Administration of paracetamol versus dipyrone by intravenous patient-controlled analgesia for postoperative pain relief in children after tonsillectomy / Administração de paracetamol versus dipirona em analgesia controlada pelo paciente por via intravenosa para alívio da dor no pós-operatório de crianças após tonsilectomia

BACKGROUND AND OBJECTIVE: We compared the efficacy of intravenous (IV) paracetamol versus dipyrone via patient-controlled analgesia (PCA) for postoperative pain relief in children. METHODS: The study was composed of 120 children who had undergone elective tonsillectomy after receiving general anesthesia. Patients were divided into 3 groups according to the dosage of postoperative intravenous-patient-controlled analgesia: paracetamol, dipyrone, or placebo. Pain was evaluated using a 0- to 100-mm visual analog scale and 1- to 4-pain relief score at 30 min, 1, 2, 4, 6, 12, and 24 h postoperatively. Pethidine (0.25 mg kg-1) was administered intravenously to patients requiring rescue analgesia. Pethidine requirements were recorded during the first 24 h postoperatively, and treatment related adverse effects were noted. RESULTS: Postoperative visual analog scale scores were significantly lower with paracetamol group compared with placebo group at 6 h (p < 0.05), dipyrone group compared with placebo group at 30 min and 6 h (p < 0.05). No significant differences regarding visual analog scale values at 1, 2, 4, 12, and 24 h were found. No significant differences were found between groups with respect to pain relief score (p > 0.05). Postoperative pethidine requirements were significantly lower with paracetamol and dipyrone groups compared with placebo group (62.5%, 68.4% vs 90%, p < 0.05). No significant differences were found between groups with respect to nausea, vomiting and the any other adverse effects of the drugs (p > 0.05). CONCLUSIONS: Paracetamol and dipyrone have well tolerability profile and effective analgesic properties when administered IV-PCA for postoperative analgesia in children after tonsillectomy.

JUSTIFICATIVA E OBJETIVO: Comparamos a eficácia da administração de paracetamol versus dipirona em analgesia controlada pelo paciente (PCA) por via intravenosa (IV) para alívio da dor no período pós-operatório em crianças. MÉTODOS: O estudo foi composto por 120 crianças submetidas à tonsilectomia sob anestesia geral. Os pacientes foram divididos em três grupos de acordo com a dose IV de analgesia controlada pelo paciente no pós-operatório: paracetamol, dipirona ou placebo. A dor foi avaliada com uma escala visual analógica de 0-100 mm e escore de 1-4 para alívio da dor nos tempos de 30 minutos, uma, duas, quatro, seis, 12 e 24 horas de pós-operatório. Petidina (0,25 mg kg-1) foi administrada IV aos pacientes que precisaram de analgesia de resgate. A necessidade de petidina foi registrada durante as primeiras 24 horas de pós-operatório e os efeitos adversos relacionados ao tratamento foram registrados. RESULTADOS: Os escores da escala visual analógica no pós-operatório foram significativamente menores no grupo paracetamol em comparação com o grupo placebo em seis horas (p < 0,05) e no grupo dipirona em comparação com o grupo placebo em 30 minutos e seis horas (p < 0,05). Não houve diferença significativa em relação aos valores da escala visual analógica nos tempos avaliados de uma, duas, quatro, 12 e 24 horas. Não houve diferença significativa entre os grupos quanto ao escore de alívio da dor (p > 0,05). A necessidade de petidina foi significativamente menor nos grupos paracetamol e dipirona em comparação com o grupo placebo (62,5%, 68,4% vs. 90%, p < 0,05). Não houve diferença significativa entre os grupos em relação à incidência de náusea, vômito e outros efeitos adversos dos medicamentos (p > 0,05). CONCLUSÕES: Paracetamol e dipirona têm um perfil de boa tolerabilidade e propriedades analgésicas eficazes quando administrados IV para ACP no pós-operatório de crianças após tonsilectomia.

Administration of paracetamol versus dipyrone by intravenous patient-controlled analgesia for postoperative pain relief in children after tonsillectomy.

