SummaryReported data suggest that 99% of transfemoral, transcatheter aortic valve implantations in the UK are performed under general anaesthesia. This before-and-after study is the first UK comparison of conscious sedation vs. general anaesthesia for this procedure. Patients who underwent general anaesthesia received tracheal intubation, positive pressure ventilation, radial arterial and central venous access and urinary catheterisation. Anaesthesia was maintained with propofol or sevoflurane. Patients who received conscious sedation had a fascia iliaca and ilioinguinal nerve block and low-dose remifentanil infusion, without invasive monitoring or urinary catheterisation. Recruitment took place between August 2012 and July 2015, with a 6-month crossover period between November 2013 and June 2014. A total of 88 patients were analysed, evenly divided between the two groups. Patients receiving conscious sedation had a shorter anaesthetic time (mean (SD) 121 (28) min vs. 145 (41) min; p < 0.001) and recovery room time (110 (50) min vs. 155 (48) min; p = 0.001), lower requirement for inotropes (4.6% vs 81.8%; OR (95% CI) 0.1 (0.002-0.050); p < 0.001) and a lower incidence of malignant dysrhythmia (0% vs 11.4%; p = 0.020). Conscious sedation appears a feasible alternative to general anaesthesia for this procedure and is associated with a reduced requirement for inotropic support and improved efficiency.

Editor-We read with great interest the review on anaesthetic considerations for penetrating trauma by Sheffy and colleagues 1 and would like to congratulate them on their very thorough and informative work. We would, however, like to share with you our recent experience that brought up some specific anaesthesia-related challenges in penetrating trauma that were not addressed in their article. The following case led to a great deal of debate and discussion in our department and we would like to invite opinion.A 29-year-old male was transferred urgently from our local trauma centre to our tertiary cardiothoracic centre for exploratory surgery. He had been impaled by a large industrial drill piece, which entered his thoracic cavity via the left side of his neck, just lateral to his cervical spine, and stopped just short of his aortic arch.The standard, universally accepted approach to managing such an impalement injury is to stabilize the object and leave it in situ until removal is possible under circumstances in which vascular injury can be controlled. Hence the patient arrived in our operating theatre in the left lateral position, with the drill piece in situ. He was awake and self-ventilating, with a saturation of 95% on high-flow oxygen. He was tachycardic, but with a stable blood pressure and a haemoglobin of 130 g litre −1 ; we were thus reassured that there was no current evidence of uncontrolled bleeding. One rapid action that we undertook was to replace both i.v. lines with 7 Fr rapid infusion catheters, and we agree with the authors that these are incredibly useful in the trauma situation.The patient presented a number of immediate problems to us. The first was that, despite receiving doses of morphine and ketamine for analgesia, he was distressed and becoming progressively more agitated. We thus needed to expedite anaesthesia to ensure he did not move and further impale himself, yet we were aware that he had a potentially difficult airway, given his lateral positioning and the need for lung isolation. We considered the options available to us; awake fibre-optic intubation of the trachea was quickly excluded, given the lack of patient compliance, and the trajectory of the drill piece meant we were unable to utilize a gap in the operating theatre table and place him in a supine position. We thus felt the safest option was to undertake a rapid sequence intubation in his current left lateral position. We proceeded to do this using a modified approach with rocuronium and successfully inserted a size 9 Left Bronchocath (Covidien, Mansfield, MA, USA) double-lumen endotracheal tube. Correct placement was confirmed with a fibre-optic bronchoscope. One area of debate that arose from this case was whether an attempt to secure the patients airway should have been undertaken either on the scene of the accident or in the emergency department of the referring hospital. As detailed in the review article 1 , indications for intervening to secure the airway include 'trauma to the box' and those patients destined for the o...