Colonoscopy Drugs and alternatives

  1. 1 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.
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    About darne20

    darne20 has '1' year(s) of experience and specializes in 'research'. From 'VA'; 60 Years Old; Joined Jan '09; Posts: 41; Likes: 22.

    42 Comments so far...

  3. Visit  ok2day profile page
    2
    I can share my experience only as a patient. I have had two colonoscopies without versed. The first one with demerol, I was alert and almost pain free. Four years later the second one with fentanyl, I got too sleepy but totally pain free. My doctor was very agreeable to my no versed request. Next time I want demerol or a lower dose of fentanyl. No versed for me! I want to be in control and know what is happening to me.
    neveragain and darne20 like this.
  4. Visit  neveragain profile page
    2
    Notice how it is patients who dislike this drug while the nurses love using it. Very peculiar. I hope some nurses read this, as it seems nobody in the medical field wants to discuss how bad this favorite drug is. For every person who likes having it there is one who hates it. So why do we all have to have it?
    serialmom12 and darne20 like this.
  5. Visit  serialmom12 profile page
    2
    Yes you can and you SHOULD refuse sedation for a colonoscopy!!!! This is NOT a painful procedure at all. I've had two of them done by two different doctors and I told them both up front that I absolutely refuse to be sedated for this short procedure. Your colon has no nerve endings so how CAN you feel pain? The only uncomfortable thing about the procedure is when the Dr puffs air into your colon, but it's not painful, just uncomfortable. I had a very small amount of Demerol for both procedures like 25-50 mgs, just to take the edge off. I watched both of them on the monitor and even pointed out when I saw something that I wanted my Dr to go back and recheck. The nurses in the room the first time tried to force me to take Versed (I had it once before and it has ruined my life totally, memories are gone...years of memories, and I was left with PTSD from the incident, stopped breathing and almost died.) I wear a medic alert bracelet now at all times stating that I'm allergic to this poison that should be banned for use on humans. I told the nurse finally that if she came near my IV with Versed that both the syrnge and she would be picked up and bodily thrown into the wall....and then sweetly asked "was I making myself clear?" (The Dr then told her...hey don't mess with this one, she means what she says!!)
    I even watched as the dr removed a 5mm precancerous polyp...totally painless. That is why I had to go back for another c-word a year later, which came out clear thank god.
    If the Dr won't do the procedure w/o sedation, find another Dr. The ones that insist on it, I'm totally suspicious of, they are NOT looking out for their patients, and just want to cover up with a memory loss drug incase they screw up and can rush through the procedure and onto their next victim.
    One thing I wanted to inform everyone about this procedure is to ALWAYS insist that your Dr use a pediatric scope for this procedure. Your chances of a colon perforation are quadrupled when the dr uses and adult sized scope, and they're so large that they often miss small polyps. Also ask of their track record. The two dr's that I used in St Pete and Clearwater had perfect records, never perforated anyone's colon during the procedure and both were caring and took their time to be thorough.
    I figured if I can have dental work done w/o novocaine and two nine-pound babies w/o any drugs that the c-word procedure would be OK...and it was. Feel free to email me if you'd like the Dr's name or the prep that they used. The one actually allows the patient to eat breakfast AND lunch. Neither one made you drink the Golitely or Nulitely...that stuff tastes like peed in ocean water...you throw up more than you can swallow which totally defeats the purpose.
    darne20 and neveragain like this.
  6. Visit  hypocaffeinemia profile page
    6
    Quote from neveragain
    Notice how it is patients who dislike this drug while the nurses love using it. Very peculiar. I hope some nurses read this, as it seems nobody in the medical field wants to discuss how bad this favorite drug is. For every person who likes having it there is one who hates it. So why do we all have to have it?
    What I notice is there are continually about a dozen posters at allnurses who only post in threads related to midazolam and who do not claim nor do they appear to be healthcare professionals.

    I also notice that, despite the dozen or so posters at allnurses and a few *out there* websites dedicated to some weird obsession against midazolam, it's used bazillions of times daily without much issue. You want to discuss how bad the drug is for you, fine. Nobody says all drugs work perfectly in all people with excellent outcomes across the board.

    What is irksome, however, is extrapolating from your poor experience with the drug that it should cease to be used by everyone. Don't like it, don't use it-- and move on.
  7. Visit  serialmom12 profile page
    2
    Hello,

    The ONLY reason we tell people about this evil poison called Versed is because it's virtually ruined our lives. I had no issues whatsoever with memory loss, anxiety, paranoia, PTSD, severe panic attacks, etc until this drug was pumped into my veins w/o my knowledge or consent (I was lied to and told it was Valium!!) It almost killed me. I don't remeber my children growing up, major events that have happened in my life, Versed and the moron's that almost killed me with it took ALL of that away from me.
    I wouldn't wish what happened to me to happen to anyone...that's why we tell people to refuse this crap, it's DANGEROUS!!!!
    If you haven't had this happen to you, you're totally clueless.
    If I can save a person from going throught the living hell I've gone through all these years, I'm happy.