BACKGROUND AND OBJECTIVE: We compared the efficacy of intravenous (IV) paracetamol versus dipyrone via patient-controlled analgesia (PCA) for postoperative pain relief in children. METHODS: The study was composed of 120 children who had undergone elective tonsillectomy after receiving general anesthesia. Patients were divided into 3 groups according to the dosage of postoperative intravenous-patient-controlled analgesia: paracetamol, dipyrone, or placebo. Pain was evaluated using a 0- to 100-mm visual analog scale and 1- to 4-pain relief score at 30 min, 1, 2, 4, 6, 12, and 24h postoperatively. Pethidine (0.25 mg kg(-1)) was administered intravenously to patients requiring rescue analgesia. Pethidine requirements were recorded during the first 24h postoperatively, and treatment related adverse effects were noted. RESULTS: Postoperative visual analog scale scores were significantly lower with paracetamol group compared with placebo group at 6h (p<0.05), dipyrone group compared with placebo group at 30 min and 6h (p<0.05). No significant differences regarding visual analog scale values at 1, 2, 4, 12, and 24h were found. No significant differences were found between groups with respect to pain relief score (p>0.05). Postoperative pethidine requirements were significantly lower with paracetamol and dipyrone groups compared with placebo group (62.5%, 68.4% vs 90%, p<0.05). No significant differences were found between groups with respect to nausea, vomiting and the any other adverse effects of the drugs (p>0.05). CONCLUSIONS: Paracetamol and dipyrone have well tolerability profile and effective analgesic properties when administered IV-PCA for postoperative analgesia in children after tonsillectomy.

[Administration of paracetamol versus dipyrone by intravenous patient-controlled analgesia for postoperative pain relief in children after tonsillectomy]. / Administração de paracetamol versus dipirona em analgesia controlada pelo paciente por via intravenosa para alívio da dor no pós-operatório de crianças após tonsilectomia.

BACKGROUND AND OBJECTIVE: We compared the efficacy of intravenous (IV) paracetamol versus dipyrone via patient-controlled analgesia (PCA) for postoperative pain relief in children. METHODS: The study was composed of 120 children who had undergone elective tonsillectomy after receiving general anesthesia. Patients were divided into 3 groups according to the dosage of postoperative intravenous-patient-controlled analgesia: paracetamol, dipyrone, or placebo. Pain was evaluated using a 0- to 100-mm visual analog scale and 1- to 4-pain relief score at 30min, 1, 2, 4, 6, 12, and 24h postoperatively. Pethidine (0.25mgkg(-1)) was administered intravenously to patients requiring rescue analgesia. Pethidine requirements were recorded during the first 24h postoperatively, and treatment related adverse effects were noted. RESULTS: Postoperative visual analog scale scores were significantly lower with paracetamol group compared with placebo group at 6h (p<0.05), dipyrone group compared with placebo group at 30min and 6h (p<0.05). No significant differences regarding visual analog scale values at 1, 2, 4, 12, and 24h were found. No significant differences were found between groups with respect to pain relief score (p>0.05). Postoperative pethidine requirements were significantly lower with paracetamol and dipyrone groups compared with placebo group (62.5%, 68.4% vs 90%, p<0.05). No significant differences were found between groups with respect to nausea, vomiting and the any other adverse effects of the drugs (p>0.05). CONCLUSIONS: Paracetamol and dipyrone have well tolerability profile and effective analgesic properties when administered IV-PCA for postoperative analgesia in children after tonsillectomy.

[Efficacy of intravenous dexketoprofen trometamol compared to intravenous paracetamol for postoperative pain management after day-case operative hysteroscopy: randomized, double-blind, placebo-controlled study]. / Günübirlik operatif histeroskopi sonrasi intravenöz parasetamol ve deksketoprofen trometamol'ün analjezik etkinliklerinin karsilastirilmasi: randomize, çift kör, plasebo kontrollü çalisma.

