The Changing Role of Monitored Anesthesia Care in the Ambulatory Setting

To the Editor: Two recent articles [1,2] suggest that anesthesiologists are at risk of abandoning a fundamental goal, to prevent human suffering. Markey et al. [1] compared two formulations of hyperbaric lidocaine for spinal anesthesia without commenting on the fact that nearly half of the patients in the study required supplemental injections of local anesthetics. A better conclusion from this series of cases would be that epinephrine should be added to or bupivacaine substituted for the spinal anesthesia (or a catheter epidural should perhaps be used in the first place). The same plan of withholding treatment until patients complain underlies "titration" of sedatives and analgesics as advocated by Sa Rego et al. [2] in their review article on monitored anesthesia care. Artful practitioners can almost eliminate patients' pain and recall of their suffering during monitored anesthesia care or with a failing regional anesthetic, but not completely, at least not if titration is used. Even if the result is judged satisfactory, it is usually not the best we could do for the patient. Shielding patients from all pain seems a more worthy and humanitarian aim than regulating the dose of pain to acceptable levels compatible with institutional goals for early discharge and lower costs. Frank L. Murphy, MD Department of Anesthesia; Hospital of the University of Pennsylvania; Philadelphia, PA 19104