When it comes to anesthesia techniques, there are many misnomers out there with a subsequent false sense of security. Briefly consider these definitions: conscious sedation implies that a patient is arousable to verbal stimulus or touch. Deep sedation implies that a patient is only arousable to a painful stimulus. If the patient sleeps through a painful stimulus (such as an injection of lidocaine), then this is general anesthesia whether or not the patient is spontaneously breathing, and irregardless of what kind of airway management is utilized. Therefore, many times deep sedation is given under the guise of conscious sedation; and similarly, many patients are under general anesthesia with a callus regard for airway protection. Only an anesthesiology physician is appropriately credentialled to diagnose and treat medical issues related to general anesthesia.

Level of Consciousness Monitor

In my practice each anesthetic is tailored to the patient’s needs and the surgeon’s expectations. This can range from monitored anesthesia care (MAC) with mild sedation, to full general anesthesia. However, the most common method is a continuum between deep unconscious sedation and total intravenous general anesthesia (TIVA) with spontaneous ventilation either with or without a Laryngeal Mask Airway or assisted mask ventilation. The primary sedative is a propofol infusion, and the target organ (the central nervous system) is constantly monitored with a BIS level on consciousness monitor assuring that the patient receives only as much anesthetic as necessary. I agree that most hospitalized patients don’t need a BIS monitor. But if the plan is to use a total intravenous anesthetic technique with meticulous attention to the level of anesthesia, thus ensuring a timely and comfortable emergence even before the bandages are on, then the BIS monitor is indispensable.

My preference is to avoid the inhalational anesthetic gases (Desflurane, Sevoflurane, Isoflurane) for several reasons. First, they require an expensive anesthesia machine equipped with a gas scavenger system. Second, they are primary culprits for causing post op nausea. Third, they are all triggering agents for malignant hyperthermia, which would require stocking the expensive antidote Dantrolene. Certainly the gases lend themselves to an easier anesthetic, but, the constant vigilance and high maintenance that’s necessary to administer TIVA is justified by the smooth wakeup and quick discharge of your patient. There is no comparison.