Jeanine P. Wiener-Kronish, M.D., Michael A. Gropper, M.D., Ph.D. Lippincott Williams & Wilkins, Philadelphia, 2000. Pages: 350. Price: $37.00
THIS 181-page handbook on conscious sedation has 15 contributors who attempt to focus on their own particular clinical practice settings. The idea is sound but the execution is mixed. Each contributor tries to carve out his or her niche in the practice of sedation–analgesia. In doing so they encounter the insurmountable, mostly terminological, problem of conscious sedation. Conscious sedation has been correctly described as an “oxymoron”. 1It is contradictory and especially confusing when the term “conscious” is combined with “sedation.” The term does not provide a distinction between the state when the patient remains fully conscious or just does not completely fit a category of unconsciousness. In addition, some of the confusion arises from the lack of objective measures of sedation depth. 2
The term “conscious sedation” was coined in 1985 to describe lightly sedated dental patients. Its use rapidly spread to various areas of medical practice with the meaning of procedural sedation including all levels of sedation. The ASA Task Force for the establishment of guidelines for monitoring patient sedation by nonanesthesiologists in 1996 replaced conscious sedation with the more precise term “sedation–analgesia,” but the confusing “conscious sedation” continues to be widely used and the authors did not attempt to confront this problem.
As is clear from the book chapters, each practice setting has different requirements, and there is no clearly defined end-point of what conscious sedation is. Each contributor clearly emphasizes what it is not supposed to be, that is, deep sedation with its potential hazards. Another weakness of the text is lack of data related to the potent pharmodynamic interactions that occur with quick acting benzodiazepines, opioids, barbiturates, and propofol. A glaring error is the dose of fentanyl given in mg/kg instead of μg/kg (page 82).
Overall, however, this handbook is a useful addition to this subject, especially because the demand for the service keeps growing. For the nonanesthesiologist the clearest message is this: Do not go out on a limb from which you cannot be rescued.