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The use of basophil activation to diagnose allergy to Gelofusine®

suggested optimum surgical procedure over the suggested optimum anaesthetic technique. On the basis of his specific problems, previous herniorrhaphy and discussions with his surgeon, our patient chose one of the possible methods of repair that he and his surgeon thought best for him. For the merits and suitability of different techniques including laparoscopic bilateral hernia repair we defer to experienced surgeons but provide a reference [1]. We recommended awake intubation to our patient. We exhaustively repeated probable and possible outcomes of asleep intubation including failure, brain injury and death. We discussed his decision with him and believed he weighed the risks and benefits of different surgical and anaesthetic combinations competently. We believe this process of consent met the standards of the ‘reasonable anaesthetist’, ‘reasonable patient’ and included risks of specific importance to him. As he had experienced an awake intubation and decided to be asleep, his confidence in and cooperation with this technique had possibly already been lost. The ethical and medico-legal issues surrounding consent and agreeing or refusing to proceed in accordance with a patient’s wishes are continuously evolving but we note updated authoritative advice increases the emphasis on the patient’s autonomy in decision-making. TheWorking Party of the Association of Anaesthetists on Consent for Anaesthesia stated ‘it is good practice for the clinician who is seeking consent to indicate whether they favour one therapeutic option over another, but the imbalance of power and influence in the doctorpatient relationship means the vulnerable patient may feel coerced by the doctor’s enthusiasm. Anaesthetists seeking consent should be aware of this and not allow their preferences to override the patients autonomy’ [2]. Moral compromises may result leading to an anaesthetic plan that is not optimal [3]. Ten metered 0.1-ml sprays of 10% lidocaine were applied to the patient’s mouth, palate, oroand laryngopharynx, a dose sufficient to insert a LMA ProSeal awake in some individuals [4]. Drs Gongireddy and Das may have misunderstood our report as indicating that we chose a specific calculated effect site propofol concentration to insert the LMA ProSeal. Believing in predictable patient responses at predicted concentrations suggests little clinical experience of target-controlled intravenous anaesthesia (TIVA). We re-refer them to the reference in our original letter showing that the concentration we found clinically effective in our case is comparable with the experiences of others [5]. Adding further detail to our letter, it is our routine practice to check the ability to ventilate when anaesthetising difficult airway cases and it was possible to assist ventilation in this patient. It is also our routine practice to insert LMA ProSeals using a jaw thrust [6]. If there is no motor response to a jaw thrust, laryngeal mask insertion is very likely to be successful [7]. Drs Gongireddy and Das prefer inhalational induction in similar cases. It may not, however, be easy on all occasions to determine the plane in which to insert an airway or fibrescope safely, nor to instrument the airway without interruption of anaesthesia, which was maintained in our patient with TIVA. A Berman airway was not available to us but, to our knowledge, there are no published comparisons between LMA ProSeals and Berman airways, nor does the Berman have all the advantages of a dedicated airway in these circumstances [8]. In conclusion this patient was given a choice of available alternative surgical procedures under local or regional anaesthesia and we agree an awake fibreoptic intubation would have been a safer option.