Sedation versus General Anesthesia for Intubation: Reply.

We read with interest Dr. Feldman’s correspondence1 regarding our study comparing sedation to general anesthesia in children enrolled in the Pediatric Difficult Intubation Registry.2 He noted correctly that 27% of the sedated cohort required conversion to general anesthesia and suggested that having a separate clinician administer the sedation may improve the success rate of tracheal intubation using sedation. Dr. Feldman highlights practice guidelines for non-anesthesiologists to support this idea. Dr. Feldman’s suggestion is an interesting one that makes intuitive sense. Although we suspect that having a clinician dedicated solely to managing the sedation would improve the success rate, we want to clarify that all the tracheal intubations in our study were managed by anesthesiologists, who routinely manage the airway and the anesthetic concurrently. We, however, agree that having a separate clinician administering sedition might improve its efficacy and allow the airway managers to focus solely on tracheal intubation. A similar model is evident in Formula One pit crews, where each team member is focused on a single task executed in a coordinated fashion. This single-task focus has facilitated significant improvements in efficient tire changes, with times decreasing from 60 s in the 1950s to about 2 s today.The issue with this proposal comes down to cost and operating room logistics. How will this additional clinician be funded? Will other operating rooms be placed on hold to accommodate this model? For example, in an ideal world, we suspect that having every anesthesiologist supervise a single anesthetic would enhance patient safety. However, this is not the case because of the inherent costs and the current critical shortage of anesthesiology clinicians. Many institutions occasionally assign an anesthesiologist to a single patient in certain complex cases. However, it remains rare for centers to staff two anesthesiologists to a single anesthetic. Maybe a sedated patient with a difficult airway is one of those circumstances where institutions should consider a 2-1 staffing ratio. We thank Dr. Feldman for his correspondence and are supportive of such an initiative. We would only add that such a change should be carefully examined to confirm that patient safety is indeed enhanced with this approach.Dr. Kovatsis declares serving as a medical advisor to Verathon Medical, Inc. (Bothell, Washington). The other authors declare no competing interests.