgesia (bolus 20 μg/kg, five minute lockout and hourly limit of 150 μg/kg). An increase in patient-controlled analgesia use was observed up to 12 hours before the decision was made to proceed to fasciotomy but neither child exceeded the hourly limit or had an excessive increase in pain scores. Clinical risk factors for compartment syndrome should be identified and appropriate monitoring instituted. A subtle increase in patient-controlled analgesia use may be an early indicator of impending compartment syndrome before classical signs such as reporting of pain, pallor, paraesthesiae, paralysis and pulselessness develop. These cases and review of the literature suggest techniques which may assist earlier diagnosis of compartment syndrome include setting a more conservative hourly limit of morphine patient-controlled analgesia such as 80 to 100 μg/kg/hour and graphing of patient-controlled analgesia demands and boluses, pain scores at rest and pain scores with passive flexion and extension of digits. These practices could identify trends that pain or analgesia requirement is increasing leading to earlier diagnosis of compartment syndrome.

Airway Management for Infants with Severe Micrognathia Having Mandibular Distraction Osteogenesis

We retrospectively reviewed the charts of seven neonates and infants with severe micrognathia and upper airway obstruction who underwent mandibular distraction osteogenesis as an alternative to long-term tracheostomy at the Children's Hospital at Westmead, Sydney, from 2004 to 2007.

All patients required a variety of airway interventions at an early age and had poor feeding or failure to thrive. These children had other anomalies and required many investigations and procedures and presented repeated airway challenges for the anaesthetist. The mean number of anaesthetics per child in this series was 6.7 (range 4 to 13).

Under anaesthesia, four patients had grade 4 laryngoscopy, one was grade 3 but two were only grade 2. Patients with a preoperative grade 4 laryngoscopy were very likely to need fibreoptic endotracheal intubation. Duration of intubation after surgery for mandibular distraction was a mean of 8.17 days (range 1 to 19). Three were extubated in the operating theatre and three in intensive care. Five patients had an improved laryngoscopy grade after completion of mandibular distraction and one remained grade four. The remaining patient had a tracheostomy from birth.

Dr Corlette and the first textbook of regional anaesthesia in Australia

The first Australian textbook on regional anaesthesia was published in 1948 by a surgeon, Dr Cyril Corlette. He was 80 years old at the time but had lectured, published and strongly promoted regional anaesthesia his whole career. He was a renowned teacher and a Founder of the Royal Australasian College of Surgeons. He also published controversial work on heat loss under anaesthesia and anaesthetic mortality. This textbook, "A Surgeon's Guide to Local Anaesthesia", subtitled "A Manual of Shockless Surgery", helped to promote the concept of regional anaesthesia in Australia.

A bibliography of articles on the history of anaesthesia and medicine in Anaesthesia and Intensive Care 1972-2005

This bibliography references all articles on the history of anaesthesia and medicine published in Anaesthesia and Intensive Care from volume 1 in 1972 to 34 years later when the first symposium on Anaesthesia History was published in the June issue of the Journal (Vol 33, 2005).

Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal function

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) can play a major role in the management of acute pain in the peri-operative period. However, there are conflicting views on whether NSAIDs are associated with adverse renal effects.

OBJECTIVES

The primary objective of this review was to determine the effects of NSAIDs on postoperative renal function in adults with normal preoperative renal function.

SEARCH STRATEGY

Electronic searches for relevant randomised and quasi-randomised controlled trials in Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were performed. Attempts were also made to identify trials from citation lists of relevant trials, review articles and clinical practice guidelines. Handsearching of conference abstracts published in major anaesthetic journals was also performed. Date of most recent search: May 2006

SELECTION CRITERIA

The inclusion criteria were randomised or quasi-randomised comparisons of individual NSAIDs with either each other or placebo for treatment of postoperative pain, with relevant postoperative renal outcome measures, in adult surgical patients with normal renal function.

