In Reply:—

I thank Drs. White, Chelly et al. , Borgeat et al. , Hadzic et al. , and Bittar for their thoughtful comments. Drs. Chelly et al.  and Borgeat et al.  took exception to my statement that performing interscalene block during general anesthesia (ISB-GA) is a common procedure; their exception was based on their own practice and the practice at their own institutions. When I first learned of the four cases I reported, I informally surveyed many anesthesiologists in many locations to get a sense as to how common the ISB-GA procedure was. I was surprised to find that in many cities (including my own) and practice settings (private practice and teaching institutions, including my own department), the ISB-GA procedure was common and was the rule of practice rather than the exception. Furthermore, in several large cities and institutions, the local regional anesthesia expert told me that he or she was aware of one or more intracord injection complications in their community (but, as my report stated, no one had ever reported this complication before). Based on this survey experience, I am confident that as one broadens the sphere of inquiry, one will find that the ISB-GA procedure is common and geographically widespread.

Drs. White, Chelly et al. , and Bittar think that ISB-GA is absolutely, not relatively, contraindicated (as did one or two of the reviewers of my report). I struggled (and still do) with the exact strength of the wording “contraindicated” for ISB-GA for four reasons. First, standards of care are set in part by what other reasonably knowledgeable, prudent, and competent practitioners do in similar cases. If, as I found in my informal survey, many otherwise reasonably knowledgeable, prudent, and competent anesthesiologists are routinely performing ISB-GA, then how can ISB-GA be absolutely contraindicated? Are so many practitioners simply flat-out negligent? Second, it was not the primary intention of the report to set a standard of care, but rather to make the anesthesia community aware of the ISB-GA intracord injection complication and then let the practitioner come to his or her own standard of care conclusion. Third, some patients refuse awake ISB; are they then eliminated as candidates for ISB? Fourth, if one remains clearly cognizant of depth of insertion of the ISB needle, then the risk of intracord injection is minimized.

The depth of insertion issue brings me to the last comment that all the letters made, namely, that proper training, education, and technique (including depth of insertion) will avoid intracord injection. I suppose so, in a perfect world. In such a world, ISB-GA would not be contraindicated because proper training, education, and technique would prevent complications. However, the world is not perfect, so we are back to where we were before: should ISB-GA be relatively or absolutely contraindicated?