To the Editor.-We read the recent case report by Schaut et al. (Anesthesiology 1997; 86:1392–4) describing a sevoflurane induction for emergency cesarean delivery. We cannot agree that the approach described is a reasonable alternative. The choice of an inhalation induction is not new to obstetric management and may be warranted under some extremely rare situations; however, to proceed without first establishing intravenous access seems to be an unnecessary risk. Bonica's classic text describes mask inhalation induction with cyclopropane, and it is stated that “.. when cesarean section is planned, an endotracheal tube is introduced with the aid of succinylcholine”. [1]Anesthesiologists are experts at establishing vascular access. An internal jugular or subclavian catheter can be rapidly inserted, and a proper induction conducted. In addition, the induction of general anesthesia, under any circumstance, should not be undertaken without the application of routine monitors. If the obstetrician is so desperately inclined to begin the operation, it can be started with local anesthetic infiltration, allowing extra time to gain intravenous access and apply the necessary monitors. If mask anesthesia is used in the obstetric population, it is commonly taught to maintain cricoid pressure until the airway is secured to reduce the risk of regurgitation of gastric contents. Finally, when intravenous access was finally secured in this case, the use of succinylcholine would have assured the most rapid onset of intubating conditions.

David R. Gambling, M.B., F.R.C.P.C.

Associate Clinical Professor; Co-Director, Obstetric Anesthesia

Laurence S. Reisner, M.D.

Professor and Vice-Chair; Co-Director, Obstetric Anesthesia; University of California, San Diego Medical Center; 200 West Arbor Drive; San Diego, California 92103–8770

(Accepted for publication September 10, 1997.)


Bonica JJ: Principles and Practice of Obstetric Analgesia and Anesthesia, Vol 1, Philadelphia, FA Davis Co, 1967, p 390.