Re: "Dueling Over Propofol" (October, page 32). Your article makes the assumption that propofol is being used for sedation, but I've always classified and documented the administration of propofol in GI units as a general anesthetic.

If you were to place an EEG monitor (brain wave) or BIS (bispectal index) on these patients, the readings would be consistent with that recorded in general anesthesia (less than 60). Anesthesia texts define general anesthesia as "a state of total unconsciousness resulting from anesthetic drugs." These patients meet those criteria. Conscious sedation implies that a patient can respond. Patients under propofol can't respond in any meaningful way.

The amount of propofol used on GI patients is equal to an induction dose in the OR (I'll typically use between 200mg and 400mg total for a 15-minute case), making propofol anesthesia in GI labs no different from the anesthesia that we use for breast biopsies, hernia repairs, peripheral vein ablations, cardioversions and closed reduction of fractures. We even use this same type of anesthesia for certain craniotomies and for pericardial windows. If removing a label from a drug lets non-anesthesia personnel come into ORs to do the same type of anesthesia as in a GI lab, our medical system will be in crisis.

Paul Mitchell, DO
Chairman of Anesthesiology and Pain Medicine
Hilton Head Regional Medical Center
Hilton Head Island, S.C.
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The biggest reason endoscopy patients are denied propofol or receive it from non-anesthesia providers is regulation. Your magazine is usually quick to point out the obvious benefits of free-market economies, allowing competition and market forces to bring quality and cost containment to health care. Yet the obvious solution to the debate, one that brings anesthesia providers with the necessary skills and experience to the endoscopy suite, is highly regulated.

It's mind boggling that regulation that inhibits rather than promotes the practice of CRNAs is the norm in 2005 - despite millions of cases and no scientific evidence of difference in outcomes. Break down the self-serving regulation based on turf, not patient safety, and watch market forces at work.

John Polechetti, CRNA, MS
Lockport, N.Y.
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Who Implants the Pain Pump?
Re: "Inside Our Pain Pump Success" (October, page 48). Who implants the pump, the surgeon or the anesthesiologist? The surgeon has done it at my institution, but the article's references to stimulating versus nonstimulating catheters made me think it intended the anesthesiologist. Also, who's responsible for follow-up questions - the surgeon, the anesthesiologist or nurses?

Debra Dunn, RN, MBA, CNOR
Nurse Manager, OR
St. Joseph's Wayne Hospital
Wayne, NJ
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Author Brian M. Ilfield, MD, MS, replies: The pump is external; it's not implantable. The anesthesiologist places any perineural catheter. The surgeon places any wound catheter. The anesthesiologist is responsible for any catheter he places, and same with the surgeon. For many of our patients with a perineural catheter, a nurse takes the initial calls and turfs them to the anesthesiologist if need be.