OBJECTIVE: Adequate pain management following day-case surgery allows early ambulation of patients. In this study, we aimed to compare postoperative analgesic efficacy of intravenous (iv) dexketoprofen vs. iv paracetamol following day-case operative hysteroscopy. METHODS: One hundred and fourteen American Society of Anesthesiologists (ASA) I-II patients scheduled for day-case operative hysteroscopy were recruited and randomized to three groups in the study. Group D received 50 mg iv dexketoprofen trometamol, Group P 1000 mg iv paracetamol and Group C normal saline solution. Visual Analogue Scale (VAS) pain intensity, pain relief, sedation, nausea-vomiting, other side effects, and additional opioid analgesic requirement were noted at postoperative 15 minutes (min), 30 min, 1 hour (h), 2 h, and 3 h. Patients with VAS>=40 mm received meperidine 0.25 mg/kg as rescue analgesic medication. RESULTS: VAS scores at 15 min, 30 min, 1 h, and 2 h were significantly lower in Group D compared to Group C. VAS scores at 15 min and 30 min were significantly lower in Group D compared to Group P. The percentages of patients who required opioid treatment were 34%, 60%, and 63% in Groups D, P and C, respectively (p<0.05). Total delivered opioid dose was 0.10±0.16 mg/kg, 027±0.33 mg/kg and 0.28±0.25 mg/kg in Groups D, P and C, respectively (p<0.05). Pain relief score was significantly better in Group D at postoperative 15 min when compared with Group C (p<0.05). CONCLUSION: Our study demonstrated that iv dexketoprofen has superior efficacy for postoperative pain management following day-case operative hysteroscopy when compared with paracetamol and placebo.

The efficacy of intravenous paracetamol versus dipyrone for postoperative analgesia after day-case lower abdominal surgery in children with spinal anesthesia: a prospective randomized double-blind placebo-controlled study.

BACKGROUND: A multimodal and preventative approach to providing postoperative analgesia is becoming increasingly popular for children and adults, with the aim of reducing reliance on opioids. We conducted a prospective, randomized double-blind study to compare the analgesic efficacy of intravenous paracetamol and dipyrone in the early postoperative period in school-age children undergoing lower abdominal surgery with spinal anesthesia. METHODS: Sixty children scheduled for elective lower abdominal surgery under spinal anesthesia were randomized to receive either intravenous paracetamol 15 mg/kg, dipyrone 15 mg/kg or isotonic saline. The primary outcome measure was pain at rest, assessed by means of a visual analog scale 15 min, 30 min, 1 h, 2 h, 4 h and 6 h after surgery. If needed, pethidine 0.25 mg/kg was used as the rescue analgesic. Time to first administration of rescue analgesic, cumulative pethidine requirements, adverse effects and complications were also recorded. RESULTS: There were no significant differences in age, sex, weight, height or duration of surgery between the groups. Pain scores were significantly lower in the paracetamol group at 1 h (P = 0.030) and dipyrone group at 2 h (P = 0.010) when compared with placebo. The proportion of patients requiring rescue analgesia was significantly lower in the paracetamol and dipyrone groups than the placebo group (vs. paracetamol P = 0.037; vs. dipyrone P = 0.020). Time to first analgesic requirement appeared shorter in the placebo group but this difference was not statistically significant, nor were there significant differences in pethidine requirements, adverse effects or complications. CONCLUSION: After lower abdominal surgery conducted under spinal anesthesia in children, intravenous paracetamol appears to have similar analgesic properties to intravenous dipyrone, suggesting that it can be used as an alternative in the early postoperative period. TRIAL REGISTRATION: Clinical Trials.gov. Identifier: NCT01858402.

Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study.

