Practice Patterns of Anesthesiologists Regarding Situations in Obstetric Anesthesia Where Clinical Management is Controversial

Comment: The authors presented an interesting study that examined the response of anesthesiologists to various situations in which clinical management is controversial. They then divided these responses into two groups: those from private practice and those from academic practice. Interestingly, there was little difference in response except for eight questions. One area of difference lay in the laboratory values requested before epidural placement. More responders in the private practice group would check a complete blood count and platelet count in healthy parturients, a fibrinogen level in mild preeclamptics, and a partial thromboplastin time, fibrinogen level, and bleeding time in severe preeclamptics. The other difference lies in the choice of intravenous agents used to supplement a regional anesthetic during a cesarean section before delivery of the baby, with the academicians preferring ketamine, fentanyl, and midazolam, whereas the private practitioners prefer ketamine. These differences demonstrate a more conservative approach with the private practitioner. Although this may be related to a more litigious patient population for the private practitioners, I feel this defines the role of academics. An anesthesiologist in academics is expected to test the limits through careful investigation and study and then share this information through presentations at meetings and publications in journals. Controversial issues become better defined, and as such, lose their controversy. An example of this is the agreement between both groups regarding the use of invasive monitoring in preeclampsia. According to this study's results, only 60% of practitioners use epinephrine routinely for test-dosing. Much has been published questioning the reliability of epinephrine as a test drug in the obstetric population. My concern is not the use of epinephrine, rather it is whether the other 40% are test-dosing before injection. Given the severe consequences of intravenous injections of local anesthetics, we hope this 40% are test-dosing with something else such as a second 100-mg dose of lidocaine or chloroprocaine or 1 cc of air with a Doppler monitor over the maternal heart.