DATA COLLECTION AND ANALYSIS

The data were extracted independently by two authors. The primary outcome measure was creatinine clearance within the first two days after surgery. Secondary outcome measures included serum creatinine, urine volume, urinary sodium level, urinary potassium level, fractional excretion of sodium, fractional excretion of potassium and need for dialysis. Weighted mean differences for continuous outcomes and relative risk (RR) and risk difference (RD) for dichotomous outcomes were estimated with 95% confidence intervals (CI).

MAIN RESULTS

Twenty-three trials (1459 patients) fulfilled the selection criteria for this review. NSAIDs reduced creatinine clearance by 16 mL/min (95%CI 5 to 28) and potassium output by 38 mmol/day (95%CI 19 to 56) on the first day after surgery compared to placebo. There was no significant difference in serum creatinine on the first day (0 umol/L, 95%CI -3 to 4) compared to placebo. No significant reduction in urine volume during the early postoperative period was found. There was no significant difference in serum creatinine in the early postoperative period between patients receiving diclofenac, ketorolac, indomethacin, ketoprofen or etodolac. No cases of postoperative renal failure requiring dialysis were described. The trials were not heterogeneous for the primary outcome.

AUTHORS' CONCLUSIONS

NSAIDs caused a clinically unimportant transient reduction in renal function in the early postoperative period in patients with normal preoperative renal function. NSAIDs should not be withheld from adults with normal preoperative renal function because of concerns about postoperative renal impairment.

Severe spontaneous intracranial hypotension and Marfan syndrome in an adolescent

We describe a 14-year-old girl with Marfan syndrome who presented with severe postural headache. Dural ectasia was demonstrated radiologically. Cerebrospinal fluid (CSF) pressure was immeasurable on formal measurement. Radionucleide cisternography failed to demonstrate a CSF leak. We consider that the underlying fibrillinopathy in Marfan syndrome rendered the dura sufficiently permeable to CSF leakage to cause the low CSF pressure headache. The patient was treated successfully with epidural autologous blood patch.

Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department

AIMS

To describe the experience of using high concentration nitrous oxide (N(2)O) relative analgesia administered by nursing staff in children undergoing minor procedures in the emergency department (ED) and to demonstrate its safety.

METHOD

Data were collected over a 12 month period for all procedures in the ED performed under nurse administered N(2)O sedation. All children greater than 12 months of age requiring a minor procedure who had no contraindication to the use of N(2)O were considered for sedation by this method. The primary outcome measure was the incidence of a major complication namely respiratory distress or hypoxia during the procedure. Secondary outcome measures were minor complications and the maximum concentration of N(2)O used.

RESULTS

Data were collected for a total of 224 episodes of nurse administered N(2)O sedation over a 12 month period. In 73.2% of children no complications were recorded. One major complication was recorded (respiratory distress) and the most common minor complication was mask intolerance in 17%. The mean maximum concentration of N(2)O used was 60.2%.

CONCLUSIONS

N(2)O is a safe analgesic in children over the age of 1 year undergoing painful or stressful procedures in the ED. It may safely be administered in concentrations of up to 70% by nursing staff after appropriate training.

The Shikani Seeing Stylet for difficult intubation in children: initial experience

The Shikani Seeing Stylet is a recently introduced reusable intubating stylet, produced in adult and paediatric versions. It combines features of a fibreoptic bronchoscope and a lightwand. Inside a malleable stainless steel sheath, the Shikani Seeing Stylet has a fibreoptic cable leading to a distal light source and high-resolution lens. In use, the stylet is placed in the lumen of the selected endotracheal tube and the light source enables the stylet to be used as a lightwand, while the fibreoptic capability enables visualization of the laryngeal inlet. It is portable, relatively inexpensive and easy to maintain. This report describes the use of the stylet on eight occasions in seven children, all of whom were assessed preoperatively as being potentially difficult to intubate. Three had been difficult to intubate previously. All were anaesthetized using inhalational anaesthesia. Once an adequate depth of anaesthesia had been achieved, conventional direct laryngoscopy was performed and identified as Grade 3 in six of the patients and Grade 1 in one. Tracheal intubation was then attempted using the Shikani Seeing Stylet. On six of the eight occasions the attempt was made by different anaesthetists, none of whom had any prior clinical experience with the stylet. There were seven successful intubations and one failure in a patient who could not be intubated by any method. The Shikani Seeing Stylet seems a useful device for use in children with difficult airway problems, suspected cervical spine instability or limited mouth-opening.

