Colonoscopy Drugs and alternatives

Specialties Gastroenterology

Published

I was wondering if I could get some general input from GI nurses and or CRNAs who provide procedural conscious sedation and pain control for colonoscopy. Since I get this exam yearly after avoiding extensive cancer surgery, I try to get as many patient who need the exam to get one. An increasing number of people do not want the amnesia/memor loss associated withh Versed (Midazolam) and opt for the exam sedation-free. I am one of them. The question often comes up with patients who do not want sedation: can they just get pain control (fentanyl)? I understand the synergy between the midazolam and the narcotic and understand that the patient be quite are of the exam, but I agree with the patients who have had or heard about negative experiences with Versed (and the number is increasing daily). So, question #1:

For colonoscopy in a patient declinig sedation, do you see any reason why they could not just have fentanyl? This option would get a fair number of patients screened who do not want sedation. Recently, a patient told me that the GI lab at our hospital told her: either accept sedation or you won't get anything for pain. Seems a little one-sided to me, but I called to schedule a colonoscopy and was told the same thing. One GI nurse said it might be a way to convince everyone to accept sedation also. If true, this is bad, leading to many not getting the test.

question #2 (for CRNAs):

For colonoscopy where propofol is given, do you also administer a narcotic (ie fentanyl) or just use propofol? I'm asking because I have noiced an increase in patient dissatifaction with colonoscopy with propofol when fentanyl was not used; and this is important to me since many patients pay extra for it when I suggest propofol. Up until recently, every patient who had colonoscopy with anesthesa coverage (propofol) was satisfied; now I am running into a lot of patients who had propofol and would never consider another exam because of painful memories. And when I review their charts, they are always the ones who got propofol without any narcotic.

Thanks in advance for your inpt. I personally would never do the exam with sedation, but I have to keep my personal opinions out of my work, although it is refreshing to run across so many patients who will not accept Versed because of its well-documented, negative reputation (askapatient or versedbusters). Thanks.

Specializes in research.

It's great to get so much information and personal opinions from people who deal with this issue on a daily basis. So far, a few things are clear to me:

1. Colonoscopy can be done with or without sedation and that's a personal choice that the patient should be offered and discussed beforehand. I can see no reason that the exam can't be done (if requested) with fentanyl only. Some places still use meperidine? (yikes!)

2. There are a significant number of people who have had very bad experiences with Versed (myself and my primary-care doc included) and this can be avoided with proper informed consent (ie: Versed is given to relax and make you forget, not it's just to make you comfy) or by doing the exam without sedation, with painkiller only or with propofol. When it comes to colonoscopy sedation, one size does not seem to fit all.

3. Most patients who receive versed/fentanyl for colonoscopy are satisfied with the procedure. Patients are generally more satisfied with propofol, but it's expensive.

4. Colonoscopy is not a drive-thru procedure and it is not risk-free.

5. Patients who are cared for by nurses who consider alternatives to "what everyone gets" will have a better and safer procedure, even if it takes a little longer. Personally, I find it refreshing that people express so many different opinions and agree to disagree. These are the kinds of nurses whom I hope are present at my next exam.

I live in the Midwest and our patients insurance fees are being covered for both the Colonoscopy fees from the Doctor and the Anesthesia fees from the Anesthesia group. As far as it being a good use of our health care dollars, I truly believe it is because it's a much more tolerable procedure with Propofol and more importantly, it's much safer. I personally used Versed and Fentynal for my own colonoscopy, before we had made the switch to Propofol and the procedure was a piece of cake. But I felt miserable afterwards...nauseated and sedated for hours. I would rather pay a higher copay and know that I was getting Propofol....a safer alternative and a more tolerable one.

For hospital endoscopy insurance will pay for anesthesia. For AEC where colonoscopies are done they don't pay (except the NE). There is an interesting model that they use in California. If you want propofol they give you a card to an anesthesia group. Cost is around $400 cash only (I'm assuming they take credit cards). At the assigned time they show up and push the white stuff. Basically if you want it you have to pay for it.

David Carpenter, PA-C

At least Propofol doesn't cause people to have permanent memory loss, severe anxiety attacks and Post Trumatic Stress Disorder like Versed does!!! Check out VersedBusters blogspot and www.askapatient.com if you want to hear the horrible things people have experienced while being lied to and overdosed with this evil poison!!!!

Specializes in Telemetry & Obs.
At least Propofol doesn't cause people to have permanent memory loss, severe anxiety attacks and Post Trumatic Stress Disorder like Versed does!!! Check out VersedBusters blogspot and www.askapatient.com if you want to hear the horrible things people have experienced while being lied to and overdosed with this evil poison!!!!

serialmom, I can appreciate that you had a bad experience with versed, but I have to wonder what you hope to accomplish by coming to a site for nurses and mounting your campaign against it??

Specializes in Telemetry & Obs.
For hospital endoscopy insurance will pay for anesthesia. For AEC where colonoscopies are done they don't pay (except the NE). There is an interesting model that they use in California. If you want propofol they give you a card to an anesthesia group. Cost is around $400 cash only (I'm assuming they take credit cards). At the assigned time they show up and push the white stuff. Basically if you want it you have to pay for it.

David Carpenter, PA-C

David, hubby and I bought opted for propofol for our colonoscopies at $125 a pop. Best money we ever spent...unless you count those shoes I bought at the beach ;)

Specializes in Critical Care.
At least Propofol doesn't cause people to have permanent memory loss, severe anxiety attacks and Post Trumatic Stress Disorder like Versed does!!! Check out VersedBusters blogspot and www.askapatient.com if you want to hear the horrible things people have experienced while being lied to and overdosed with this evil poison!!!!

