We thank Dr. Richman for his thoughtful letter in response to our editorial1; however, we believe he misinterpreted our statement regarding risk of combined general and regional anesthesia. We never said, or intended to imply, that mortality per se  is increased with a combined general and regional anesthetic technique when compared with a single technique. Rather, we said that basic probability tells us that the risk of complications will be greater when two techniques are combined as compared with each technique alone. We agree that combined techniques may result in benefits, and those benefits may offset the risk.

When deciding whether a patient should have a combined anesthetic technique versus  a single technique, the patient and anesthesiologist must decide whether the benefit outweighs the risk. The patient should have the opportunity to make an informed choice. As an example, for a patient who requires general anesthesia for a procedure and is considering the addition of a regional technique, is the benefit of 2 days of modestly improved pain control with a combined anesthetic technique (visual analog scale pain score of 3 with parenteral opioids vs.  2 with epidural analgesia)2worth the risk of nerve injury? Although our current knowledge of true estimates of risk is imprecise, we do know that some risks of regional anesthesia are very rare, such as epidural hematoma, but others, such as nerve injury, are more common. Because long-term complications are generally identified by retrospective surveys of clinicians, claims, or chart reviews rather than prospective clinical follow-up of patients, the true risk of injury may be higher than that published for any given anesthetic technique. Are patients informed that they may be trading a potential long-term complication for a short-term gain?

We hope research continues to provide us with more precise estimates of risks and benefits. In the meantime, to the extent possible, patients should be apprised of these risks so they can make an informed choice.

We agree with Dr. Augoustides that evidence-based guidelines are imperative for achieving safe practices for central venous catheter insertions, and we applaud efforts to standardize training in and placement of central venous catheters. There is one published guideline on the use of ultrasound guidance for central venous catheter insertion. The Agency for Healthcare Research and Quality published an evidence report in 2001 that listed the use of real-time ultrasound guidance during central venous catheter insertion to prevent complications as being a highly rated safe practice.3The strength of the evidence was considered powerful enough to support widespread implementation.

*Quality and Safety Research Group and Johns Hopkins School of Medicine, Baltimore, Maryland. eheitmil@jhmi.edu

Heitmiller E, Martinez E, Pronovost P: Identifying and learning from mistakes. Anesthesiology 2007; 106:654–56
Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowen JA, Wu CL: Efficacy of postoperative epidural analgesia versus  systemic opioids: A meta-analysis. JAMA 2003; 290:2455–63
Wachter RM, McDonald KM: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Report No. 43. Rockville, Maryland, Agency for Healthcare Research and Quality, 2001
Rockville, Maryland
Agency for Healthcare Research and Quality