Colonoscopy Drugs and alternatives

Specialties Gastroenterology

Published

  • by darne20
    Specializes in research.

You are reading page 3 of Colonoscopy Drugs and alternatives

darne20

41 Posts

Specializes in research.

I appreciate all of these replies; I had to read them again before I schduled my own exam for friday. This will be at a new freestanding endo facility, when I went in to pick up the rx for the prep, I was surprized that an RN did the informed consent and was frank about the sedation options. She said that most patients do well with versed/fentanyl, but some find it inadequate and the amnesia "creepy". When she noticed that I worked at the local hospital as a clinical pharmacist, she said "you want propofol", and they have a CRNA to give it (no extra charge, a professional courtesy-pretty nice). When I politely declined this, the CRNA came out and told me that sedation-free was fine, but that this might result in an incomplete exam. Her advice was to bring a driver, plan to do the exam without sedation, but let them start an IV and have propofol and fentanyl ready if you ask for it. That's hard to argue with. I did ask the CRNA about the bad press that Versed is getting lately, she mentioned that the endo center was trying to switch to propofol because they had a significant number of patients complain about Versed, and a lot of complaints came from professional people who aren't prone to exaggeration.

darne20

41 Posts

Specializes in research.

Thanks for all of the replies to this thread. I just got back from my colonoscopy without sedation, the endo center had no problem with this request and mentioned that an increasing number of patients are requesting this option although they do not advertise it. The endo center that I went to has a CRNA on staff and tries to do most exams with propofol; they explained that although most motivated patients can do the exam without sedation, they encourage it for several reasons: it makes the exam easier to do and more comfortable which means that a patient will be more likely to return for a repeat exam if needed..the endo doc mentioned that she prefered sedation for public relations; if one patient has a really painful exam and remembers it, then they will tell others and a lot of people won't get screened. But she said that if someone asks for an unsedated exam, they will do it. They didn't have a problem when I declined the propofol, but the CRNA asked if I had a problem with fentanyl if needed (I didn't object to pain control). She was super nice and said that analgesics are a good idea because without pain control, the doc will subconsciously rush the exam if she know that the patient is in pain. Made sense to me. What I really liked is how honest she was, she told me that prn means 50-75mcg now and more as needed. No side-effects at all, the exam took a long time, several polyps and biopsies (painless); the CRNA held my hand for the entire time and everyone could not have been nicer. Colonoscopy with analgesic only is a great alternative, for me anyway.

serialmom12

17 Posts

I'm so glad that everything turned out ok. Also I'm glad that someone listened to me and found out that this is NOT a painful procedure and that sedation is totally unnecessary and a total waste of time and money. Pain meds are a good idea, I did both of my tests with 50mgs of demerol. Polyp removal was painless also. It was interesting to watch the test and talk to the Dr and nurses during the procedure. I learned alot.

Kudos to you!!!!!!!

creo

26 Posts

We use Versed and Fentanyl. I have not seen too many patients with major adverse reactions to Versed. Some of these patients do not have amnesia and in a few cases they had a paradoxical reaction to Versed (extreme agitation). I think that a colonoscopy could be done without sedation and even without analgesia only if the endoscopist has an excellent technique.

darne20

41 Posts

Specializes in research.

Creo-I think that you are 100% right, if the endoscopist is experienced and willing to take a little extra time, drugs are probably unecessary. My last one was done with a little fentanyl only and afterwards they told me that I didn't really need it. I have to have a repeat exam for another biopsy and the endo doc told me that she's perfectly o.k. with doing it with nothing; but she has done literally thousands of these exams and doesn't do them assembly line style..they take a while and this makes a difference. It's nice not to have to find a driver for the exam and we get to skip the IV, pulse-ox, EKG, oxygen...not that it matters. And my endo doc also says that she only takes a little credit for a comfortable exam; anatomy plays a big role. thanks for the info..

neveragain

40 Posts

Its very telling to see posts like hypocaffeinemia! To have patients concerns dismissed as "anecdotal" and

Specializes in Critical Care.

Ah yes, once again neveragain resurfaces to post on a thread involving midazolam.

You clearly have missed the point of my posts and have elected to deconstruct straw men instead.

Advocacy, for the record, is a two way street. Giving people false information about therapies via scare tactics and unsupported anecdotes (the plural of anecdote is not data) is what I and most others would consider being a bad advocate.

By the way, I'm still waiting on citations to claims you made earlier in this thread.

neveragain

40 Posts

Yes, I surface on Midazolam discussions. I am a patient advocate with personal experience with Midazolam. It is not false to tell patients that Midazolam causes AMNESIA! It isn't false to tell the patient that under Midazolam they will be unable to stop the procedure whether or not they get amnesia! It isn't false to say that this drug is given so that you will be obedient. If a patient wishes to remain "awake and alert" it is unethical to give them Midazolam. I guess I would be one of those "tin hat" people who feel that because of the abuse associated with Midazolam that it should be banned. While I agree that some people prefer not to have any memory of a medical event, I strongly feel that this should be up to the patient with FULL disclosure. (actually this is the law, not just a strong feeling) Respect is also a two way street. I respect the fact that medical professionals have superior knowledge of general patient care. This does not apply to ALL patients ALL the time. What I do not understand is the vitriol expressed towards those patients who desire or need something different than "I know what's best and you are going to get whatever I want" type care. It is anecdotal to say that Versed is a good drug. Good for whom? Specific patients with phobias? Prove that Midazolam is good. Prove that patients are not suffering from this drug. By your own statement

Specializes in Critical Care.