UNLABELLED: Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management. OBJECTIVE: In this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children. METHOD: 120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted. RESULTS: No significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study. CONCLUSION: Intravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

Paracetamol e dipirona por via endovenosa aplicados à analgesia pós-operatória de pacientes pediátricos submetidos à amigdelectomia em hospital-dia: um estudo prospectivo, randomizado, duplo-cego, placebo controlado / Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study

O manejo da dor pós-amigdelectomia pode ser feito com uma série de medicamentos. OBJETIVO: O presente estudo duplo-cego placebo controlado pretendeu avaliar a eficácia de paracetamol e dipirona administrados por via endovenosa na analgesia de pacientes pediátricos pós-amigdelectomia. MÉTODO: Cento e vinte crianças com idades entre três e seis anos submetidas à amigdelectomia com ou sem adenoidectomia e/ou entubação foram randomizadas para receber infusões de paracetamol (15 mg/kg), dipirona (15 mg/kg) ou placebo (0,9% NaCl) durante a cirurgia. As avaliações foram executadas com 0,25, 0,50, 1, 2, 4, 6h de pós-operatório. Petidina 0,25 mg/kg foi utilizada como analgésico de resgate. Dose acumulada de petidina foi o desfecho primário. Medições de intensidade da dor, alívio da dor, nível de sedação, náusea e vômitos, hemorragia no pós-operatório e outros efeitos adversos foram anotados. RESULTADOS: Nenhuma diferença significativa foi encontrada na dose acumulada de petidina entre os grupos paracetamol e dipirona. A dose acumulada de petidina foi significativamente menor nos grupos paracetamol e dipirona em comparação ao grupo placebo. Nenhuma diferença significativa foi observada entre os escores de dor no pós-operatório dos grupos durante o estudo. CONCLUSÃO: Paracetamol endovenoso tem eficácia analgésica semelhante à da dipirona endovenosa; ambos ajudam a reduzir a necessidade de opioides na analgesia pós-operatória de pacientes pediátricos submetidos à amigdelectomia em hospital-dia.

Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management. OBJECTIVE: In this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children. METHOD: 120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted. RESULTS: No significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study. CONCLUSION: Intravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

Comparison of intrathecal levobupivacaine combined with sufentanil, fentanyl, or placebo for elective caesarean section: a prospective, randomized, double-blind, controlled study.

BACKGROUND: The addition of opioids to local anesthetics contributes to the quality of spinal anesthesia and postoperative analgesia. OBJECTIVE: In our prospective, randomized, double-blind, controlled study, our aim was to compare the effect of low-dose sufentanil plus levobupivacaine or a fentanyl plus levobupivacaine mixture on anesthesia quality, block characteristics, newborn and mother well-being, surgeon satisfaction, and duration of postoperative analgesia. METHODS: Ninety-three patients were randomized into 3 groups (n = 31). Patients in Group C received 0.5% levobupivacaine (2.2 ± 0.2 mL), Group S received 2.5 µg sufentanil plus 0.5% levobupivacaine (2.2 ± 0.2 mL), and Group F received 10 µg fentanyl plus 0.5% levobupivacaine (2.2 ± 0.2 mL) intrathecally completed to a volume of 3 mL with the addition of saline in all groups. Patients' demographics, sensory and motor block characteristics, hemodynamics, Apgar scores, umbilical blood gas values, maternal side effects, surgeon satisfaction score, time to first analgesia requirement, and additional analgesic use within 24 hours were recorded. RESULTS: In Group S and Group F, target levels of sensory and motor block were achieved more rapidly (P < 0.001). The hemodynamic values were lower (P < 0.05), and the duration of sensory blockade and the time of first analgesic requirement were longer (P < 0.001) in Group S. Additional analgesic requirement during first 24-hour period was lowest in Group S, and highest in Group C (P < 0.001). Apgar scores and umbilical blood gas samples were similar between groups. Postoperative pruritus was more frequent in Group S (P < 0.001) and surgeon satisfaction score was significantly lower in Group C (P = 0.003). CONCLUSIONS: We suggest that the addition of sufentanil and fentanyl to intrathecal levobupivacaine during caesarean section surgery is more effective than the administration of levobupivacaine alone. The addition of sufentanil to levobupivacaine allowed rapid onset time for sensory and motor block levels. It also extended the duration of postoperative analgesia and led to a decrease in total analgesic requirement. ClinicalTrials.gov identifier: NCT01858090.

