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Department of Anaesthetics, Mayo General Hospital, Castlebar, County Mayo, Ireland
In Response:
Although we respect Smith and Elliott’s comments, as adult and pediatric anesthesiologists we agree with the Central Consultants and Specialists Committee of the British Medical Association that generalist anesthesiologists require greater training (1), thereby acquiring broader experience, than specialist anesthesiologists, and we believe that anesthetic practices should be rationalized by investigation (2,3) rather than essentially unreferenced opinion.
We agree that no studies compare safety of IV versus inhaled induction in adults or children and consider them warranted. As regards a 90-kg excited adult, of our 5500 patients offered sevoflurane since 2000 (4) only one male soldier removed the mask and requested IV induction; none developed airway problems or regurgitated. This overall satisfactory experience is shared by others (5).
Regarding methods of minimizing cannulation discomfort, audits comparing these with inhaled induction on the induction satisfaction of needle phobic patients are required. Although we minimize (6,7) or avoid cannulation pain and use eutectic mixture of local anesthetics in adults (8), all methods have nursing, cost, and administrative constraints. Furthermore, routine cannulation in day surgery units is not universal and, where practiced, is often causes morbidity and needle-phobia because various trainees frequently cannulate unpremedicated patients without cutaneous analgesia.
The popularity of midazolam IV for anxiolysis when bringing patients to the operating room (9) is unresearched and neglects anxiety before transportation in 50% of adults who desire earlier oral premedication (10). Although the considerations promoting ambulatory surgery have resulted in patients not receiving nocturnal or timely preoperative anxiolysis, satisfactory sedation follows midazolam (11,12) or temazepam (13,14), 0.25 to 0.5 mg/kg per os administered per nursing protocol on patient arrival in the day surgery unit.
Regarding halothane toxicity (15) and sevoflurane safety, halothane vaporizers have been removed from anesthetic machines in many countries. We endorse this and consider halothane an historical anesthetic.
Neuroexcitation after sevoflurane is not described in adults. Of greater concern in anesthesia are various propofol (di-isopropyl-phenol) induced iatrogenic morbidities that prohibit propofol’s use in children <3 yr and pregnancy (16). Invariable pain on injection, hypotension and rare neuroexcitatory phenomena demonstrate the peripheral and central neurotoxicities of phenols (17,18).
We strongly believe that patient satisfaction is optimized when patient preferences are canvassed and encourage "patient-centered anesthesia" (where appropriate patient opinion is implemented) rather than "practitioner-centered anesthesia" (where anaesthesiologist preference irrespectively prevails). In this respect, our "sister" audit of children’s induction route choice and opinionable age may interest Dr. Smith. We found that children >2 yr occasionally and children >5 yr invariably express preferences; approximately 20% choose IV induction (of whom approximately 50% subsequently opt for inhalation), approximately 60% choose inhalation, and approximately 20% are undecided or unable to choose (19). We now also canvass induction opinion of children, in whom cannulation is often difficult (20).
References
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