Tracheal intubation with the direct and indirect laryngoscopes in patients with cervical spine immobilization

Editor—We thank Drs Birts and Combeer for their constructive comments on the use of and consent for general anaesthesia for Caesarean delivery in patients with pre-eclampsia in our study. In particular, they are concerned about a transient but severe hypertension along with cerebral haemorrhage and cardiac failure after tracheal intubation, and risk of airway complications. We understand, in most Western countries, neuraxial anaesthesia is the standard for elective Caesarean delivery and has become a preferred technique to provide labour analgesia or anaesthesia for Caesarean delivery even among women with severe pre-eclampsia. 4 However, there are many differences in ethical and cultural values in different countries. We had 2257 cases of Caesarean delivery during the last 5 yr (2006–10). There were 814 (36.1%) elective sections, of which 718 (88.2%) had general and 96 (11.8%) had spinal or epidural anaesthesia. On the other hand, we had 1443 (63.9%) emergency Caesarean deliveries, 1371 (95.0%) of which were done under general anaesthesia and only 72 (5.0%) under spinal or epidural anaesthesia. For East Asians, airway problems (e.g. difficult intubation or ventilation) are not a major problem and thus major issue in determining the anaesthetic technique for Caesarean delivery. Moreover, we feel that the incidence of aspiration pneumonia during general anaesthesia for Caesarean delivery is lower compared with Western countries. In fact, neuraxial anaesthesia is not considered safer than general anaesthesia for elective Caesarean delivery in our country. There is no set standard of care for elective Caesarean delivery, although general anaesthesia using volatile anaesthetic in 50% N2O is still the most popular anaesthetic technique in most institutions. Nevertheless, the potential risks and benefits of general, spinal, or epidural anaesthesia were explained to patients, who accepted the anaesthetist’s inclination towards general anaesthesia and gave their written informed consent to participate in our study. As far as exaggerated pressor response to laryngoscopy and tracheal intubation is concerned, we feel that general anaesthesia with the aid of ultra-short-acting remifentanil described in our article would be acceptable, if not ideal, for gestational hypertensive women. To date, we have not encountered any disastrous consequences due to pressor response and airway problems during Caesarean delivery. While there is a preference for regional anaesthesia for Caesarean delivery in current anaesthetic practice in Western countries, we believe that whether the regional anaesthesia has advantages for both the mother and baby over general anaesthesia has yet to be determined in East Asia.