Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

How the advent of propofol changed the meaning of the term “sedation”

Karen S. Sibert, MD
Meds
February 19, 2015
686 Shares
Share
Tweet
Share

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient — brightly alert, with a colorful headband and bright red lipstick — was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Propofol revolutionized anesthesia care

Though “twilight” isn’t a medical term, people often use it to mean sedation or light sleep, as opposed to general anesthesia. Most patients don’t want to be awake, even if their operation doesn’t require general anesthesia. They prefer an intravenous “cocktail” to make them oblivious to pain and unaware of anything that’s happening. Today, the main ingredient is likely to be an anesthetic medication called propofol.

Propofol came on the U.S. market in 1986 and revolutionized anesthesia care, though the public heard little about it before the deaths of Michael Jackson and Joan Rivers. For the first time, we had a medication that allowed patients to sleep through unpleasant procedures like colonoscopies and wake up quickly with no nausea or “hangover.”

But we soon learned that propofol causes other problems. In older patients and anyone with heart trouble, propofol can make the blood pressure drop dangerously low. It also reduces the drive to breathe. Trickling propofol into the IV line in exactly the right dose to keep a patient breathing well but not moving during surgery — that can be a real challenge.

There’s no magic way to mark the moment when a patient under propofol crosses the thin line between comfortably sedated and deeply unconscious. This can progress quickly to the point where the patient is not breathing at all. The results can be catastrophic.

Sedation or general anesthesia?

So is propofol sedation really “sedation”? Or is it really general anesthesia with an unprotected airway and no way to control breathing? General anesthesia without a safety net?

Part of the problem is confusion about the term “sedation.” Before propofol, when procedures were done under local anesthesia with sedation, surgeons used local anesthesia to numb the target area, and patients received medications like Valium or Demerol, which helped them relax and eased any discomfort. But the patient was still awake. This technique is referred to today as “conscious sedation.”

Propofol sedation is different. Today, when surgeons say an operation can be done under “sedation,” they assume the patient will be asleep under propofol. The same is true for the gastroenterologist who needs to perform an uncomfortable endoscopy. Understandably, they want their patients asleep and still. Few patients want to be awake. On goes the propofol drip, and everyone is happy — most of the time.

What’s the difference between deep sedation and general anesthesia? Not much except semantics. If my patient is unconscious, then I’ve induced general anesthesia.

No more ether or chloroform

But wait. What about the nasty-smelling anesthesia gasses, breathing tubes, and postoperative nausea? Don’t they always go along with “old-school” general anesthesia?

Anesthesiology has come a long way from the days of ether and chloroform, which made everyone vomit. Modern anesthesia gasses like sevoflurane and desflurane are far more pleasant. They’re often tolerated better than propofol in terms of maintaining normal heart function and safe blood pressure. They clear out of the body quickly with normal breathing at the end of the operation.

Medicine has become so specialized that most physicians have little training in anesthesiology unless they enter the field. Many doctors never step into an operating room again after they finish the basic surgery rotation in medical school. They aren’t familiar with today’s operations. Even “minimally-invasive” surgery often requires general anesthesia and a breathing tube. Some physicians assume — and advise their patients — that sedation is always preferable to general anesthesia, even though that isn’t true.

There’s no reason to fear anesthesia, but every reason to respect it. The best choice of anesthesia technique will vary depending on the patient’s health and the type of procedure.

My 85-year-old patient? I decided to use a propofol drip, at a dose that made her completely unconscious. She couldn’t have tolerated the surgery otherwise. I took her blood pressure every two minutes, watched every breath she exhaled with a carbon dioxide monitor and adjusted the propofol dose up and down to match the level of surgical stimulation. Airway equipment was ready in case her breathing needed support.

With all those precautions, my patient survived her surgery and woke up just fine. But I wouldn’t call her anesthesia “twilight.”

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.  She blogs at A Penned Point.

Prev

Driving advice from a trauma surgeon

February 19, 2015 Kevin 6
…
Next

The power of expensive placebos

February 19, 2015 Kevin 0
…

Tagged as: Surgery

Post navigation

< Previous Post
Driving advice from a trauma surgeon
Next Post >
The power of expensive placebos

More by Karen S. Sibert, MD

  • You’re a doctor when you’re not giving anesthesia?

    Karen S. Sibert, MD
  • Why it may be time for doctors to unionize

    Karen S. Sibert, MD
  • How the board certification exams infantilize resident training

    Karen S. Sibert, MD

More in Meds

  • The deadly consequences of a shortage: The Pluvicto crisis leaves metastatic prostate cancer patients in limbo

    Matt Drewes
  • The real story of Xylazine contamination in street fentanyl and how we can manage it

    Julie Craig, MD
  • The cannabis education gap: Why patients are left in the dark

    Timothy Byars
  • Are doctors ready to discuss psychedelic therapies with patients?

    Thaís Salles Araujo, MD
  • The rise and dark side of fungi: Exploring health benefits and pathogenic threats

    Sandra Vamos, EdD and Deanna Lernihan, MPH
  • Advocacy and collaboration lead to major patient safety benefits on sterile pharmaceutical compounding: a review of USP’s revisions to Chapter <797>

    Elizabeth Rebello, MD
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
  • Past 6 Months

    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • Empowering Black nurses for lasting change [PODCAST]

      The Podcast by KevinMD | Podcast
    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Novel Anti-HER2 Drugs 'Impressive' in Advanced Biliary Cancer
  • What Was Tied to Lower Long COVID Risk?
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test

Meeting Coverage

  • Novel Anti-HER2 Drugs 'Impressive' in Advanced Biliary Cancer
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test
  • Pricey Drug Combo Boosts PFS in First-Line Advanced Ovarian Cancer
  • Most Popular

  • Past Week

    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
    • Boxing legends Tyson and Foreman: powerful lessons for a resilient and evolving health care future

      Harvey Castro, MD, MBA | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
  • Past 6 Months

    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
  • Recent Posts

    • Decoding name displays in health care: Privacy, identification, and compliance unveiled

      Deepak Gupta, MD | Physician
    • Empowering Black nurses for lasting change [PODCAST]

      The Podcast by KevinMD | Podcast
    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...