[Our experiences with spinal anesthesia in pediatric patients]. / Pediyatrik hastalarda spinal anestezi deneyimlerimiz.

OBJECTIVES: The aim of this study was to evaluate the characteristics of spinal anesthesia, including its efficacy, adverse effects and complications, in order to determine if it can be applied safely in pediatric patients at high-risk for general anesthesia. We emphasize our positive outcomes in children undergoing lower abdominal surgery in our previous experience. METHODS: The perioperative data of 86 pediatric patients who received spinal anesthesia between 2007 and 2008 were scanned retrospectively. Demographic data, operation types, anesthetic applications, duration of surgery, motor blockade degree, two dermatomes regression time, postoperative analgesic requirements, adverse effects, and complications were recorded. RESULTS: The operation time and two dermatomes regression times were found as 49.8 ± 24.1 minutes and 73.0 ± 21.9 minutes, respectively. At the end of the operation, motor blockade had disappeared in 17 patients and persisted in 68 patients. Block time was measured as 67.3 ± 16.2 minutes in these patients. During the intraoperative period, hypotension was observed in two patients, and bradycardia occurred in one patient. Except for these, hemodynamic parameters did not change more than 20% from control values at any time. In three children, surgery was continued under general anesthesia. Forty-six patients required additional analgesic doses in the postoperative period. The time to first analgesic requirement was 2.3 ± 1.2 hours. During the postoperative period, no hemodynamic or respiratory complications were observed. CONCLUSION: Spinal anesthesia continues to gain acceptance as an alternative to general anesthesia in children. However, we conclude that accumulated experience is required in order to apply this technique safely in pediatric patients. We emphasize the positive outcomes, adverse events and complications observed in our experience.

An alternative central venous route for cardiac surgery: supraclavicular subclavian vein catheterization.

OBJECTIVE: To evaluate the clinical success rate, safety, and usefulness for intraoperative central venous pressure monitoring, and the intravenous access of the supraclavicular subclavian vein approach when compared with the infraclavicular subclavian vein approach and the internal jugular vein approach for central venous catheterization during open-chest cardiac surgery. DESIGN: A prospective, randomized, single-center study. SETTING: A university hospital. PARTICIPANTS: One hundred ninety-five patients scheduled for open-chest cardiac surgery. INTERVENTIONS: The study population consisted of patients for whom central vein catheterization was intended during cardiac surgery. Patients were randomized to 3 groups according to the route of central vein catheterization: the supraclavicular group: the supraclavicular approach for the subclavian vein (n = 65); the infraclavicular group: the infraclavicular approach for the subclavian vein (n = 65); and the jugular group: the internal jugular vein approach (n = 65). After the induction of anesthesia, central venous catheterization was performed according to the assigned approach. MEASUREMENTS AND MAIN RESULTS: The success rates for the assigned approach were 98%, 98%, and 92% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). The success rates in the first 3 attempts in patients who were catheterized successfully according to the assigned approach were 96%, 100%, and 96% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). There was no difference among groups in catheter insertion time (p > 0.05). After sternal retraction, central venous pressure trace loss and difficulty in fluid infusion were significantly more frequent in the infraclavicular group (21%) when compared with the supraclavicular (3%) and jugular groups (0%) (p = 0.01). There was no difference among groups in terms of catheter malposition, complications during catheterization, and rate of catheter-related infection. CONCLUSION: The supraclavicular approach for subclavian vein catheterization is an acceptable alternative for central venous access during cardiac surgery in terms of procedural success rate, ease of placement, rate of complications, and usability after sternal retractor expansion.

Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy.

A case series of patients with diabetic nephropathy, who underwent lower limb debridement or amputation below the knee during successful combined sciatic and femoral nerve block with bupivacaine 0.25%, is presented. Because impaired nerve conduction in diabetes mellitus results in lower local anesthetic agent requirement, a dose-sparing, minimal effective concentration for surgical anesthesia for peripheral nerve blockade may be more favorable for patients with diabetes and chronic renal disease.

