Eliciting paraesthesia during combined spinal epidural anaesthesia

it takes too long to perform (even if the kit is instantly available) and there is a considerable possibility of failure. However, retrograde intubation might have been useful when our patient presented electively. We agree that there are alternative ways in which we might have managed the patient’s airway when he presented for elective surgery. The alternatives do naturally tend to have a greater appeal when one knows that the technique chosen has failed. Alternatives that might have been used in our case include several variations of retrograde intubation, use of one of the many available rigid intubating fibrescopes (for example the Bullard and similar others), a fibreoptic stylet (for example the Bonfils and similar others) or an intubating conduit (intubating laryngeal mask airway or C-Trach laryngeal mask airway). Each of these alternatives may have worked (or failed) and each may have produced its own inherent difficulties and complications. Many of these options were not available to us as we do not have access to the equipment. For this patient in the elective setting the presence of an epiglottic tumour and previously operated larynx would raise concerns over the possibility of trauma or failure to advance the tracheal tube during retrograde intubation. The technique described by Bagade is elegant, as the incorporation of a fibrescope allows the possibility of ensuring that intubation is not entirely ‘blind’. Acquiring a view from a fibrescope relies on its tip remaining in an airspace. When the fibrescope is over a semirigid wire and is guided by the wire it is likely that the movement of the tip will be somewhat constrained, perhaps affecting the ability to remain in the airspace and maintain a view. We have limited clinical experience with this and other retrograde techniques, making it an unwise choice for us in this difficult case. Latto and Vaughan [1] comment that ‘it is not ethical to practice on elective cases and in consequence few clinicians have either seen or tried retrograde techniques...only 16.5% of clinicians in a retrospective survey have tried retrograde intubation techniques’. To finish on a lighter note, in difficult airway management an analogy with cats may be apposite: there’s more than one way to skin a cat, but you only get one chance per cat.