To the Editor:-Although I read with interest the case report by Schaut et al., their report raises the concern that inhalation induction of anesthesia with sevoflurane for emergency cesarean section should be considered a “suitable alternative” when intravenous access is not available. [1]Whereas the authors endeavor to justify their decision, they minimize the significance of the maternal risk involved. The authors correctly state that the parturient undergoing emergency cesarean section is considered to have a full stomach and acknowledge the risk for aspiration. However, they do not clarify that the parturient has decreased lower esophageal sphincter tone and increased intragastric pressure and that the stimulus of uterine traction during cesarean section delivery places the parturient at extremely high risk of regurgitation. Additionally, laryngeal reflexes are absent during the stage of general anesthesia described in this case, and spontaneous ventilation with an unprotected airway makes this patient particularly susceptible to aspiration.

The authors also contend that infiltration with local anesthetics may take several minutes to accomplish and that the technique is no longer taught in most obstetric residencies. [2]However, this technique is described in major obstetrics textbooks. [3,4]Additionally, an informal survey of staff obstetricians practicing at our institution revealed that all are familiar with local anesthetic infiltration for cesarean section, and most state that they would use this technique in an obstetrical emergency. Although the authors described a case with good maternal and fetal outcome, the risk involved and the potential for an unfavorable outcome advocate against suggesting inhalation induction with sevoflurane as a “suitable alternative” for emergency cesarean section.

B. Todd Sitzman, M.D., M.P.H.

Department of Anesthesiology; Mayo Clinic Jacksonville; 4500 San Pablo Road; Jacksonville, Florida 32224

(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.
Busby T: Local anesthesia for cesarean section. Am J Obstet Gynecol 1963; 87:399-404.
Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC, Hankins GDV, Clark SL: Williams Obstetrics, 20th Edition. Stamford, Connecticut, Appleton & Lange, 1997, pp 387-8.
Hawkins JL, Chestnut DH, Gibbs CP: Obstetric anesthesia, Obstetrics: Normal and Problem Pregnancies, 3rd Edition. Edited by Gabbe SG, Niebyl JR, Simpson JL. Churchill Livingstone, 1996, pp 425-68.