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Anesthesia

Sleep talking While under Twilight?

12/19/2005

Question:

I am soon to undergo surgery and understand I will be under twilight anesthesia for about 30 minutes. First, is this the same as MAC? Also, Do patients ever "talk in their sleep" while under this and/or say/do things that could be embarassing to them after coming out of this state of sedation? The amnesia that occurs from this is a bit disconcerting .

Answer:

Thanks for your questions about sedation and its effects. There are several terms used to describe the anesthetic "state" in which the patient is sedated but not under general anesthesia. Among the most commonly used terms are the ones you've mentioned.

"MAC" or Monitored Anesthesia Care is "a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure." A rather vague definition. In fact, MAC is often used to describe a state of "moderate" or "deep" sedation (more on that later). "Twilight" anesthesia has no official definition that I am aware of but is often used to describe the same type of sedative or anesthetic state that "falls short" of general anesthesia.

The official terms and definitions, developed by the American Society of Anesthesiologists, and adopted by other national organizations, involves a "continuum" of sedation. The continuum starts with "minimal" sedation, and moves through to moderate and deep sedation, and, finally, general anesthesia. Along the continuum, with increasing doses of sedative or anesthetic drugs, a patient becomes less responsive, but also gradually loses the ability to keep the airway open, breathes less well, and experiences more depression of cardiovascular function.

Moderate sedation is also known as "conscious sedation" - a bit of a misnomer really. There is a common misconception that sedation acts like a "truth serum" and that patients are compelled whilst in this twilight zone to divulge secret and embarrassing personal details. If only it were that exciting! In more than 15 years of anesthetic practice I have yet to take care of a patient who has revealed to me any juicy secrets!

It is true however that sedated patients sometimes become a bit disinhibited, much as an inebriated person under the influence of alcohol might behave. This could be an embarrassing experience, however the amnesia effect means that you are unlikely to remember what you said. Whether this is a good or bad thing depends I suppose on your perspective. The goal of the anesthetic state is to allow the surgical procedure to be accomplished quickly, safely and effectively. A patient who is behaving in a disinhibited, drunken state will very quickly be given more anesthesia (or, sometimes, less) in order to create better conditions for the surgical procedure to take place.

Unfortunately, the treatment of medical and surgical conditions sometimes involves the inevitable loss of one's physical dignity for a period of time. Hopefully the highest ethical standards surround the care we deliver. Let's recall that doctors and other healthcare providers are meant to observe the highest levels of respect for a patient's privacy. We all become patients at one time or another in our lives, and hopefully we learn to accept the occasional embarrassment or loss of physical dignity with humor, in return for the benefit of excellent and compassionate care.

On a final note, I always encourage our readers to engage their anesthesiologist (and surgeon) in a discussion of risks, benefits and alternatives of anesthesia care. It is possible that the procedure you are about to undergo can be accomplished with minimal or even no sedation, using local or regional anesthesia techniques. This approach will help you to avoid the problems that you have raised in your question.

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Response by:

Gareth S Kantor, MD Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University