Annals of Emergency Medicine
Volume 39, Issue 4 , Pages 433-435, April 2002

Procedural sedation terminology: Moving beyond “conscious sedation”☆

Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA

Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA

Address for correspondence: Steven M. Green, MD, Loma Linda University Medical Center A-108, 11234 Anderson Street, Loma Linda, CA 92354; 909-553-8071, fax 909-794-5706; E-mail stevegreen@tarascon.com.

Article Outline

Abstract 

[Green SM, Krauss B. Procedural sedation terminology: moving beyond “conscious sedation.” Ann Emerg Med. April 2002;39:433-435.]

 

It's time to retire the terminology “conscious sedation” from the emergency medicine literature and clinical practice. This antiquated term is now wholly obsolete. The expression is widely misinterpreted, widely misused, confusing,1 “imprecise,”2 and an “oxymoron.”1, 3 Conscious sedation is no longer a primary sedation level in the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards,4 and the anesthesia community has already taken the lead in abandoning this term.2, 3

The phrase “conscious sedation” was coined in 1985 to describe lightly sedated dental patients.5 It was then incorporated into pediatric sedation guidelines in a manner that carefully kept it distinct from more advanced levels of sedation (ie, “deep sedation,” “general anesthesia”).6, 7 According to its technical definition, conscious sedation only exists when the sedation depth “permits appropriate response … to physical stimulation or verbal command, eg, ‘open your eyes.'”7 This corresponds with only mild to moderate degrees of common emergency department sedation practice. Emergency physicians also regularly administer “deep sedation,” during which by definition patients “cannot be easily aroused but respond purposefully following repeated or painful stimulation.”4

Despite the focused intent of the definition, however, practitioners quickly came to label all levels of sedation as conscious sedation.8, 9, 10 When the JCAHO mandated hospital-wide sedation policies, many practitioners were quick to refer to them as “conscious sedation policies.” Thus, over time, conscious sedation has functionally acquired the secondary meaning of a generic label for all procedural sedation.11 Practitioners say things like “I'm doing a conscious sedation in room 10,” even when the sedation end point is incompatible with the definition of the conscious sedation (ie, deep or dissociative sedation).

It could be readily predicted that the original intent of the phrase “conscious sedation” would blur, given the vague and confusing nature of the expression itself. Some health care providers naturally assume that the inclusion of the word “conscious” implies that patients must remain essentially fully conscious to qualify, and therefore incorrectly surmise that any real obtundation is never unacceptable and potentially hazardous. Conversely, others assume that sedation can be cleanly divided into “conscious” and “unconscious” camps,12 and, as long as the patient is not entirely unconscious, they can happily label their technique conscious sedation. Both viewpoints ignore the basic understanding that nondissociative sedation exists as a continuum; however, both are encouraged by the inherent ambiguity of the term itself. The underlying clash of the words “conscious” and “sedation” has been derided as an “oxymoron.”1, 3

Some of the confusion surrounding sedation terminology arises from the lack of objective measures of sedation depth in emergency medicine practice. Classical sedation states have been defined based on a subjective measure of level of consciousness, that is, the ability to follow verbal commands. Such a response is difficult to assess, especially in young children. Level of responsiveness is likely only a crude surrogate marker for the real physiologic parameter of interest, the retention of protective airway reflexes.13

In the past 5 years, anesthesiologists have made progress in quantifying sedation depth and awareness during anesthesia, using processed electroencephalogram (EEG) and auditory evoked potential technologies.14, 15, 16, 17, 18 Although these technologies appear validated in the operating room setting, investigation of their use in the ED is just beginning. At present, emergency department sedation terminology continues to await validated objective measures of sedation depth.

The 2001 revised JCAHO sedation care standards replaced the term conscious sedation with “moderate sedation/analgesia” and provided clearer (although still subjective) definitions of this and other sedation levels.4 The JCAHO nomenclature is more intuitive, clear, and logical. Emergency physicians should use this more specific language when describing their sedation practices, adding “dissociative sedation” for procedures facilitated by ketamine.19

When referring to the generic practice of administering sedation and analgesia for ED procedures, we believe that the preferred term should be “procedural sedation and analgesia,” or simply “PSA,” as noted in the 1998 American College of Emergency Physicians clinical policy.20 When referring to individual levels of sedation, emergency physicians should follow JCAHO nomenclature. A uniform terminology for PSA is essential to the conduct of meaningful discourse and research in this area of emergency medicine (Figure).

It is time to abandon the term “conscious sedation” for the confusing, unfortunate misnomer that it is. We now have better terminology.

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References 

  1. Murphy MF. Sedation. Ann Emerg Med. 1996;27:461–463
  2. American Society of Anesthesiologists . Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 1996;84:459–471
  3. Cote CJ. Conscious sedation: time for this oxymoron to go away. J Pediatr. 2001;139:15–17
  4. Joint Commission on Accreditation of Healthcare Organizations . 2001 Sedation and Anesthesia Care standards. Available at http://www.jacho.org/standards_frm.htmlFebruary 15, 2002; Accessed
  5. National Institutes of Health . Consensus conference: anesthesia and sedation in the dental office. JAMA. 1985;254:1073–1076
  6. American Academy of Pediatrics Committee on Drugs . Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics. 1985;76:317–321
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  13. Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation: an examination of the role of fasting and sedation depth. Acad Emerg Med. 2002;9:35–42
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  15. Drummond JC, Weiskopf RB. Monitoring depth of sedation. Anesthesiology. 2000;93:823–876
  16. Johansen JW, Sebel PS. Development and clinical application of electroencephalographic bispectrum monitoring. Anesthesiology. 2000;93:1336–1344
  17. Todd MM. EEGs, EEG processing, and the bispectral index. Anesthesiology. 1998;89:815–817
  18. Rampil IJ. A primer for EEG signal processing in anesthesia. Anesthesiology. 1998;89:980–1002
  19. Green SM, Krauss B. The semantics of ketamine. Ann Emerg Med. 2000;36:480–482
  20. American College of Emergency Physicians . Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 1998;31:663–677
  21. Sacchetti A, Schafermeyer R, Gerardi M, et al.  Pediatric analgesia and sedation. Ann Emerg Med. 1994;23:237–250

☆ Reprints not available from the authors.

PII: S0196-0644(02)82553-7

doi:10.1067/mem.2002.122770

Annals of Emergency Medicine
Volume 39, Issue 4 , Pages 433-435, April 2002

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