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Thursday, January 3, 2008

What’s the Best Anesthestic for Colonoscopy?

Anesthesia for Colonoscopy

Note: The Colonoscopy Chronicles attempts to provide information that is as accurate as possible. It is not intended as medical advice. You should consult your personal physician regarding your own medical condition.


Most patients are, predictably, worried about whether the colonoscopy will be painful. Virtually every colonoscopy done these days is performed under anesthesia to make the procedure comfortable. There are several types of anesthesia available. It is advisable to have a frank discussion with the physician performing the colonoscopy to be sure you understand this important aspect of the procedure, and to make sure you have realistic expectations of the anesthesia. For the sake of simplicity, I’ll break them down into two main categories:
1) Conscious sedation
2) Monitored Anesthesia Care(MAC)

Conscious Sedation

The vast majority of anesthesia used for colonoscopy is conscious sedation. This is generally administered by the physician doing the colonoscopy. Usually, it takes the form of two different medications, given into an intravenous line that has been inserted into the patient’s vein prior to the procedure. The two medications normally given are 1)a narcotic analgesic(painkiller)-usually Demerol(meperidine) or Sublimaze(fentanyl) 2)a benzodiazepine(sedative/hypnotic)-usually Versed(midazolam) or Valium(diazepam).

The physician generally gives a small starting dose, then small subsequent doses until the patient is sufficiently sedated. Then the physician will start the colonoscopy, giving repeated doses of the medicine as necessary during the procedure. The vast majority of physicians who perform colonoscopy are experienced administering conscious sedation, and know what it takes to keep the patient comfortable and safe during the procedure. These medications can provide extremely effective, safe sedation for colonoscopy, but must be administered by a physician who is well trained in their use. The most common serious adverse effect is respiratory depression(decreased breathing). Changes in blood pressure, heart rate, and heart rhythm can occur as well. In most centers, patients are closely monitored before, during, and after the anesthesia-using monitors that check the pulse rate, heart rhythm, oxygen level, and blood pressure. Reversal agents-drugs that can reverse the effect of the anesthetic drug-exist for meperidine, fentanyl, and versed. These are generally only given if the patient experiences a significant, persistent decrease in breathing or blood pressure that is felt to be anesthetic related. This is relatively rare. Most physicians advise that, following conscious sedation, the patient be accompanied home, and they may not drive until the following day. Your physician should give you specific instructions regarding restrictions of your activity following the anesthetic.

There are several issues regarding conscious sedation that bear discussing:

· Because this form of anesthesia is not deep anesthesia or general anesthesia, it is possible that the patient may have some discomfort during the procedure-usually quite minor, although in rare cases it can be severe. I try to be quite honest with my patients: There is about a 95-99% chance they will be totally comfortable throughout the procedure-but I cannot give them an ironclad guarantee. If they expect and demand a virtually 100% guarantee then I suggest they consider MAC anesthesia(discussed below).
· Versed, which is commonly given, can cause transient amnesia. The main practical consequence of this is that patients often forget the conversation with the physician in the recovery area after the procedure. It is a good idea to ask ahead of time that the physician write down the findings, and also discuss them with the person accompanying them to the procedure.
· It is sometimes difficult to achieve adequate sedation in certain patients-including those who are unusually anxious, or are on certain medications, such as narcotic painkillers, medication for anxiety, sleeping pills, or those who have a history of being difficult to sedate for other procedures in the past. Again, these are situations where MAC anesthesia may be considered.

Monitored Anesthesia Care(MAC)

MAC anesthesia is a somewhat generic term, but basically describes anesthesia services that are under the supervision of an anesthesiologist or registered nurse anesthetist. As you recall, I mentioned that in conscious sedation, the physician performing the procedure also supervises the sedation. In contrast, with MAC anesthesia, there is a separate physician or nurse whose sole job is to administer and monitor the anesthesia. The anesthesiologist may choose to use the same drugs that I mentioned in the section on conscious sedation. In addition, they have a wide variety of other medications available which they are trained to give. One of the most commonly used medications used in MAC anesthesia for colonoscopy is called Diprivan(propofol). Propofol is well suited to colonoscopy due to its rapid onset of action, and short duration. It can be given alone, or in combination with a painkiller and/or sedative-depending on the preference of the anesthesiologist. Like the medications mentioned above, propofol can decrease the breathing, and patients receiving it must be carefully monitored by the anesthesia specialist during the procedure. Depending on the amount given, patients can go into deep sedation or even general anesthesia from propofol. MAC anesthesia has the advantage of being more effective for the “hard-to-sedate” patients, and also allows the physician performing the colonoscopy to focus on the procedure and not the anesthesia.

There is currently some controversy about who is qualified to use propofol as an anesthetic agent. Some feel that only those trained specifically in anesthesia-such as anesthesiologist and registered nurse anesthetists-should give propofol. Others feel that Gastroenterologists and other physicians who perform colonoscopy can-with proper training-safely give the medication.
I, personally, do not administer propofol, but commonly have an anesthesiologist or nurse anesthetist available to administer it to my patients.

A few things to mention about MAC anesthesia.

· Because an anesthesia specialist will be used, there will be an additional fee involved. Your insurance company may or may not cover this fee-depending on your particular policy, and the details of your case. You may want to clarify this in advance if MAC anesthesia will be used.
· Anesthesia specialists may not be available at the particular center where your colonoscopy will be performed. If MAC anesthesia is something your physician deems necessary, he or she may have to schedule it at a particular center or hospital where an anesthesia specialist is available.

Conclusion

Colonoscopy is safer, and more comfortable than ever. Physicians performing the procedure generally take great care to make it a pleasant and safe experience for patients. Don’t let fear of being uncomfortable stop you from having this important test. Be a good consumer, and make sure to discuss any questions or concerns you have with your physician prior to the colonoscopy.

14 comments:

sage6482 said...

Do doctors offer general anesthesia to patients for colonoscopy?

Joseph said...

I am to have MAC next week. I am just afraid of accidental colon tear. How often does this happen?

Doofus said...

My first colonoscopy at age 50 used conscious sedation. I had absolutely no memory of the procedure which for me was a big disappointment as I wanted to know what was going on. My spouse told me I was a bit "goofy" post-procedure. I was taken home, slept the day away, and didn't even eat until much later.

My second colonoscopy at age 59 used MAC (propofol). Of course, I missed the whole show again but awoke refreshed and alert, enough so that I had an extensive conversation with my gastroenterologist about the polyps removed during the procedure. I left the building on my own two feet (but did NOT drive that day), had a nice lunch at a nearby restaurant, and carried on normal activities the remainder of the day.

This is not to endorse one course of action over another but rather just to relate my experience. Your mileage will vary.

Jeremy Smith said...

I have had a colonoscopy on two occassions ten years apart with no drugs whatsoever. If you can just wrap your mind around letting it happen, it is over so fast that IMHO, sedation is not required. Pain is non-existant sans for a moment of cramping, sometimes, when the scope turns the corners of the transverse colon. Being totally lucid throughout the procedure and not needing a driver to return home is well worth it to me. I hate pain and discomfort as much as the next person, but this is so small a discomfort that it astounds me that sedation is SOP.

madcapzany said...

Each time I have a colonoscopy the pain and my own screams wake me up. It is awful. I still remember each of these incidents. Do not listen to anyone who gives blanket assurances that it will not hurt!

Jennifer said...

I just had my first colonoscopy at age 40 (due to a family history of colon cancer, I had to start early). I was expecting the Versed/fentanyl combo since my husband got that about six months ago. Instead, I got propofol from a nurse anesthetist and was out cold for the entire procedure, but woke up refreshed and ready for a big breakfast at IHOP. My post operative report said my colon was normal, and to return in 5 years - then it said "must have propofol at next colonoscopy as well." ??? Why would I "have" to have propofol? Is it because I have interstitial cystitis and being a female it's hard for the doc to avoid poking my inflamed bladder during the test? Is it because I'm asthmatic? Is it because I take hydrocodone for pain fairly often? Or could it be because Versed, while relaxing, doesn't usually cause amnesia or sleep for me - I've gotten it as premedication for other surgeries and will usually carry on conversations with the OR staff and can remember everything that happened in the OR until the propofol hit my brain to induce general anesthesia for those surgeries. Am just interested to know why it says I *must* have propofol…..

