REPLY Ventilation in patients with tracheal obstruction can create serious problems, particularly when the cross-sectional diameter of the trachea is narrowed to 5-6 mmHg. That is why the anaesthetic management and method of ventilation in our patient followed a step-by-step algorithm to ensure safety. The anaesthetic plan started by awake tracheal intubation, to be followed by spontaneous inhalation anaesthesia in 100% oxygen. Neuromuscular blockade and controlled ventilation were initiated after ensuring adequate jet ventilation. In his letter, Dr. Agarwal shouM have agreed with us, rather than disagreed, since we shifted to controlled ventilation as soon as we ensured its safety.

Background: We examined the optimal concentration of sevoflurane to prevent cardiovascular depression after induction of general anesthesia with remifentanil and propofol. Methods: Seventy-five adult patients were randomized to one of three groups (n = 25). Midazolam (0.025 mg/kg) and remifentanil (0.5 µg/kg/min) were administered to all patients, followed by propofol (1.0 mg/kg) and rocuronium (0.6 mg/kg) after 2 min. The lungs were ventilated manually with sevoflurane and oxygen via a tightly fitted face mask. The trachea was intubated when end-tidal sevoflurane concentration reached 1%, 1.5%, and 2% in each group, respectively. Three min after the start of administration, remifentanil was decreased to 0.25 µg/kg/min. The effect-site concentration of remifentanil was 6.0 ng/ml for 4 min after it was started. Hemodynamic variables were recorded from before induction of anesthesia to 15 min after tracheal intubation. Results: There were no serious adverse events such as severe bradycardia or asystole. Relative change of mean arterial pressure after induction of general anesthesia in the end-tidal sevoflurane 1% group was smaller than that of the end-tidal sevoflurane 1.5% and end-tidal sevoflurane 2% groups. Conclusion: An end-tidal sevoflurane concentration of 1% was sufficient when general anesthesia was induced with an effect-site concentration of remifentanil of 6.0 ng/mL and propofol of 1 mg/kg.

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