Patient-controlled analgesia: an appropriate method of pain control in children

Patient-controlled analgesia (PCA) is an analgesic technique originally used in adults but now with an established role in paediatric practice. It is well tolerated in children as young as 5 years and has uses in postoperative pain as well as burns, oncology and palliative care. The use of background infusions is more frequent in children and improves efficacy; however, it may increase the occurrence of adverse effects such as nausea and respiratory depression. Monitoring involves measurement of respiratory rate, level of sedation and oxygen saturation. Efficacy is assessed by self-reporting, visual analogue scales, faces pain scales and usage patterns. This is optimally performed both at rest and on movement. The selection of opioid used in PCA is perhaps less critical than the appropriate selection of parameters such as bolus dose, lockout and background infusion rate. Moreover, opioid choice may be based on adverse effect profile rather than efficacy. The concept of PCA continues to be developed in children, with patient-controlled epidural analgesia, subcutaneous PCA and intranasal PCA being recent extensions of the method. There may also be a role for patient-controlled sedation. PCA, when used with adequate monitoring, is a well tolerated technique with high patient and staff acceptance. It can now be regarded as a standard for the delivery of postoperative analgesia in children aged >5 years.

Efficacy and safety of nitrous oxide in alleviating pain and anxiety during painful procedures

AIMS

To evaluate the efficacy and safety of nitrous oxide for children undergoing painful procedures.

METHODS

Ninety children requiring repeated painful procedures (lumbar puncture, bone marrow aspirate, venous cannulation, or dressing changes) were given nitrous oxide at a variable concentration of 50-70%. Procedure related distress was evaluated using the Observational Scale of Behavioral Distress-Revised (OSBD-R). OSBD-R scores were obtained for each of the following phases of the procedure: phase 1a, waiting period; phase lb, during induction with nitrous oxide; phase 2, during positioning and cleaning of the skin; phase 3, during the painful procedure; and phase 4, immediately following the procedure and withdrawal of nitrous oxide. Side effects were monitored and recorded by a second observer.

RESULTS

OSBD scores reached a maximum during the induction phase with lower scores during subsequent phases. Children over the age of 6 showed a lower level of distress during nitrous oxide administration and the painful procedure. Eighty six per cent of patients had no side effects. The incidence of vomiting, excitement, and dysphoria was 7.8%, 4.4%, and 2% respectively. Eight patients developed oxygen desaturation (SaO(2) < 95%), but none developed hypoxia, airway obstruction, or aspiration. Ninety three per cent of patients fulfilled the criteria for conscious sedation, and 65% had no recollection of the procedure. Mean recovery time was three minutes.

CONCLUSIONS

Inhalation of nitrous oxide is effective in alleviating distress during painful procedures, with minimal side effects and short recovery time.

Intraoperative fibreoptic bronchoscopy during neonatal tracheo-oesophageal fistula ligation and oesophageal atresia repair

Maintenance of adequate ventilation under anaesthesia can be difficult during identification and ligation of congenital tracheo-oesophageal fistula with repair of oesophageal atresia. Anaesthesia may also be complicated by problems associated with prematurity, pre-existing aspiration pneumonitis, and difficulty positioning the endotracheal tube to prevent inflation of the stomach with increased risk of aspiration and diaphragmatic splinting. Even intubation of the fistula and gastric rupture may occur. Two neonatal cases are presented where use of a 2.2 mm neonatal bronchoscope passed through a 3.0 mm ID tracheal tube facilitated surgical identification of the fistula, diagnosis of fistula intubation and other airway problems intraoperatively.