I am skeptical your citations exist. If you'd like me to be a better patient advocate, you'd kindly provide them.

Burden of proof, friend. Burden of proof.

Speaking of burden of proof, you asked me to provide evidence "midazolam is good". By, "good", I take it you are referring to its efficacy. I believe this will be a good jumping off place for you to review:

1: Maslekar S, Gardiner A, Hughes M, Culbert B, Duthie GS. Randomized clinical

trial of Entonox versus midazolam-fentanyl sedation for colonoscopy. Br J Surg.

2009 Apr;96(4):361-8. PubMed PMID: 19283736.

2: Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P,

Margolis BD, Byrne DW, Ely EW, Rocha MG; SEDCOM (Safety and Efficacy of

Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs

midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009

Feb 4;301(5):489-99. Epub 2009 Feb 2. PubMed PMID: 19188334.

3: Morris MI. Posaconazole: a new oral antifungal agent with an expanded spectrum

of activity. Am J Health Syst Pharm. 2009 Feb 1;66(3):225-36. Review. PubMed

PMID: 19179636.

4: Xue FS, Liu HP, He N, Xu YC, Yang QY, Liao X, Xu XZ, Guo XL, Zhang YM.

Spray-as-you-go airway topical anesthesia in patients with a difficult airway: a

randomized, double-blind comparison of 2% and 4% lidocaine. Anesth Analg. 2009

Feb;108(2):536-43. PubMed PMID: 19151284.

5: Zier JL, Rivard PF, Krach LE, Wendorf HR. Effectiveness of sedation using

nitrous oxide compared with enteral midazolam for botulinum toxin A injections in

children. Dev Med Child Neurol. 2008 Nov;50(11):854-8. PubMed PMID: 19046178.

6: Tao J, Nunery W, Kresovsky S, Lister L, Mote T. Efficacy of fentanyl or

alfentanil in suppressing reflex sneezing after propofol sedation and periocular

injection. Ophthal Plast Reconstr Surg. 2008 Nov-Dec;24(6):465-7. PubMed PMID:

19033843.

neveragain

40 Posts

lolol benzodiazepines linked to post-icu depression here is just one. i didn't really want to get into a *war* of citations. i assume that you will pick apart any of the studies i bring up. you may also want to look at studies of brain activity in people with a high iq. their brains are different and this may be part of the problem with versed. just a thought, i am not a neuro doc, but neither are you... remember that midazolam is highly favored by health care workers. having a blindly obedient patient who can't question or stop the procedure, and usually has amnesia is a huge draw. it is also very expensive to get "conscious sedation." there are other studies as well. look how old some of the citations you give are! a lot of what you cite are studies comparing (midazolam with drug x) or (midazolam with drug y.) this isn't really asking patients if they want to be medical zombies or not. they are also from the perspective of the practitioner not the patient. as paindoc says, it's a matter of perpective. as with any drug there is a curve of efficacy. there are people who want the drug (sedation dentistry comes to mind) and people who don't want the drug or have a paradoxical or bizarre reaction to it. i am saying that midazolam does cause these problems in at least some patients, with or without disclosure. (you seem to admit that) i am saying that this drug should be an option with full disclosure, not be routinely administered without explanation and with disregard and disrespect for the patients rights, wishes and/or experience with anesthesia drugs. as more and more people have an anecdotal experience with this drug and talk about it, you will find that more and more patients exclude versed. i really hope that you in particular hypocaffeinemia are actually on a quest for knowledge that will make you a better nurse and not just wanting to squabble with me.

Specializes in Critical Care.

your article (review) does not support what you think it supports.

here's just one part:

compared with other ali survivors, those with depression were more likely to have suffered greater severity of organ failure and to have received a daily dose of 75 mg or more of a benzodiazepine.

these patients were on a continuous benzodiazepine sedation drip of 75mg or more, daily. it does not identify the agent, but it was likely lorazepam or midazolam. this might be regional variation, but lorazepam is preferred in this neck of the woods for continuous sedation.

in addition, the patients were on this drip for days, weeks, even months.

compare this to limited bolusing of typically less than 5-10 mg over thirty minutes or so during a procedure.

even then, with long term heavy use, there was only a correlation in a small percentage of individuals- individuals with complex morbidities and treatment plans.

---

you are putting words in my mouth again regarding midazolam. i have no particular love affair with the drug. i selected propofol when i did my first scope, as it is a superior drug (one that requires a trained anesthesia expert, mind you).

i am simply attempting to combat blatant disinformation about it. being a patient advocate. go back and read some of the explicitly crazy things said about its use in this thread, for context.

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