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Excerpt
We thank Drs. Ware and Liu for their valuable comments on our study [1]. We agree with them that positive heart rate (HR) criteria for identifying intravascular injection should have been defined according to the HR changes after saline injection using the 95% confidence interval. In addition, the lower bound of the 95% confidence interval for HR increases after epinephrine 15 micro gram intravenously (IV) should also be considered.
After epinephrine 15 micro gram IV, the average increase of the peak HR was 26 +/- 8 bpm (mean +/- SD) above the baseline. Using the lower bound of the 95% confidence interval, we should accept an increase >9 bpm above the baseline as diagnostic of intravascular injection. On the other hand, IV saline produced an average increase in HR of 0 +/- 4 bpm (mean +/- SD) above the baseline, indicating that the criterion of HR increase >9 bpm should also be met.
Hence, in adult patients anesthetized with 1% isoflurane under stable conditions, it seems appropriate to modify the HR criterion to an increase >9 bpm, which had in fact given the same sensitivity, specificity, and positive and negative predictive values as reported in our article [1], since no patients receiving IV saline had developed an increase in HR >9 bpm.