Intrathecal catheterization after unintentional dural puncture during orthopedic surgery.

PURPOSE: We investigated whether inserting an intrathecal catheter and leaving it in place for 24 h after an unintentional dural puncture in orthopedic patients reduced the incidence of post-dural puncture headache (PDPH). METHODS: The study consisted of 427 patients in whom a total of 21 unintentional dural punctures had occurred during orthopedic surgery performed between 2002 and 2006. Seven patients (phase I; evaluated retrospectively) each underwent placement of an epidural catheter at another level after dural puncture during the period January 2002 to February 2004. Fourteen patients (phase II; evaluated prospectively) received an epidural catheter through the dural tear after an unintentional dural puncture during the period February 2004-March 2006 RESULTS: In phase I, 5 of the 7 patients experienced PDPH, and one required an epidural blood patch. In phase II, only one of the 14 patients complained of PDPH, which resolved after 48 h of medical therapy. No patient experienced paresthesia, neurologic or hemorrhagic complication, or infection. CONCLUSION: Inserting an epidural catheter through the dural tear following an unintentional dural puncture and leaving it in place for 24 h significantly reduces the incidence of PDPH.

Comparison of ropivacaine 0.2% and 0.25% with lidocaine 0.5% for intravenous regional anesthesia.

STUDY OBJECTIVE: To compare the anesthetic effects of two different concentrations and doses of ropivacaine (0.2% and 0.25%) with those of a conventional dose of lidocaine 0.5%. DESIGN: Prospective, randomized, double-blinded, clinical investigation. SETTING: Large metropolitan university hospital. PATIENTS: 66 adult ASA physical status I and II patients undergoing forearm and hand surgery. INTERVENTIONS: Patients were randomly allocated to three groups to receive intravenous regional anesthesia (IVRA). Study groups were: ropivacaine 0.2% (Group I, n = 22), ropivacaine 0.25% (Group II, n = 22), and lidocaine 0.5% (Group III, n = 22). MEASUREMENTS: Tourniquet tolerance times and regression of sensory analgesia were noted. Verbal numerical pain scores (VNS), cumulative analgesic consumption, and side effects were recorded during surgery and postanesthesia care unit (PACU). Time to first pain medication intake and number of patients receiving analgesics in the PACU were recorded. MAIN RESULTS: Additional tolerance times for the distal tourniquet were significantly higher in the ropivacaine 0.25% group than the other two groups. Regression of sensory anesthesia was fastest in the lidocaine group. During the PACU stay, VNSs were significantly lower in the first 20 minutes in the ropivacaine groups than the lidocaine group. Time to first intake of pain medication in the PACU was soonest in the lidocaine group. The number of patients given analgesics in the PACU was highest in the lidocaine group. The number of patients taking > two tablets of tramadol was significantly lowest in the ropivacaine 0.25% group. No serious side effects were observed in any study group. CONCLUSION: Longer tolerance times for the distal tourniquet, prolonged analgesia after tourniquet release, and lower analgesic requirements postoperatively make ropivacaine 0.2% and 0.25% an alternative to lidocaine for IVRA.

Delayed recognition of intrathecal methotrexate overdose.

A 10-year-old girl who presented to our hospital was diagnosed as having B-precursor cell acute lymphoblastic leukemia. St Jude's Total XIII protocol was started. In the second block of the consolidation phase, 10 hours after triple intrathecal treatment, we realized that instead of 12 mg, 120 mg of methotrexate had accidentally been given. Although the patient had no symptoms 10 hours after intrathecal treatment, to prevent the possible neurotoxic effects of methotrexate, a cerebrospinal fluid exchange was performed. Simultaneously, systemic dexamethasone and calcium folinic acid were given. At the time of this writing (2 y), the patient has had no symptoms and has continued on the chemotherapy protocol as planned. Administration of high-dose intrathecal methotrexate may not lead to symptoms, as was the case in our patient. This may be related to individual variations in cerebrospinal fluid dynamics and drug metabolism.