Difficult tracheal intubation following midface distraction surgery

A case of difficult intubation in a patient with Apert syndrome, who had recently undergone bilateral internal midface distraction, is described. The 14-year-old boy had no antecedent history of such difficulty, despite numerous previous anaesthetics. We suggest that trismus due to temporalis muscle fibrosis, and the altered relationships of the maxilla and mandible following midface advancement, were causal.

The effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on postoperative renal function: a meta-analysis

The aim of this systematic review was to assess the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on post-operative renal function. Eight randomized placebo-controlled double-blinded trials (n = 345) were identified from searches of MEDLINE, EMBASE and the Cochrane Controlled Trials Register databases. The summary effect size and 95% confidence intervals (95% CI) were calculated by a weighted mean difference analysis using a random-effects model. The NSAIDs (diclofenac, ketorolac, indomethacin, ibuprofen) were used for up to three-days after surgery. There were no reported cases of postoperative renal failure requiring dialysis. NSAIDs reduced creatinine clearance by 22 ml.min-1 (95% CI: 7 to 37), sodium output by 54 mmol.day-1 (95% CI: 5 to 103) and potassium output by 38 mmol.day-1 (95% CI: 19 to 56) on Day 1 but not on Day 2. Serum creatinine increased on Day 2 by 15 mumol.l-1 (95% CI: 2 to 28). Urine volume did not change significantly at any time. There was therefore a clinically unimportant transient reduction in renal function. NSAIDs should not be withheld from patients with normal preoperative renal function because of concerns about postoperative renal impairment.

Nurse-controlled analgesia using a patient-controlled analgesia device: an alternative strategy in the management of severe cancer pain in children

Nurse-controlled analgesia (NCA) using a patient-controlled analgesia (PCA) device has been described for intensive care and postoperative use. This report describes the effective use of this technique for severe episodic and procedural pain in four children with advanced malignancy and high opioid requirements where conventional parenteral analgesia had been inadequate. Both morphine and fentanyl were used. Average duration of NCA was 6.75 days (range 4-12).

Continuous extrapleural intercostal nerve block for post thoracotomy analgesia in children

The safety and efficacy of continuous extrapleural intercostal nerve block has been well established in adults. This review of our initial paediatric experience suggests a role for this technique in children and discusses risks and benefits relative to other forms of regional analgesia for thoracotomy. Nine children aged one to twelve years received extrapleural infusions of bupivacaine 0.1-0.2% following lateral thoracotomy for lung resection. An extrapleural catheter was placed by the surgeon prior to thoracotomy closure, and correctly positioned under direct vision external to the parietal pleura alongside the vertebral column. An intraoperative loading dose of bupivacaine, 0.25-0.5% (0.28 +/- 0.1 ml/kg, mean +/- SD) was injected so as to raise a bleb under the parietal pleura which spread longitudinally to bathe several intercostal nerves in the paravertebral gutter. The chest wall was then closed. Infusions of bupivacaine were commenced in the recovery room and continued at a constant rate of 0.21 +/- 0.09 ml/kg/h for 72 +/- 15 hours. The mean dose of bupivacaine was 284 +/- 97 micrograms/kg/h. Patients also received standard analgesia as an intravenous morphine infusion (10-50 micrograms/kg/h), or patient-controlled analgesia. Nursing staff were specifically instructed not to alter their usual management of variable rate morphine infusions which are titrated to adequate analgesia. Morphine requirements in the first 48 postoperative hours remained less than 30 micrograms/kg/h, oral fluids were well tolerated after 31.2 +/- 19.1 hours, nasogastric tubes were removed at 16.7 +/- 11.2 hours. Postoperative nausea and vomiting and respiratory depression were not observed in any patient and all were able to comply with physiotherapy. There were no complications of catheter placement or bupivacaine administration. Our initial experience suggests that this is a safe technique which minimizes complementary opioid administration and provides adequate analgesia for children postthoracotomy for lung resection.

