Colonoscopy awake, pain-free, no amnesia or hangover

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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, unable to be awake/alert with propofol etc). A number of patients want to be awake and aware but pain-free during their colonoscopies, but are often told that this is impossible. As an insider, it's hard for me to accept "sedation" -versed/fentanyl) when you know that this combo is basically used to induce (maybe) amnesia of a painful event and may not be effective in some patients. Seeing many of these exams with the usual "sedation" is sobering. I was surprized when my gastro told me that getting a colonoscopy awake, aware, pain-free without amnesia or hangover would be no problem. The anesthesiologist administered a remifentanyl infusion and titrated the dose per my instructions. Pain-free, no drowsiness, no creepy amnesia no hangover and I was able to leave immediately after the test. Has anyone else heard of this option? The anesthesiologist told me that remifentanyl is perfect for someone who want to be awake but that it's sometimes discouraged since it's expensive. This makes no sense since having anesthesia involved doubles the cost of the colonoscopy anyway; I would never have this exam any other way. When I talk to others who had bad experiences with colonoscopy sedation, they can't believe how well mine went. Is remifentanyl a secret option?
  2. 18 Comments so far...

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    remifentanil has a couple really neat properties. it is ultra-short acting with a half life of approx. 4 minutes. additionally, unlike other synthetic opioids which are metabolized in the liver, remifentanil has an ester linkage which undergoes rapid hydrolysis by non-specific tissue and plasma esterases. this means that accumulation does not occur and its context-sensitive half-life remains at 4 minutes after a 4 hour infusion. it's metabolite only has 1/4600th the potency of the parent compound.
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    As the original poster I was surprized that nobody responded about the remifentanyl infusion for colonoscopy. Last week I had to repeat the earlier exam (biopsy was botched) and the GI doc was apologetic (no big deal, it happens). The repeat exam was easy, pain-free, no drowsiness, no driver required and no hangover or amnesia of any kind wth an anesthesiologist and the remifentanyl infusion. This was in marked contrast to the other patients that I saw after their versed/fentanyl/propofol experience.....these patients had an awful experience and were impaired and miserable after the colonoscopy.
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    I'm sure it's a cost thing. Most things in health care are, as we know, about money, not about what's best for the patient. I had an upper GI with versed, fentanyl, and benadryl (no propofol), and I remember nothing... I was happy as a clam when I woke up. If they didn't have pictures I would swear it never even happened. I had someone drive me home, but that wasn't a hardship. I wouldn't have it any other way, really. I would rather be completely unaware, but that's just me. What do you feel like on the remifentanyl? Do you remember everything? Is an anesthesiologist required for this alternate protocol? My procedure was done in a GI lab with a procedural sedation nurse, not an anesthesiologist. Maybe that is the reason this is not routinely done?
    Last edit by CarryThatWeight on May 7, '12 : Reason: Spelling
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    Remifentanyl is expensive and is not on a lot of formularies. Versed is most often used because most patients have no desire to remember their colonoscopy. It has nothing to do with making them forget their pain. Fentanyl is given to reduce or eliminate the pain of the procedure. Versed/Fentanyl/Demerol are the most common drugs used in colonoscopies because they are all in the scope of practice of RNs to give for moderate/conscious sedation. Versed and fentanyl are both relatively short acting and usually allow most patients to be discharged home within a short amount time. Propofol is usually, per the scientific literature, considered the most preferable drug by provider(s) for a variety of reasons and preferred by patients that do not want to remember the procedure.
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    Tammy: this was done at a major hospital (military) where I get my flight physicals as a reservist. the anesthesiologist cranked up the infusion rate as the GI doc told her that she was approaching a sharp curve..no drowsiness, no creepy amnesia and absolutely no pain whatsoever. the drug is totally gone by the time you get dressed..I had a check ride in a complex aircraft 4 hours later (with the anesthesia doc's blessing) and did fine.
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    I've read so much regarding sedation for colonoscopy and this is a first regarding Remifentanyl.
    I too wonder why this option is not mentioned or offered in the same regard as Propofol is.
    Expensive I'm sure, but to have such a positive outcome as you did I think it would be money well spent.
    Secret ? not sure. I'll bring this up w/ my pcp as she is hounding me to go for the usual Versed/Fent. combo.
    (lol, not in this lifetime) and say's I'll be just fine. I asked what she would have for her own... quick change of
    subject. Thanks for the post.
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    Quote from Jacksmack
    I've read so much regarding sedation for colonoscopy and this is a first regarding Remifentanyl.
    I too wonder why this option is not mentioned or offered in the same regard as Propofol is.
    Expensive I'm sure, but to have such a positive outcome as you did I think it would be money well spent.
    Secret ? not sure. I'll bring this up w/ my pcp as she is hounding me to go for the usual Versed/Fent. combo.
    (lol, not in this lifetime) and say's I'll be just fine. I asked what she would have for her own... quick change of
    subject. Thanks for the post.
    It depends on what you want out of your colonoscopy. Do you want to be awake? Do you want to remember the whole thing and watch the procedure or do you want to just get it over with and be out of there as quickly as possible while not remembering much? Remifentanil is an ultra short acting opioid that really isn't appropriate for a non-anesthesia provider to try to use it on its own for colonoscopies. Propofol gives the results most people are looking for (don't remember and very fast recoveries/discharge). Staying awake for colonoscopies is all well and good, but most patients aren't really up for it.

    The reason your pcp is probably opting for fentanyl/versed is because they use RNs for the sedation and not anesthesia providers so the options on sedation are going to be limited. Most insurance companies are not going to pay for Monitored Anesthesia Care/MAC i.e. they are not going to pay for anesthesia to do the sedation unless there is a physiological reason for it (CHF, OSA etc.).
    suanna likes this.
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    Thank you for your reply. As to what I want out of the procedure, let me put it this way.
    1. Not feeling sedated for hours after the procedure.
    2. Not taking the chance that the Versed/Fent. combo. will have an adverse reaction w/ me.
    3. Having a short recovery and clear mind in as short a period as possible.
    4. Not remembering is not as important as being 100% pain free.

    I do understand the cost would not be covered, but for my own sake I will gladly pay for it.
    I have two sisters that have had horrible results w/ the standard combo. much like we have all read about.
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    Quote from Jacksmack
    Thank you for your reply. As to what I want out of the procedure, let me put it this way.1. Not feeling sedated for hours after the procedure.2. Not taking the chance that the Versed/Fent. combo. will have an adverse reaction w/ me.3. Having a short recovery and clear mind in as short a period as possible.4. Not remembering is not as important as being 100% pain free.I do understand the cost would not be covered, but for my own sake I will gladly pay for it.I have two sisters that have had horrible results w/ the standard combo. much like we have all read about.
    You will probably just need to request for anesthesia to do your procedure not an RN then, and do it early enough that it can be arraigned that way. Most places don't have anesthesia do the sedation for GI procedures. Propofol or fospropofol would be a good choice. It will be hard to find someone or someplace that routinely uses remifentanil for colonoscopies.


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