Category‐1 caesarean section, airways and Julius Caesar. A reply

We thank Sorbello and Micaglio for their comments. We agree that pregnant patients present unique challenges for airway management 1. In our study on anaesthesia management for emergency caesarean delivery in women with predicted difficult intubation/ventilation 2, literature searches focused on data sources exclusively from obstetric patients. However, in some nodes on the decision tree, obstetric data was unavailable and we had no alternative but to make some assumptions and extrapolate data from non-obstetric situations (e.g. obese patients). It is likely that the true (unknown) obstetric data would be somewhat different, but based on our sensitivity analysis 2, this would not impact greatly on the final outcome of our study. Yentis wrote that while decision analysis “involves many assumptions and estimations” it “emphasises the role of using such evidence as exists in a more structured and focused way” 3. By contrast, he stated that the traditional decision making process “relies purely on assumptions and estimations–worse, there is no structured incorporation of evidence or estimation of actual likelihoods at all. Instead the process is entirely intuitive”. In light of these remarks, we challenge both clinical assertions made by Sorbello and Micaglio, firstly that “regional anaesthesia should not even be attempted if difficult ventilation is anticipated”, and secondly, that “awake technique is preferable if there is anticipated difficult ventilation”. We do not agree that regional anaesthesia should not be attempted. In fact, most obstetric anaesthetists would prefer regional anaesthesia under these circumstances if time permitted and appropriate backup equipment was available 4. Indeed, the most important contribution of epidural labour analgesia to maternal safety has been the ability to rapidly and safely convert epidural labour analgesia to surgical anaesthesia for unscheduled caesarean delivery. This advantage is particularly beneficial in mothers with predicted difficult intubation and difficult ventilation. We agree that rapid sequence induction with videolaryngoscopy (RSI-VL) is not ideal 5, but the scenario under discussion involved a time-critical category-1 caesarean section. The key message of our paper is that the time for successful airway management in RSI-VL was 100 (87–114) s, vs. 9 min for awake fibreoptic intubation and 6.3 min for rapid spinal. The risks of RSI-VL are relatively low (21 incidents per 100,000), and we consider them to be acceptable if slower techniques would entail much greater long-term risks to the fetus. Although we disagree with Sorbello and Micaglio, such disagreement is legitimate; maybe their intuition and experience are different from ours. This is exactly why an attempt to obtain and marshal literature-based evidence is so important. Where direct evidence is lacking and where the question is not amenable to a randomised clinical trial, decision analysis may provide a literature-based estimation of likely outcomes. Otherwise, to echo their quote from Julius Caesar, ‘libenter homines id quod volunt credunt’ (man will readily believe what he wishes to be true).

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