To the Editor:--I disagree with the comments made on terminology in the correspondence by Ben-David et al. These authors state that the terms "general anesthesia," "conscious sedation," and "combined technique" "confuse and frustrate communication [and create] a linguistic trap with wide ramifications." The patients I interview have no difficulty with these terms or the concepts that they represent. Simply put, a general anesthetic is a drug-induced loss of consciousness, administered usually for the purposes of performing an otherwise unpleasant surgical procedure. Our own definition within the specialty may refer to muscular relaxation and reduction of reflex activity, but those descriptions are unnecessary during discussions with patients. Whether the entire autonomic and hormonal response to a surgical procedure is blocked by the general anesthetic is irrelevant to the patient as long as there is no awareness of pain (Ben-David et al. misuse the word pain, which is a conscious sensation). It may be true that the nervous system is not entirely insensitive, but with adequate anesthesia, the patient does not move in response to a supramaximal stimulus, e.g., the patient appears to be insensitive, and therefore, the word anesthesia fits with its original derivation (an = neg, aisthesis = Greek for sensation).
Conscious sedation is sedation that occurs without the loss of consciousness. Although some philosophers may have difficulty with the term consciousness, it is a common lay word that simply means the presence of self-awareness. If one is sedated but still conscious, then this is "conscious sedation." Finally, the patient who wants to have a regional anesthetic but also wants to be unconscious during the procedure can readily understand that a "combined anesthetic" can meet their needs, even though they would not have pain with a regional method alone. Patients having upper abdominal surgery with epidural anesthesia may be upset if they feel like they cannot breathe adequately. In these cases, I find it useful to have the patients asleep, with tracheal intubation and controlled ventilation. It would be ludicrous if I would refer to this anesthetic, as the authors suggest, as "epidural anesthesia with deep sedation."
If we say to our patients that we are now about to begin "the anesthetic," ask them to turn on their side, and begin to insert a 10-cm needle into their back, I think most people of average intelligence would ask for a more specific definition of what is meant by the term "anesthetic" in this case. I submit that, if we introduce the subject with the term "combined anesthetic" and proceed to define what advantages this technique offers (such as fewer systemic drugs used, painless emergence, and reduction of the "stress" response), we have distinguished this method from the ordinary "anesthetic." During the ensuing discussion, they will understand the reasoning behind the procedures that are performed and why they are recommended. Until a better phrase is advanced I see no reason to abandon the one that is in common use.
Merlin D. Larson, M.D., Associate Professor of Anesthesia, Moffitt-Long Hospitals, Department of Anesthesia, Box 0648, 521 Parnassus Avenue, Room M-480, San Francisco, California 94143-0648.
(Accepted for publication May 27, 1995.)