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Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, timsmith{at}wfubmc.edu
To the Editor:
We read the van den Berg et al. (1) article with interest. As pediatric anesthesiologists who daily perform inhaled inductions of anesthesia and observe both the common and uncommon complications, we were provoked at the "suggestion" of the practice of routinely offering the choice of inhaled induction to adults for routine cases. The article states that "patient safety is preeminent," and, although there are no studies comparing the relative safety of IV versus inhaled induction in adults, it is our contention that inhaled induction adds several real and unnecessary risks when compared to IV induction. For instance, management of a healthy, muscular, 90-kg male for knee arthroscopy who is in the excitement phase of anesthetic induction with laryngospasm or regurgitation without an IV is problematic, at best, or may result in significant morbidity or possibly mortality at worst. There is also the very real potential of injury to the patient and/or staff in the situation of a robust patient becoming combative during an inhalational induction.
There are a number of situations during which consideration of an inhalational induction of an adult may be justified, including treatment of nonobese, healthy patients with needle phobia or patients who have extremely difficult IV access in whom there is no contraindication for inhalational induction. In these types of patients, the anesthesiologist must weigh the potential risks and benefits in determining a course of action.
Although we agree that "minimizing needle stick discomfort is a modality of good patient care," there are other ways to achieve this, including, but not limited to, topical creams (EMLA and LMX), iontophoretic technology, local injection of lidocaine, and patient reassurance.
Furthermore, efficiency may be impaired by adding an additional task in the operating room. IV catheters are routinely started in a preoperative holding room and can be in place before the anesthesiologist is ready, facilitating efficient transport to the operating room for IV induction of anesthesia. This allows the IV placement to be done in parallel, rather than in series with a surgeon’s operative procedure.
Many patients are anxious in anticipation of surgery and are routinely treated with anxiolytics before transport to the operating room. The practice of offering inhalational induction, although "decreasing the discomfort of a needle stick," leaves less effective routes of delivery for anxiolytic drugs (i.e., oral, nasal).
The authors refer to anesthesiologists’ concerns over the risks of halothane and the relative safety of sevoflurane. Though this is true, it is important to mention the reports of muscle rigidity and myoclonus with sevoflurane, as well as concern over subclinical seizure activity attributed to this drug (2,3). Finally, although sevoflurane is less pungent than most of the inhaled anesthetics used in clinical practice, it is not "essentially odorless." In fact, many patients find the odor to be significantly unpleasant.
References
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