Nurses Pushing Propofol for Conscious Sedation -Your Thoughts? - page 3

by *traumaRN*

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I would be interested in getting feedback from GI nurses that are involved in propofol sedation in settings with and without anesthesia. Your thoughts and experiences please. Thank you, Randy... Read More


  1. 0
    my experience with a tucson endoscopist and nurse pushing propofol was appalling. first the relevant background information:

    i had an intake with a dnp(c), fnp but didn’t schedule the colonoscopy on that same day so i wasn’t given the prep instructions. when i called later to schedule it, i was directed to get the instructions from their website.

    since i wasn’t able to talk with the endoscopist directly, i faxed this message to him: “[color=windowtext]as a 65 year-old retired health care professional who has worked in hospitals (i didn’t reveal in what capacity), i am aware that there are risks/ complications of colonoscopy related to sedation… actually, i would prefer no meds at all but i understand female physiology tends to make this procedure more difficult especially with a redundant colon, which i have…[so] i [color=windowtext]would like to have this noted on the consent form for my signature: no sedation; analgesics only- i.e. fentanyl and usage of a pediatric colonoscope[color=windowtext]…”.

    i also asked a staffer about the meds, and she responded, “i think it might be sedation or nothing at all”; but since she wasn’t sure, she referred my call to the endoscopy center (owned by the physicians) where i spoke to a nurse who told me that he uses propofol, while also assuring me that i have rights as a patient.

    the day before the scheduled procedure, his med asst called and relayed his non-committal response i.e. that he would speak with me about the meds before the procedure. i then said that i needed to know beforehand whether he would agree to my request. her response was, "procedures are done here without sedation all the time". when i asked about the pediatric scope, her response was, “we have pediatric scopes in the center”. i also noticed that she said nothing about the analgesic; but i realized i probably wouldn’t get a direct answer to that either, so i left it at that and decided to keep the appointment, and anticipated pressure to agree to the propofol. (i think reading about his military background added to that anticipation).

    on the day of the procedure, as i lay on the gurney awaiting his arrival in the examinationroom, i reported to the nurse that i was quite nervous and my heart was beating fast. as i expected, when he arrived, he (and she) tried to pressure me to take the propofol and to discourage me from taking the fentanyl. when i insisted on having only an analgesic so that i could be awake during the procedure and refused the propofol unless the pain became too great, he seemed annoyed; and when he instructed the nurse to administer 50 mg of fentanyl and i asked if he could start at 25 mg, he angrily and insistently demanded to know if i had medical training (fearing more hostility, i avoided mention that dosage is recommended in some guidelines for geriatric patients); and then when he asked what was written on the instruction sheet re the second prep dose and i explained that one had not been written, he retorted, "i don't believe that!" -in essence calling me a liar. in addition to feeling weak from having no food for 24 hours as part of the prep, i felt quite nervous and intimidated: but what followed was even worse:

    i had read that fentanyl “is approximately 100 times more potent than morphine"; so of course my expectation was that fentanyl would relieve any pain. however, i experienced excruciating pain a few times during the procedure even though i heard him give instructions to titrate the fentanyl twice. in fact, i felt none of the narcotic effects - no analgesia, no relaxation, no euphoria, no drowsiness, nothing; and no nausea afterwards as he had warned.

    naturally this raises suspicions, especially after reflecting on the responses of the medical assistant and aforementioned phone staffer, as well as the nurse’s warning before the procedure began: take deep breaths when you experience pain because if you don’t, the pain could make you tighten up, causing the colon to contract and exacerbate the pain. since i have ibs, it’s possible that my colon was already in spasm.

    also, i read in gastroenterology & endoscopy news that one of the reasons some gastroenterologists push propofol is because the recovery period is minimized, so their costs are reduced.

    note: my first colonoscopy was a pleasant experience. i was administered only a narcotic; and during the procedure i was fully awake, experienced euphoria and no pain and had no nausea afterwards- the same experience i had when i was given a narcotic after a surgery in 1971. however, while under anesthesia during that surgery, even though i wasn't conscious, i experienced a horrifying nightmare. i would imagine that undergoing surgery for most people is probably more physically painful than a colonoscopy but in any case, it is possible to experience such unconscious aspects of pain while under anesthesia. (i also read such reports by other colonoscopy patients). this is another reason i opted only for pain meds during this colonoscopy.

