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Guilt by association?

Iowa City, Iowa

Letter to the Editor:

We read with interest the article by Han et al.¹ on the use of laryngeal mask airway in Cesarean delivery. We agree with the editorial by Roanne Preston² that regional anesthesia (RA) is the preferred choice of anesthesia for Cesarean delivery. However, we disagree with Dr. Preston’s assertion that Hawkins et al.³ data showed general anesthesia (GA) to be 16 times more lethal than RA. David Chestnut⁴ pointed out the serious limitations of the statistics and their interpretation not the least of which was that at risk patients may have received GA instead of RA.

The British have been rigorously collecting data on maternal mortality. The data is much more complete and in their most recently published triennium of 1994–96,⁵ there was only one death solely attributed to anesthesia. It was a regional anesthetic.

Josten et al.⁶ reported their experience with maternal mortality from 1988 to 1996. Of 890,422 births, there were no fatalities attributable to anesthesia. The distribution of anesthesia for Cesarean section was 60.8% GA and 39.2% RA during this time period. There is no suggestion from the German data that one technique is better than another, but that they are both safe.

We believe RA to be the preferred technique to GA but think we are doing ourselves as a group a disservice by stating there is a 16-fold lethality associated with GA over RA. This may be guilt by association, not by causality. By branding GA as intrinsically much more dangerous we encourage other health care providers, regulators, and the public to consider it reckless disregard any time we elect to, or have to, administer a GA. More hard data is needed before we can come to meaningful conclusions and statements.

References

1 Han TH, Brimacombe J, Lee EJ, Yang HS. The laryngeal mask airway is effective (and probably safe) in selected healthy parturients for elective cesarean section: a prospective study of 1,067 cases. Can J Anesth 2001; 48: 1117–21.[Abstract/Free Full Text]

2 Preston R. The evolving role of the laryngeal mask airway in obstetrics (Editorial). Can J Anesth 2001; 48: 1061–5.[Free Full Text]

3 Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology 1997; 86: 277–84.[Medline]

4 Chestnut DH. Anesthesia and maternal mortality (Editorial). Anesthesiology 1997; 86: 273–6.[Medline]

5 Gwyneth L, James D. Why mothers die, report on confidential inquiries into maternal deaths in the United Kingdom 1994–1996. London: The Stationary Office, November 16, 1998.

6 Josten KU, Wolf H, Schafer RD. Obstetric anesthesia 1988–1996 in Northrhine/Germany: results of the Perinatal Survey at the Chambers of Physicians. Anesthesiology 1998; 89: 1288–90.[Medline]

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