    Serialmom
    Last edit by Elvish on Mar 17, '09 : Reason: getting personal
    darne20 and neveragain like this.
  8. Visit  core0 profile page
    12
    Quote from serialmom12
    Yes you can and you SHOULD refuse sedation for a colonoscopy!!!! This is NOT a painful procedure at all. I've had two of them done by two different doctors and I told them both up front that I absolutely refuse to be sedated for this short procedure. Your colon has no nerve endings so how CAN you feel pain? The only uncomfortable thing about the procedure is when the Dr puffs air into your colon, but it's not painful, just uncomfortable. I had a very small amount of Demerol for both procedures like 25-50 mgs, just to take the edge off. I watched both of them on the monitor and even pointed out when I saw something that I wanted my Dr to go back and recheck. The nurses in the room the first time tried to force me to take Versed (I had it once before and it has ruined my life totally, memories are gone...years of memories, and I was left with PTSD from the incident, stopped breathing and almost died.) I wear a medic alert bracelet now at all times stating that I'm allergic to this poison that should be banned for use on humans. I told the nurse finally that if she came near my IV with Versed that both the syrnge and she would be picked up and bodily thrown into the wall....and then sweetly asked "was I making myself clear?" (The Dr then told her...hey don't mess with this one, she means what she says!!)
    I even watched as the dr removed a 5mm precancerous polyp...totally painless. That is why I had to go back for another c-word a year later, which came out clear thank god.
    If the Dr won't do the procedure w/o sedation, find another Dr. The ones that insist on it, I'm totally suspicious of, they are NOT looking out for their patients, and just want to cover up with a memory loss drug incase they screw up and can rush through the procedure and onto their next victim.
    One thing I wanted to inform everyone about this procedure is to ALWAYS insist that your Dr use a pediatric scope for this procedure. Your chances of a colon perforation are quadrupled when the dr uses and adult sized scope, and they're so large that they often miss small polyps. Also ask of their track record. The two dr's that I used in St Pete and Clearwater had perfect records, never perforated anyone's colon during the procedure and both were caring and took their time to be thorough.
    I figured if I can have dental work done w/o novocaine and two nine-pound babies w/o any drugs that the c-word procedure would be OK...and it was. Feel free to email me if you'd like the Dr's name or the prep that they used. The one actually allows the patient to eat breakfast AND lunch. Neither one made you drink the Golitely or Nulitely...that stuff tastes like peed in ocean water...you throw up more than you can swallow which totally defeats the purpose.
    So much incorrect information:
    1. The colon does have nerve endings. The colonic mucosa does not, which is why you do not need additional pain medication for a biopsy or polypectomy. There are tons of studies on pain scales during colonoscopy and comparative studies on colonoscopy vs. CT colonoscopy or BE. The pain ratings go all the way to the top suggesting this is a very painful procedure for some people. Concern over pain or inadequately treated pain is a common reason for people not getting their colonoscopy. To suggest that the colon does not have nerve endings is factually incorrect.

    2. Statistically Demerol is a much more dangerous drug than Versed (even if they were in the same class of drugs). It can cause seizures and Serotonin syndrome. As an analgesic it is less effective than virtually all other narcotics. Most hospitals have banned it except in the case of rigors because of these problems. Its main advantage is that it dries up secretions which makes the endoscopy easier.

    3. There have been a number of studies on pediatric vs. adult scopes. There is probably some advantage in using long pediatric variable stiffness scopes in female patients (especially if they have had a hysterectomy). For males (especially young males) there are advantages to a long adult scope. For most of the rest it probably doesn't matter. Most GIs are probably using peds scopes for the variable feature not for the diameter. The physician should use the scope that is most appropriate for the situation.

    4. Perforations. As a consumer you have no way of independently confirming the perforation rate of a gastroenterologist. Complications from colonoscopy occur between 3 and 5/1000. Perforation rates are around 1/1000. Perforation rates during polypectomy can be as high as 11/1000. Statistically if a gastroenterologist has done more than 10,000 colonoscopies they most likely had a perforation. If someone claimed that they had no perforations they are either very lucky or I would be concerned that they were not recognizing complications.

    Colonoscopy is not risk free. Any procedure should have a full explanation of the risks and benefits. If someone has concerns over a part of the procedure that should be brought out into the open. However, the benefits of colonoscopy outweigh the risks in terms of colon cancer prevention.

