To the Editor.-Schaut et al. [1]described a successful mask inhalation induction for emergency cesarean section in a patient without intravenous access. The authors acknowledged the limitations associated with two other anesthetic options for this challenging scenario: local infiltration by the obstetrician and intramuscular rapid sequence induction. A third alternative in this situation is an awake intubation under topical anesthesia followed by inhalation induction. Although this method requires some time and patient cooperation, securing the airway before induction of anesthesia affords an element of safety lacking in a mask inhalation induction. [2]Less optimal, alternative approaches include a single shot spinal anesthetic (in the case of a prolapsed umbilical cord, performed with the patient in the lateral decubitus position) with simultaneous intramuscular ephedrine, or perseverance in securing peripheral or central venous access before induction. Although all of the previously mentioned approaches have significant limitations, one should at least acknowledge that a variety of options exist.

Jerome M. Klafta, M.D.

Assistant Professor of Anesthesia and Critical Care; University of Chicago, MC 4028; 5841 S. Maryland Avenue; Chicago, Illinois 60637

(Accepted for publication September 10, 1997.)

Schaut DJ, Khona R, Gross JB: Sevoflurane inhalation induction for emergency cesarean section in a parturient with no intravenous access. Anesthesiology 1997; 86:1392-4.
Cooper SD, Benumof JL, Reisner LS: The difficult airway: Risk, prophylaxis, and management, Obstetric Anesthesia Principles and Practice, 1st Edition. St. Louis, Mosby Yearbook, 1994, pp 577-605.