    ps. note these familiar remarks from your website:
    http://allnurses.com/gastroenterolog...es-377308.html
    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...for colonoscopy where propofol is given, do you also administer a narcotic (ie fentanyl) or just use propofol? i'm asking because i have noticed 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.
    Last edit by health professinal on May 16, '11 : Reason: grammar corrections
  2. 1
    Quote from health professinal
    my experience with a tucson endoscopist and nurse pushing propofol was appalling. first the relevant background information:

    i had an intake with a dnp(c), fnp but didn’t schedule the colonoscopy on that same day so i wasn’t given the prep instructions. when i called later to schedule it, i was directed to get the instructions from their website.

    since i wasn’t able to talk with the endoscopist directly, i faxed this message to him: “[color=windowtext]as a 65 year-old retired health care professional who has worked in hospitals (i didn’t reveal in what capacity), i am aware that there are risks/ complications of colonoscopy related to sedation… actually, i would prefer no meds at all but i understand female physiology tends to make this procedure more difficult especially with a redundant colon, which i have…[so] i [color=windowtext]would like to have this noted on the consent form for my signature: no sedation; analgesics only- i.e. fentanyl and usage of a pediatric colonoscope[color=windowtext]…”.

    i also asked a staffer about the meds, and she responded, “i think it might be sedation or nothing at all”; but since she wasn’t sure, she referred my call to the endoscopy center (owned by the physicians) where i spoke to a nurse who told me that he uses propofol, while also assuring me that i have rights as a patient.

    the day before the scheduled procedure, his med asst called and relayed his non-committal response i.e. that he would speak with me about the meds before the procedure. i then said that i needed to know beforehand whether he would agree to my request. her response was, "procedures are done here without sedation all the time". when i asked about the pediatric scope, her response was, “we have pediatric scopes in the center”. i also noticed that she said nothing about the analgesic; but i realized i probably wouldn’t get a direct answer to that either, so i left it at that and decided to keep the appointment, and anticipated pressure to agree to the propofol. (i think reading about his military background added to that anticipation).

    on the day of the procedure, as i lay on the gurney awaiting his arrival in the examinationroom, i reported to the nurse that i was quite nervous and my heart was beating fast. as i expected, when he arrived, he (and she) tried to pressure me to take the propofol and to discourage me from taking the fentanyl. when i insisted on having only an analgesic so that i could be awake during the procedure and refused the propofol unless the pain became too great, he seemed annoyed; and when he instructed the nurse to administer 50 mg of fentanyl and i asked if he could start at 25 mg, he angrily and insistently demanded to know if i had medical training (fearing more hostility, i avoided mention that dosage is recommended in some guidelines for geriatric patients); and then when he asked what was written on the instruction sheet re the second prep dose and i explained that one had not been written, he retorted, "i don't believe that!" -in essence calling me a liar. in addition to feeling weak from having no food for 24 hours as part of the prep, i felt quite nervous and intimidated: but what followed was even worse:

    i had read that fentanyl “is approximately 100 times more potent than morphine"; so of course my expectation was that fentanyl would relieve any pain. however, i experienced excruciating pain a few times during the procedure even though i heard him give instructions to titrate the fentanyl twice. in fact, i felt none of the narcotic effects - no analgesia, no relaxation, no euphoria, no drowsiness, nothing; and no nausea afterwards as he had warned.

    naturally this raises suspicions, especially after reflecting on the responses of the medical assistant and aforementioned phone staffer, as well as the nurse’s warning before the procedure began: take deep breaths when you experience pain because if you don’t, the pain could make you tighten up, causing the colon to contract and exacerbate the pain. since i have ibs, it’s possible that my colon was already in spasm.

    also, i read in gastroenterology & endoscopy news that one of the reasons some gastroenterologists push propofol is because the recovery period is minimized, so their costs are reduced.

    note: my first colonoscopy was a pleasant experience. i was administered only a narcotic; and during the procedure i was fully awake, experienced euphoria and no pain and had no nausea afterwards- the same experience i had when i was given a narcotic after a surgery in 1971. however, while under anesthesia during that surgery, even though i wasn't conscious, i experienced a horrifying nightmare. i would imagine that undergoing surgery for most people is probably more physically painful than a colonoscopy but in any case, it is possible to experience such unconscious aspects of pain while under anesthesia. (i also read such reports by other colonoscopy patients). this is another reason i opted only for pain meds during this colonoscopy.

    ps. note these familiar remarks from your website:
    http://allnurses.com/gastroenterolog...es-377308.html
    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...for colonoscopy where propofol is given, do you also administer a narcotic (ie fentanyl) or just use propofol? i'm asking because i have noticed 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.
    i am not sure what kind of health professional (not professinal) you were, but you have some misunderstandings about certain medications and dosages.

    1. fentanyl in general is somewhere between 75-100x more potent than morphine, but it isn't given in mg (milligrams) it is given in mcg (micrograms) if they had given you 75mg of fentanyl you would have coded immediately from respiratory depression.
    2. there is more than 1 reason to give other medications with the fentanyl. the meds we usually use in combination for sedation work synergistically, and allow us to use each one in lower doses while providing more consistent sedation/analgesia.
    3. using a pediatric scope degrades the quality of your colonoscopy by decreasing the view. i don't really understand why someone would want to put themselves through colonoscopy to have poorer than standard imaging that could miss the findings you are getting the colonoscopy for in the first place.
    4. demanding that a procedure to be done a certain way that is unfamiliar to the provider and nursing staff is a certain way to expect poor outcomes. a gi doc that isn't familiar with giving only narcotics for gi procedures is going to have a hard time ordering an effective dosing to cover procedure.
    5. there isn't a conspiracy among healthcare providers to try to just make more money and move patients through. the recommendation to use propofol with or without versed/fentanyl for gi sedations has been shown in well over 300k cases to be the most beneficial to patients undergoing sedation in the gi suite. propofol sedation provides quicker recovery, quicker return to baseline cognitive function, hemodynamic stability in asa 1-4 patients, better patient satisfaction, and better provider satisfaction.

    here are some good references (see the bottom of the page):
    http://www.gastroenterologistnewyork...enterology.php
    Horseshoe likes this.
  3. 0
    typo- mcg vs mg.

    The Endoscopy Center said all they use is a pediatric scope.

    I mentioned financial incentives but I didn't say there is a "conspiracy among healthcare providers to try to just make more money and move patients through".

    You mention nothing about the endoscopists behavior and possible deceit; so I guess that's OK with you.
  4. 0
    single use of fentanyl in colonoscopy is safe and effective and significantly shortens recovery time.

    lazaraki g, kountouras j, metallidis s, dokas s, bakaloudis t, chatzopoulos d, gavalas e, zavos c.
    department of medicine, second medical clinic, ippokration hospital, aristotle university of thessaloniki, thessaloniki, greece. lazarakg@yahoo.com
    abstract

    colonoscopy remains an uncomfortable examination and many patients prefer to be sedated. the aim of this study was to evaluate the efficacy and safety of intravenous administration of fentanyl in titrated doses compared with intravenous administration of the well-known midazolam in titrated doses.

    methods: one hundred twenty-six patients scheduled for ambulatory colonoscopy were randomly assigned to receive either 25 mcg fentanyl (fentanyl group, n = 66, 35 females, mean age = 61.5 years) and titrated up to 50 mcg or 2 mg midazolam (midazolam group, n = 60, 33 females, mean age = 63.2 years) and titrated up to 5 mg. patients graded discomfort on a scale from 0 to 4 and pain on a scale from 0 to 10. success of the procedure, time to cecum, complications, and recovery time for each patient were independently recorded.


    results: mean discomfort scores were 0.4 in the fentanyl group and 1.0 in the midazolam group (p = 0.002). similarly, mean scores for pain and anus to cecum time were lower in the fentanyl group than in the midazolam group [2.59 vs. 4.43 (p = 0.002) and 8.7 vs. 12.9 min (p = 0.012), respectively]. no adverse events were reported in the fentanyl group, while in the midazolam group a decrease in oxygen saturation was noted in 23/60 (35%) patients. mean recovery time was 5.6 min in the fentanyl group and 16 min in the midazolam group (p = 0.014). mean dosage was 36 mcg for fentanyl and 4.6 mg for midazolam.


    [color=#323232]conclusion: administration of fentanyl in low incremental doses is sufficient to achieve a satisfactory level of comfort during colonoscopy.


    pmid: 17762959 [pubmed - indexed for medline]


    gastroenterology & endoscopy issue: september 2008 | volume: 59:09

    propofol sedation for colonoscopy: a consensus?
    compiled by christina frangou
    propofol, the powerful anesthetic often used to sedate patients for colonoscopy, continues to stir up plenty of controversy in the field of gastroenterology....
    Last edit by health professinal on May 17, '11 : Reason: forgot to include source
  5. 0
    PS. I was trained in psychiatry where compassion was emphasized. I did not work for a drug manufacturer.
  6. 0
    Perhaps it's time to review this?:
    A Patient’s Bill of Rights
    A Patient's Bill of Rights was first adopted by the
    American Hospital Association in 1973.

    Effective health care requires collaboration between patients and physicians and other health care professionals. Open and honest communication, respect for personal and professional values, and sensitivity to differences are integral to optimal patient care. … must ensure a health care ethic that respects the role of patients in decision making about treatment choices and other aspects of their care. The collaborative nature of health care requires that patients, or their families/surrogates, participate in their care.
    All these activities must be conducted with an overriding concern for the values and dignity of patients.


    Bill of Rights

    1. The patient has the right to considerate and respectful care.
    2. The patient has the right to and is encouraged to obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.

    Except in emergencies when the patient lacks decision-making capacity and the need for treatment is urgent, the patient is entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risks involved, the possible length of recuperation, and the medically reasonable alternatives and their accompanying risks and benefits.


    3. The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides or transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.
    4. The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services. The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case. ..
    5. The patient has the right to ask and be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient's treatment and care…
  7. 0
    I did my Masters research looking at sedation practices for GI procedures. I am sorry your outcome was less than satisfactory, but I see this all the time where patients come in wanting all these things that are out of the normal for that particular place and expect excellent outcomes. These patients set themselves up for failure before the procedure even starts.
  8. 0
    Quote from wtbcrna
    I did my Masters research looking at sedation practices for GI procedures. I am sorry your outcome was less than satisfactory, but I see this all the time where patients come in wanting all these things that are out of the normal for that particular place and expect excellent outcomes. These patients set themselves up for failure before the procedure even starts.
    There are 4 docs at that endoscopy center and they all use different med protocols. Besides, as an endoscopist, they should be familiar with different medications. And if not, since advance notice was given, they should familiarize themselves with a patient's choice of meds. So there is no "normal for that particular place". And this has nothing to do with expecting "excellent outcomes". I find it intteresting that you keep mis-characterizing the concerns expressed in my report.
    Last edit by health professinal on May 17, '11
  9. 0
    Quote from health professinal
    There are 4 docs at that endoscopy center and they all use different med protocols. Besides, as an endoscopist, they should be familiar with different medications. And if not, since advance notice was given, they should familiarize themselves with a patient's choice of meds. So there is no "normal for that particular place". And this has nothing to do with expecting "excellent outcomes". I find it intteresting that you keep mis-characterizing the concerns expressed in my report.
    You don't just familiarize yourself with a medication and hope to become proficient in its use for sedation. Do you think the endoscopist became proficient in doing colonoscopies by just doing one or two? There is a reason people in anesthesia spend thousands of hours getting experience doing sedations.

    I don't think I am mischaracterizing your concerns at all. I am giving you a provider's perspective and you can do with it what you want.

    It is also interesting to note that many countries do not routinely do sedation/analgesia at all for colonoscopies, because it isn't considered that painful. A lot of what we perceive is based on cultural perception.

    I have to ask what is/was your profession in psychiatry and level of education? I am a CRNA with a MSN.

    I don't see where the endoscopist was deceitful. You asked for a pediatric scope to be used, and you got a pediatric scope. You asked for only fentanyl. You got only fentanyl even though you got 3x the starting dose of fentanyl you quoted in the study it was still painful for you. The endoscopist and the nurse tried to convince to use propofol for your sedation you refused and got exactly the sedation done the way you wanted....

    I also don't see how the GI clinic violated any patient rights that you quoted also. They could have provided better customer service and been nicer, but again this maybe just a perception issue or they could just be jerks...
  10. 0
    "I am giving you a provider's perspective and you can do with it what you want". I am giving you a patient's perspective and you can do with it what you want. Amen.


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