    David Carpenter, PA-C
    Rose_Queen, Karley9336, netglow, and 9 others like this.
  9. Visit  serialmom12 profile page
    2
    whatever
    neveragain and darne20 like this.
  10. Visit  Booty Nurse profile page
    1
    Quote from darne20
    So, question #1:
    For colonoscopy in a patient declinig sedation, do you see any reason why they could not just have fentanyl?
    I've been an endo nurse for just over a year. Every colonoscopy I've assisted with has been under either fentanyl and Versed or Demerol and Versed (or with MAC). One doc I work with has done colos without any medication if the patient requests it, but no one has requested it since I've been working with him. I think a narcotic alone would be fine if that's what the patient wants. However, I see huge benefits to Versed; patients come in very nervous, and with Versed on board the anxiety goes away. Patients can chill out or snooze through the procedure. Versed also help make the procedure go easier because the abdomen is more relaxed. I don't buy the argument that the only reason for giving Versed is for the amnesia.

    Quote from darne20
    question #2 (for CRNAs):
    For colonoscopy where propofol is given, do you also administer a narcotic (ie fentanyl) or just use propofol?
    In my hospital, the CRNAs give propofol, Versed, and fentanyl to almost every colonoscopy patient.
    darne20 likes this.
  11. Visit  GIRN profile page
    2
    Thanks for your accurate, concise reply, David Carpenter. There ARE risks with colonoscopies and every GI Doc I've worked with so far, has had at least one perforation in their career. To say you would only pick the Doc without a perforation means you're picking a Doc who's inexperienced.

    As far as sedation with propofol, I LOVE IT!!! We used Versed and Demerol then Versed and Fentanyl for years and had many patients that were either uncomfortable or downright painful. Now that we use CRNA's to give Propofol our patient's are not only comfortable but ecstatic that it was so easy. They wake up quickly, aren't sedated or nauseated for hours, and feel like they've had a power nap. We don't give any other drug besides the Propofol unless there are extenuating circumstances. We don't have to use Hurrican Spray to numb the throat before an EGD because the Propofol is so effective. Our patients are able to be discharged within thirty minutes and they usually go out to breakfast on their way home. We all win because of quick turnover.

    Propofol is so much safer than Versed for this procedure because it's so much more effective for sedation. With Versed, there were patients that required high doses to keep them comfortable and we got to the limit of what we could give. They were asking for more pain control but we knew that as soon as we stopped the stimulation of the scope, they'd become so sedated their respirations would be at risk. And it brought our unit to a screeching halt to pull a nurse to do a 'one on one' with an overly sedated patient. Propofol is our answer and I hope it's only a matter of time before all units switch over.
    darne20 and truern like this.
  12. Visit  core0 profile page
    1
    Quote from GIRN
    Thanks for your accurate, concise reply, David Carpenter. There ARE risks with colonoscopies and every GI Doc I've worked with so far, has had at least one perforation in their career. To say you would only pick the Doc without a perforation means you're picking a Doc who's inexperienced.

    As far as sedation with propofol, I LOVE IT!!! We used Versed and Demerol then Versed and Fentanyl for years and had many patients that were either uncomfortable or downright painful. Now that we use CRNA's to give Propofol our patient's are not only comfortable but ecstatic that it was so easy. They wake up quickly, aren't sedated or nauseated for hours, and feel like they've had a power nap. We don't give any other drug besides the Propofol unless there are extenuating circumstances. We don't have to use Hurrican Spray to numb the throat before an EGD because the Propofol is so effective. Our patients are able to be discharged within thirty minutes and they usually go out to breakfast on their way home. We all win because of quick turnover.

    Propofol is so much safer than Versed for this procedure because it's so much more effective for sedation. With Versed, there were patients that required high doses to keep them comfortable and we got to the limit of what we could give. They were asking for more pain control but we knew that as soon as we stopped the stimulation of the scope, they'd become so sedated their respirations would be at risk. And it brought our unit to a screeching halt to pull a nurse to do a 'one on one' with an overly sedated patient. Propofol is our answer and I hope it's only a matter of time before all units switch over.
    The problem with Propofol is that its not moderate sedation. The package insert states that is should only be used by those trained in general anesthesia. There are states where nurse administered propofol is allowed. However, it remains controversial.

    Anesthesia administered sedation for endoscopy remains confined for the most part to the northeast. The priniciple reason is cost. Medicare reimburses around $900 for an outpatient colonoscopy. This is an all inclusive cost including sedation. If anesthesia is going to be given it comes out of those costs. With the exception of the NE most commercial insurance follows the same policy. BC/BS in Mass attempted to do the same thing but backed down after patients complained. Again the reason is cost. The anesthesia portion of the colonoscopy adds approximately approximately 30% to the cost of the colonoscopy. Given the safety profiles of sedation for colonoscopy is that the best use of our health care dollar?

    If colonoscopy become more therapeutic and less diagnostic with the advent of non-invasive methods such as CT colonography then it may be possible.

    David Carpenter, PA-C
    darne20 likes this.
  13. Visit  GIRN profile page
    2
    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.
    neveragain and darne20 like this.
  14. Visit  darne20 profile page
    1
    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.
    Booty Nurse likes this.

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