Delegation of sedation to non-anaesthetist has been a fact of life for a very long time; clearly, anaesthetists are not able to provide all sedation within a hospital setting, and safety in others’ hands is derived from the production of and adherence to strict protocols.  Intravenous sedation practice is widespread including dentistry and expressing a degree of concern is understandable.

The margin of safety is affected by drug(s) used, operator and administration mechanism and any safety standard must apply to the whole system of care; this is increasingly important with the expansion of office-based procedures, and movement into the primary care setting.

I was surprised to find no mention in the editorial of patient-controlled sedation.  Patient-controlled sedation in a variety of guises has been around for a long time.  A review of  published work in 1996 [1] referenced a first report from 1988 commenting that ‘patient controlled administration of sedation is safe and acceptable to patients, surgeons and anaesthetists alike, but its use remains limited’.  Patient controlled sedation using a number of drugs including propofol (from 1991) has been used for a wide range of procedures.

Patient controlled sedation has been advocated as a method for dealing with the narrow therapeutic window for moderate sedation> with patient controlled sedation, control throughout the procedure is moved from the sedationist to the patient and allows for  the normal variation that exists between patients in susceptibility to the drugs administered. Furthermore, patient-controlled sedation allows the patient choice in the time of sedative administration and the desired level of comfort which delivers patient satisfaction. However, the level of sedation change may be slow, with reliance upon the patient to be aware of this and thus behave accordingly.

Recent studies have considered patient controlled sedation alone [2] and in comparison with sedation administered by the anaesthestist [3] and nurse [4], the latest review concludes that a general applicable approach in any clinical setting has yet to be found [5]. The challenge remains to produce fast onset sedation without the risk of over sedation.

Individual patient characteristics and attitudes toward self-control are crucial for the success of patient controlled sedation.  Individual propofol consumption and associated plasma levels to obtain satisfactory levels of sedation are highly variable, and indeed are unique for each patient [6].

1. Dell R. A review of patient-controlled sedation.  European Journal of Anaesthesiology 1996; 13:547-52.

2. Tripathi, M, Nath SS, Chaudhary A, Singh PK, Pandey CM.  Patient controlled sedation during central neuraxial anesthesia.  Journal of Postgraduate Medicine 2009; 55: 108-12.

3. Wahlen BM, Kilian M, Schuster F, Muellenbach R, Roewer N, Kranke P.  Patient-controlled versus continuous anesthesiologist-controlled sedation using propofol during regional anesthesia in orthopedic procedures--a pilot study.  Expert Opinion on Pharmacotherapy 2008; 9: 2733-9.

4. Yun, MJ, Oh AY, Kim KO, Kim YH.  Patient-controlled sedation vs. anaesthetic nurse-controlled sedation for cataract surgery in elderly patients.  International Journal of Clinical Practice 2008; 62: 776-80.

5. Atkins JH, Mandel JE. Recent advances in patient-controlled sedation.  Current Opinion in Anaesthesiology 2008; 21: 759-65.

6.  Lake APJ. Every prescription is a clinical trial.  British Medical Journal 2004; 329: