Colonoscopy awake, pain-free, no amnesia or hangover - page 2

by inforesource

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I was reviewing the comments about the commonly used sedation meds for colonoscopy and was surprized to see how many patients are not satisfied with the various protocols (pain and unwanted amnesia, hangover from Versed/fentanyl,... Read More


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    Thank you again.
    Last edit by Jacksmack on May 17, '12 : Reason: mistake
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    Jack: I agree with you about not consenting to the usual Versed/fentanyl combo; it may be common but many patients experience a painful procedure and report memory loss for extended periods (hardly procedural amnesia). My neighbor got a colonoscopy because I kept bugging her to get one (she has a first-degree relative with colon cancer). I was her driver and she had a terrible colonoscopy with versed/fentanyl; I could hear her crying during the exam and she was a wreck when I drove her home. Many weeks later she still has significant memory loss (birthdays, PIN numbers) and since she's a college teacher, I doubt that she's making this up. After this episode and reading hundreds of similar examples on the net I decided to have an anesthesiologist do my case. She told me if I wanted to "sleep" thru the colonoscopy that propofol as the sole agent would be best. I wanted to be awake and pain-free so remifentanyl infusion was perfect. My wife just had a colonoscopy and wanted to remain awake; her endo center CRNA initially told her that remifentanyl "wasn't done" but when we scheduled the procedure with the anesthesiologist, no problem..Her insurance pays the same for a CRNA as for an anesthesiolgist (as does not insurance)..personally I don't care what it costs, if we need anesthesia, I'll pay for the anesthesiologist every time even if it's out of pocket (it won;t be, you just have to insist). Good luck.
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    Quote from inforesource
    Jack: I agree with you about not consenting to the usual Versed/fentanyl combo; it may be common but many patients experience a painful procedure and report memory loss for extended periods (hardly procedural amnesia). My neighbor got a colonoscopy because I kept bugging her to get one (she has a first-degree relative with colon cancer). I was her driver and she had a terrible colonoscopy with versed/fentanyl; I could hear her crying during the exam and she was a wreck when I drove her home. Many weeks later she still has significant memory loss (birthdays, PIN numbers) and since she's a college teacher, I doubt that she's making this up. After this episode and reading hundreds of similar examples on the net I decided to have an anesthesiologist do my case. She told me if I wanted to "sleep" thru the colonoscopy that propofol as the sole agent would be best. I wanted to be awake and pain-free so remifentanyl infusion was perfect. My wife just had a colonoscopy and wanted to remain awake; her endo center CRNA initially told her that remifentanyl "wasn't done" but when we scheduled the procedure with the anesthesiologist, no problem..Her insurance pays the same for a CRNA as for an anesthesiolgist (as does not insurance)..personally I don't care what it costs, if we need anesthesia, I'll pay for the anesthesiologist every time even if it's out of pocket (it won;t be, you just have to insist). Good luck.
    I just love these CRNA bashing posts of yours. Your posts show that you have an abundance of ignorance about anesthetic agents and anesthesia providers in general. Instead stating what you think is or isn't the best agents for colonoscopies why not use EBP and do a lit review. Anesthesia isn't a one size fits all. A good provider adjust the meds and dosaging for the individual patients based on desired outcomes.
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    Quote from wtbcrna
    I just love these CRNA bashing posts of yours. Your posts show that you have an abundance of ignorance about anesthetic agents and anesthesia providers in general. Instead stating what you think is or isn't the best agents for colonoscopies why not use EBP and do a lit review. Anesthesia isn't a one size fits all. A good provider adjust the meds and dosaging for the individual patients based on desired outcomes.
    Question for you: Is there anything that would preclude a CRNA from administering remifentanyl? Given it's short half life and non-accumulative properties I would think it would be a fairly easy and safe drug to manage. Seems to me either could do it just fine.

    If I have a criticism, it's the apparent overwhelming unwillingness of the medical profession to really listen to what their patients want. In my experience they push what they are comfortable with and used to doing, and will go to great extents to cajole, coerce, or otherwise browbeat the patient into going along, with little or no respect for the patient's wishes.

    Don't the patient's desired outcomes count? So the particular drug isn't in the formulary - if the patient is willing to pay for it, what's the problem? It's not like a colonoscopy is an emergency procedure - there's time to make the necessary arrangements if need be.
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    Quote from sharkdiver
    Question for you: Is there anything that would preclude a CRNA from administering remifentanyl? Given it's short half life and non-accumulative properties I would think it would be a fairly easy and safe drug to manage. Seems to me either could do it just fine.If I have a criticism, it's the apparent overwhelming unwillingness of the medical profession to really listen to what their patients want. In my experience they push what they are comfortable with and used to doing, and will go to great extents to cajole, coerce, or otherwise browbeat the patient into going along, with little or no respect for the patient's wishes. Don't the patient's desired outcomes count? So the particular drug isn't in the formulary - if the patient is willing to pay for it, what's the problem? It's not like a colonoscopy is an emergency procedure - there's time to make the necessary arrangements if need be.
    1. If a drug is not on the hospital formulary that means it is not available in the hospital for us to give. It doesn't matter if you are willing to pay for it or not. That is different than if a certain department doesn't stock a certain drug.2. CRNAs can and do the same things anesthesiologists do as far as anesthesia goes. The only restrictions on CRNA practices are facility only, and have no basis other than to ensure high salaries for anesthesiologists.3. I am willing to try different methods of anesthesia with my patients, but some providers (anesthesia or otherwise) aren't comfortable using different drugs. Patients rarely understand the full implications of what they are asking for when they request a certain drug or technique. Some providers are willing and able to explain the benefits/risks of those choices and others are not. 4. Most places that do colonoscopies on a regular basis are basically factories for lack of better description. The procedure doesn't pay a lot, but you can do several in a day if you and your staff are very efficient. When that happens providers tend to want to do exactly the samething every time, and if you want something different telling them right before you are about to go back for scope is not the time. 5. When you want anesthesia to do your sedation you should tell your referring provider upfront, and make those plans accordingly. 6. I have looked at some of the Pubmed studies on using remifentanil, and those studies do not support its routine use for sedation/analgesia for GI procedures.
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    wtb:my comments were to jack who had a reasonable question...I don't "bash" anyone, I'm just sharing an experience that may be helpful to another individual. Your comment: "I just love these CRNA bashing posts of yours. Your posts show that you have an abundance of ignorance about anesthetic agents and anesthesia providers in general" is quite immature; I could respond by stating that I've forgotten more about anthesthesia that you will ever know, but I really don't have to..your comments make that perfectly clear...
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    Quote from inforesource
    wtb:my comments were to jack who had a reasonable question...I don't "bash" anyone, I'm just sharing an experience that may be helpful to another individual. Your comment: "I just love these CRNA bashing posts of yours. Your posts show that you have an abundance of ignorance about anesthetic agents and anesthesia providers in general" is quite immature; I could respond by stating that I've forgotten more about anthesthesia that you will ever know, but I really don't have to..your comments make that perfectly clear...
    Yep, you would never belittle CRNAs or their education. Your responses show how little you care about CRNAs and your knowledge of anesthesia. I would really like to hear all about your anesthetic training that gives you such insight.

    "As an Air Force O-6 (currently active duty as a PIC C141), I do not appreciate that a nurse (CRNA) may or may not be designated to provide my anesthesia care......anesthesia is the practice of medicine not nursing. CRNA are fine under the direction of anesthesiologists but totally unsafe as "solo" practitioners............yes, I was an advance practice nurse...so. please. nurses (CRNA) pleae spare me the "wannabee anesthesiologist drivel....you are not as safe as anesthesiologists"...suce substitution of midleval nurses as "anesthesia providers" is an insult to the USAF......................."
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    Quote from inforesource
    wtb:my comments were to jack who had a reasonable question...I don't "bash" anyone, I'm just sharing an experience that may be helpful to another individual. Your comment: "I just love these CRNA bashing posts of yours. Your posts show that you have an abundance of ignorance about anesthetic agents and anesthesia providers in general" is quite immature; I could respond by stating that I've forgotten more about anesthesia that you will ever know, but I really don't have to..your comments make that perfectly clear...
    Since this is an anonymous site you can not tell what one's qualifications truly are or are not.....so to make that kind of blanket statement can be considered rude and is without merit. Telling someone they are ignorant in their speciality and immature is unnecessary.

    A reminder......You can disagree without being disagreeable.
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    This is one of many reviews, interesting reading.

    Remifentanil compared with midazolam and pethidine sedation during colonoscopy: a prospective, randomized study.

    Authors
    Manolaraki MM, Theodoropoulou A, Stroumpos C, et al.
    Institution
    Department of Anesthesiology, Benizelion General Hospital, Heraklion-Crete, Greece.
    Source
    Dig Dis Sci 2008 Jan; 53(1) :34-40. Abstract
    The objective of our study was to compare the safety and efficacy of remifentanil during colonoscopy with those of the standard combination of midazolam and pethidine.One-hundred and sixteen consecutive patients scheduled for colonoscopy were randomly assigned to groups A or B. Patients in group A (n = 56) received intravenous (IV) midazolam and pethidine. Patients in group B (n = 60) received IV remifentanil.Recovery was faster in group B (0 min) than in group A (56 +/- 11.3 min) (P < 0.001). There was a marked difference between groups B and A with regard to the time of hospital discharge-28.7 +/- 4.3 and 148.9 +/- 34 min, respectively (P < 0.001). Patients in group A rated the procedure as comfortable, as also did those in group B. A combination of midazolam and pethidine had a greater affect on patients' cardiorespiratory characteristics.Remifentanil during colonoscopy provides sufficient pain relief with better hemodynamic stability, less respiratory depression, and significantly faster recovery and hospital discharge than moderate sedation with midazolam and pethidine.


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