Subcutaneous cannulae for morphine boluses in children: assessment of a technique

Indwelling subcutaneous cannula for the administration of intermittent morphine boluses postoperatively have been used in several centers as an alternative to intramuscular (IM) injections. We introduced this technique to our hospital, assessed it for complications in 220 children, and conducted a survey to see if nursing staff preferred it to IM injections. The injections through the subcutaneous cannulae caused minimal distress to the children. There were no major complications, 95% of the nursing staff preferred this technique, and 74% would give morphine more readily to a child with a subcutaneous cannula in situ.

Continuous brachial plexus neural blockade in a child with intractable cancer pain

A 6-year-old boy presented with a large, rapidly growing osteosarcoma of the upper humerus and severe neuropathic arm pain. Despite large doses of morphine (100 micrograms/kg/hr), which resulted in intermittent somnolence and respiratory depression, his pain was poorly controlled. An interscalene brachial plexus catheter was inserted, and bupivacaine was injected on ten occasions over 5 days, with markedly improved analgesia and decreased opioid requirement. Cancer pain in children can be controlled by opioids in 95% of cases; however, circumstances such as intractable neuropathic pain may require specific regional anesthetic techniques.

Pain and symptom control in paediatric palliative care

Important differences become evident in a comparison of cancer pain between children and adults. Management of pain in children is commonly multidisciplinary, is less dependent on invasive measures and relies more on systemic therapy. Children are not little adults: their immaturity, developing cognition and dependence all influence their experience and interpretation of pain. Much progress has been made in altering practices such as under-prescribing and underdosing that have adversely affected adequate control of pain in children. The challenge for paediatric health care providers in the mid 1990s is not only to be informed of current practices in pain and symptom control in paediatric palliative care, but also to remember to establish those practices in day to day management. Even though pain and its effects in children are now better understood, it is often still not managed optimally. Good management of pain in children depends on accurate assessment. In the past 10 years, assessment of pain in children has advanced considerably. However, assessment of pain in the preverbal child is still inadequate and in need of attention. Sedation, tolerance and involuntary movements may occur as side effects of opioids in children and may cause significant problems in management of the dying child. Psychostimulants can diminish sedation to some extent, but there is little information as yet on the value of these drugs in children. Tolerance to opioids may develop quickly, leading to poor control of pain and distress for the child. Strategies to improve management of tolerance include use of regional anaesthetic techniques such as the epidural/intrathecal route for opioid administration. Involuntary movements induced by opioids are uncommon but have the potential to cause significant distress. The mechanisms underlying these side effects of opioids need to be established. Strategies are needed for the effective treatment and prevention of these side effects. Neuropathic pain can be severe, distressing and difficult to treat. Experience of its treatment in terminally ill children is limited. Effective use of tricyclic antidepressants and systemically administered local anaesthetics is still to be determined. Regional anaesthetic techniques may be of great benefit when neuropathic pain cannot be controlled with systemic therapy. Procedural pain is more common than pain related to disease in the management of paediatric cancer. Further research is needed to identify the best approach to its management. We have found nitrous oxide to be of great benefit in management of procedural pain in children. Non-pharmacological methods of treatment of pain in children, such as transcutaneous electrical nerve stimulation or acupuncture, may also be useful and should receive continuing evaluation. There are significant and current issues in paediatric palliative care besides management of pain. There are difficulties in the provision of home nursing care for children with cancer in the terminal phase of their illness, including lack of community nursing services at night and on weekends and lack of adequate home help for parents. Attitudes of staff involved in the care of the child and family and their commitment to working as a multidisciplinary team strongly influence the quality and success of care given. Pain control and palliative medicine are evaluable by measures of quality assurance or outcome, and adoption of such evaluations should improve standards of care. Euthanasia in children is even more difficult as an ethical dilemma than in adults. Optimum symptom control with current techniques should almost always obviate its consideration. We are opposed to euthanasia. Psychosocial and cultural issues all influence the family's experience of palliative care. Further research is necessary in all of these areas.(ABSTRACT TRUNCATED)