I'm starting to think this is parody.

Poe's Law, anybody?

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Never the less, midazolam does not cause permanent memory loss, severe anxiety attacks, or post traumatic stress. This is not documented anywhere outside of tinfoil websites.

Midazolam is actually one of many novel treatments for post traumatic stress, and we're all quite aware of how any of the benzodiazepines relieve anxiety.

If anything causes anxiety and post traumatic stress, it's likely the actual procedure (and the prep, which is equally as bad, in my opinion).

Specializes in Critical Care.
For hospital endoscopy insurance will pay for anesthesia. For AEC where colonoscopies are done they don't pay (except the NE). There is an interesting model that they use in California. If you want propofol they give you a card to an anesthesia group. Cost is around $400 cash only (I'm assuming they take credit cards). At the assigned time they show up and push the white stuff. Basically if you want it you have to pay for it.

David Carpenter, PA-C

Thanks for clarifying. I was going to point out that virtually all inpatient and outpatient scopes done at local hospitals in this area (suburban Houston) used MAC.

Personally, I wouldn't do it without versed. I mean it.

There are a lot of people who have a bad reaction to Versed. Not just tin foil hat people either. I have noted that people who do not get the amnesia claim that they were immobile, that their blood pressure shot up and that they were NOT relaxed. Their muscles were flaccid, but it was traumatizing to be rendered compliant and incapable of resisting or having their pain addressed. Even people who did get the amneisa have problems with Versed after effects. There are scientific studies which show an INCREASE in implicit memory with Versed even though it pretty much knocks our the EXPLICIT memory. For some people whose brains have (incomplete?) access to implicit memory this drug does cause long term problems. It is just blamed on the patients' life experiences, previous trauma, other drugs etc.

Specializes in Critical Care.
There are a lot of people who have a bad reaction to Versed.

All drugs have a lot of people who have a bad reaction to them. Even if a studied rate of x major side effect is only 0.5%, when you extrapolate for a drug that is probably used 100,000 times a week nationwide, that's still ~500 people each week.

Not just tin foil hat people either.

True. The tinfoilers are the ones who claim it is a dangerous poison that should be banned and that it causes permanent and extensive memory loss.

I have noted that people who do not get the amnesia claim that they were immobile, that their blood pressure shot up and that they were NOT relaxed. Their muscles were flaccid, but it was traumatizing to be rendered compliant and incapable of resisting or having their pain addressed.

Anecdotal.

Even people who did get the amneisa have problems with Versed after effects. There are scientific studies which show an INCREASE in implicit memory with Versed even though it pretty much knocks our the EXPLICIT memory.

Citations to said studies, please.

For some people whose brains have (incomplete?) access to implicit memory this drug does cause long term problems. It is just blamed on the patients' life experiences, previous trauma, other drugs etc.

A spurious claim at best. Citations needed.

I've worked endoscopy for 5-6 years in 3 different facilities in South Florida. First an in hospital endo suite that does both inpatient and outpatient. Later 2 different free standing outpatient endoscopy centers. In the beginning at the hospital we were using mostly moderate sedation with demerol & versed, sometimes propofol by anesthesiologist or CRNA. Demerol & versed worked ok, patients always woke up and said they didn't feel a thing, but often during the actual procedure they were moaning and writhing in pain. I felt like a few of the docs did not wait long enough for the drugs to kick in. Patients took longer to wake up so they were in recovery longer. A few of the docs started using propofol given by anesthesia and quickly realized the patients did better and the procedure was easier & quicker. The patients who had both liked the propofol much better. They were amazed how quickly they were awake. In the year I worked in the hospital endo suite we went from maybe 20% of cases with propofol to about 90%.

In the 2 outpatient centers I have worked in it's almost 100% propofol. Occasionally we would do a case with demerol/versed if the patient was self pay and didn't want to pay for anesthesia. I don't know much about insurance/medicare billing or reimbursement, but it must be covered or we would be getting a lof of complaints. This is in FL, not the Northeast.

Rarely we have a patient that says they don't want any sedation of any kind. When that happens I try to assess the reason they don't want it. Have they had a colonoscopy without sedation before? If so no problem, they know what they're getting into. If they've never had a colonoscopy and insist they don't want sedation then we try to get them to sign the consent anyway and tell them we will only give it if they ask for it during the procedure. Usually a few minutes into the procedure they wind up wanting the sedation. Only one time did I have a patient that absoulutely refused sedation and had never had a colonoscopy. The reason she didn't want it was because she had to be able to drive to pick up her kids from school, there was no one who could pick up the kids for her. She was extremely anxious about the procedure and I had a bad feeling it wasn't going to go well. Well the doc attempted the prodcedure anyway and she cried the whole time. Of course he couldn't get to the cecum because she was too tense and and in too much pain to continue. I tried to comfort her and let her hold my hand, I thought she was going to break it. It was afwful for her and awful to witness. So don't tell me a colonoscopy is not painful. Certianly some people can tolerate the procedure with out any meds, but I feel that is the exception not the rule. When it is my turn it will be propofol all the way.

Actually, I work at an Outpatient Endoscopy Center in the Midwest (Michigan) and our patient's insurance covers the Anesthesia cost for Propofol. (Medicare included.) Of course, the co-pay is higher to cover the fact that Anesthesia fees bring the cost of the whole procedure up, but...it's money very well spent. Our patient's tell us just that, time and time again. They can't believe how quick and painless the whole procedure is. I hope the wave of the future will be to allow Propofol to be used for all scopes, not just in certain parts of the country.

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