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Time to push aside the diagnosis of infantile colic

almost diagnostic of an opiate overdose, this may not always be the case. Two patients recently treated in this intensive care unit have had widely dilated pupils following a dose of narcotic sufficient to depress their consciousness and respiration. The first patient had undergone liver transplantation and received a morphine infusion for postoperative pain relief and to facilitate artificial ventilation. On the ninth day after a stormy postoperative course (which included renal failure) concern was expressed over his conscious state. He had received 225 mg of morphine in this period and was still requiring artificial ventilation. His pupils were noted to be large. Despite this a sample of blood was taken for plasma morphine assay (measured by radioimmunoassay'), and he was given several small doses of naloxone with improvement in his conscious level. The second patient, who had a history of chronic renal failure, was admitted to the unit six days after a road traffic accident. He had received 510 mg of dihydrocodeine for pain relief during this six day period. He was unconscious and was intubated without the use of any drugs; respiratory depression was present, and his arterial carbon dioxide pressure was raised (7-11 kPa (53 mm Hg). His pupils were noted to be dilated. Blood was taken for plasma morphine assay and analysed by the same method. He responded to 0 3 mg naloxone with an increase in conscious level and respiration (arterial carbon dioxide pressure falling to 4-84 kPa (36 mm Hg)) and was subsequently maintained on a naloxone infusion. In both patients the plasma morphine concentrations were very high (1185 ng/ml in the first, 3963 ng/ml in the second), confirming the clinical impression of narcotic toxicity in the absence of small pupils. Renal failure may have contributed to the problems seen in both patients,2 and we hope to report them both in greater detail when further assays ofblood and urine have been undertaken.