In Reply:—
Thank you for the opportunity to reply to the letters from Drs. Cooper and Calder regarding my editorial.1 I agree with Dr. Cooper on both of his perceptive points, which reinforce the lack of clear definitions in this area. Further, because many anesthetists will have their own preference for “special” equipment, one person's easy case may be another person's nightmare, and yet comparative studies between such equipment are few.
Unfortunately, I do not share Dr. Calder's optimism that the public will take the slightest notice of anything we say about obesity (or anything else for that matter), although that should not stop us from trying. His second point, that the evidence in the article by Kheterpal et al.2 suggests that neuromuscular blocking drugs should be given sooner rather than later, provokes in me a sense of déjà vu. As he describes, in the United Kingdom, we have gone through phases of giving these drugs before induction of anesthesia, then after induction, and now only after a couple of “quick puffs”—the latter practice seemingly universal among today's trainees. When I have challenged trainees to tell me what they are going to do if their “test” ventilations are awkward, they generally do not have a useful answer and often admit that they would probably give a neuromuscular blocking drug and intubate the trachea! Personally, I have always thought that one's best chances of successful mask ventilation came from the onset of paralysis that early administration of neuromuscular blocking drugs—i.e., immediately after induction—can achieve, although an attempt to investigate whether this was so was unable to find a difference (partly, I suspect, from the difficulty translating the subjective feel of the bag in the hand to an objective measure of “ease of ventilation”).3 As to giving the neuromuscular blocking drugs before the induction agent (as I remember being taught when I started), this seems less crucial with today's modern, rapidly acting agents—and the memory of a senior consultant who gave the pancuronium before checking that there was actually any thiopental in the room is still vivid in my mind.