Tiffany Carr said...

I just went through my first endoscopy/colonoscopy. I have to tell you I felt nothing during or after. The next day I have a slight sore throat from the endoscopy, they had to remove polyps and take biopsies. Small amount of gas and cramping but I had that before anyways. I was given propofol and didnt even realize I was asleep, then woke up in the recovery room.. More alert and I guess "refreshed" is the word. I though I would feel groggy and unbalanced, even sick. I was hungry after and went to Burger King and ate an Angry whopper, which tasted really good. I was impressed with the procedure and my doctor and the anesthesiologist and nurses were great..

SUGAR AIN'T SWEET said...

I had versed and fentanyl for mine. I had a lot of pain during the procedure and was told to be quiet, and that I would not remember anything later WRONG.

Worse, I had a terrible attack of PTSD in the recovery room. I thought I was being kept prisoner against my will, and sat in the recovery room bed trying to figure out how to use common desk objects in order to kill the nurse. I was sure she was the one holding me prisoner. What scared me was that my body didn't seem to work very well and I wasn't sure I could depend on it to work when I needed it to.

As time when by, the paranoid faded, but it was a hideously frightening thing while in progress. If I ever have to have a c-scope again, it will be in writing that they will knock me out ENTIRELY.

Gail Stapleton said...

Just had my second colonoscopy...tons better than my first one about 20 years ago...I was like 23 when I had my first one then...I was conscious so they only used light meds and local anesthetic at the time because it was so incredibly painful...and they had just started. It sucked because they couldn't do more for me...I was a noodle but I felt the horrible pain. So this time around I insisted to be unconscious and knocked out or no deal. They got me.. they understood. They said things have changed in meds but I only cared that I was to be knocked out. So I was given proprifol and some other stuff by a very nice and great anesthesiologist. ..I was out in a minute after he gave me stuff thru my iv. I hated being woken up purposely after because I have alot of sleep issues and it felt so good to get some deep sleep. Seemed to go quick....I was not hungry at all after or rest of day really. But am happy this time around was much much better. Friendly staff...they were great. One small polyp removed to be tested for cancer...wont know results for a week or two. Im a little scared but im aure its benign. Im 41. Single mom. I have diverticulitis/losis. None of this in my family...or heritage that i know of...just me.

James Douglas said...

Have you read up on intravenous sedation. There are a lot of mixed feelings about it, but it would be worth your time to research. There are pros and cons of course.

James | intravenous sedation

viking1960 said...

I just had my first with the fentanyl versed combo. I felt it went very well. At worst I felt mild discomfort and was aware enough to follow the procedure. I dozed off in the recovery area for 15-20 minutes. Woke up and my wife took me home. No issues.

William Wiley said...

Does anyone know which anesthetic is best to use when the person takes anti-seizure drugs? I take Keppra, Tegretol and Lamictal and want to be sure my anesthesia is safe.

Ann said...

The best advice I can give to anyone is find out IN ADVANCE whether your insurance carrier will cover the fee of the anesthesiologist. I have Connecticare and I was allowed to have a "free colonoscopy" in January since I am over 50 years old. What they didn't tell me is that I am liable for the anesthesiologist's bill of $1,050. (I was out cold for the procedure.)

I am madder than hell now since I could have waited until Medicare kicks in in two years' time and paid about $160 in total for the entire colonoscopy, which is what my husband paid last year.

Placerville Wing said...

I'm a 64 year old male and have just completed my third colonoscopy with conscious sedation. While my first two were relatively uneventful (just a bit of pain during the second one), my most recent one was a horror show. After being sedated, I woke up in extreme pain. I was fully aware that someone was holding on to my arms and legs yelling, "Don't move" at me over and over. The pain was so bad that I remember begging them to stop to which they kept replying, "It's almost over." After the procedure, it seemed that I was moved to the recovery room and out of the hospital in record time. I don't remember talking to the Doctor. From reading the accounts of others, I'm starting to think that the pain experienced by the patient is in direct relation to the skill of the physician. I can't state this for certain but, I won't be using this Doctor again.