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Professor of Anesthesia and Perioperative Care; University of California, San Francisco; San Francisco General Hospital; San Francisco, CA; kdrasner{at}anesthesia.ucsf.edu
In Response:
I appreciate the interest and comments of Drs. Lang and Benumof. The purpose of the editorial (1) was to highlight the potential, albeit undefined, additional risk associated with thoracic epidural placement in the anesthetized patient. In the absence of exceptional circumstances (e.g., the pediatric or uncooperative patient) such risk argues that patients should be awake during catheter placement. Dr. Lang's letter questions the logic advanced in the editorial to support this view, noting, "Logic is the science of reasoning or inference that results in a conclusion following a given premise." and that "If the premise is invalid, the conclusion will be flawed." Somewhat ironically, I agree with Dr Lang's conclusions, though the premise on which he basis his arguments are not quite correct—it was not stated in the editorial, nor is it my belief, that an "awake patient consistently provides information that will prevent or mitigate damage." Clinical experience tells us that needles (or catheters) may impinge upon the spinal cord without evoking a response from the patient. However, sometimes they will. And when they do, both logic and experience (2,3) tell us that injury is likely to occur, or to be enhanced by injection of anesthetic solution.
As Dr. Lang notes, the consent process may be more challenging when risk is ill-defined, but neither uncertainties, nor the pressure of time or production, provide reasonable justification for its omission. Perhaps his suggestion to develop consent forms for such circumstances might facilitate this process. That performing epidural anesthesia in an awake patient still carries risk justifies his emphasis on developing safer techniques and technology for catheter placement.
Drs. Lang and Benumof both raise an important point that cannot be overemphasized. The considerations discussed in the editorial regarding the benefits of performing regional anesthesia in a responsive patient are not restricted to central neuraxial blockade.
References
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