Sedation Options

Our goal is to provide you with a comfortable procedure through the use of expert endoscopic technique and personalized, safe and effective sedation services.  We encourage you to discuss any questions you may have regarding your sedation options with our staff and your gastroenterologist prior to your procedure.  We have extensive experience with endoscopist-directed propofol sedation, which we initially implemented in 2006 and used for more than 99% of the procedures we performed at the Southwest Endoscopy Center from 2007 through May 2010.  In June 2010 we added a certified registered nurse anesthetist (CRNA) to our sedation team.

Endoscopist-Supervised Propofol Sedation
Used for most procedures at the Southwest Endoscopy Center

Endoscopist-supervised propofol sedation consists of the intravenous administration of individualized doses of a single sedative-hypnotic agent (propofol) by a certified registered nurse anesthetist (CRNA) under the endoscopist's supervision.  In our facility, a small dose of midazolam and/or fentanyl is usually given just before beginning propofol administration.  Propofol is a rapid and short acting agent that came into widespread use by anesthesiologists for induction of general anesthesia in the late 1980's.  In recent years propofol has been adapted to the endoscopy laboratory, where it is being used increasingly to induce the levels of moderate-deep sedation typically needed for the comfortable and effective performance of endoscopic procedures.  Over 10,000 procedures have been performed using endoscopist-directed propofol sedation (a form of propofol sedation in which a specially trained RN, rather than an anesthesiologist or CRNA, administers the propofol), at our center, where we have over 4 years of experience with this technique.  Because of new federal regulatory requirements we are no longer able to offer endoscopist-directed propofol sedation, though we continue to utilize many of its advantages in the form of endoscopist-supervised propofol sedation, in which a certified registered nurse anesthetist (CRNA) administers the sedative.

The major advantages of propofol sedation compared to older forms of endoscopic sedation include:
  -Very rapid onset of action, allowing accurate personalized dose adjustments as needed to maintain optimal comfort during the procedure
  -Very rapid recovery, without lingering amnesia or a sense of being drugged persisting after the procedure
  -Nausea during recovery nearly never occurs 
  -Higher patient and physician satisfaction with the quality of sedation and effectiveness of the procedure
  -Superior patient safety

Safety

While high quality comparative data are lacking, the available studies suggest that propofol sedation may be safer than traditional endoscopic sedation when administered by gastroenterologists and nurses who have undergone specific training in its use and who follow propofol-specific sedation protocols.  As with any sedative, a small risk of allergic or cardiopulmonary complications exists, even with proper use by experts.

We participated, with 27 other centers, in an international multi-center project reporting on the safety of endoscopist-directed propofol sedation.  Our collective experience in 646,080 cases was published in the October 2009 issue of the journal Gastroenterology.  In this large series there were no sedation-related deaths or other serious adverse events in any patients undergoing colonoscopy or in any patients of the low anesthesia risk categories eligible for care at the Southwest Endoscopy Center.

Read our paper:  Endoscopist-Directed Administration of Propofol: A Worldwide Safety Experience.

Cost
While we previously provided endoscopist-directed propofol sedation at no charge other than Digestive Health's routine professional charge and Southwest Endoscopy's facility fee, federal facility requirements as specified by the Department of Health and Human Services' Center for Medicare and Medicaid Services (CMS), now require that a designated anesthesia provider other than the doctor performing the procedure administer sedation whenever a patient may need to be sedated to the point of sleep, or "deep sedation," a depth of sedation that is often necessary for the successful performance of endoscopic procedures in a comfortable and effective manner.  These requirements affect the manner in which we must deliver care to all of our patients, regardless of the type of health plan under which they are covered. 

While there are no routine facility or physician charges for the endoscopist's supervision of sedation delivery by a CRNA at the Southwest Endoscopy Center, the CRNA will charge for anesthesia professional services.  Animas Anesthesia Associates, LLC provides sedation/anesthesia services at the Southwest Endoscopy Center and bills separately for its services.  These charges are generally covered by health insurance policies in accordance with the insurance contract, though some health plans may only pay for anesthesia services for endoscopy in special medical situations.

See our Sedation/Anesthesia FAQs


Why do you use anesthesia services when my insurance company says that anesthesia is not "medically necessary" for my type of procedure, and refuses to provide payment for anesthesia?  They say I only need moderate sedation.

We are committed to providing you with a comfortable procedure through the use of expert endoscopic technique and personalized, safe and effective sedation.  The depth of sedation needed to provide a comfortable procedure varies from patient to patient based on many factors, only some of which are known when a procedure is planned (medical history, gender, body habitus, current medication, previous tolerance for and doses of sedatives used during prior endoscopic procedures).  Other factors only become evident during the actual performance of the procedure (degree of sensitivity to colonic manipulation, technical difficulty of the procedure related to unpredictable anatomic factors).

During moderate sedation the patient is conscious and purposely responsive.  While moderate sedation is effective for many patients undergoing endoscopic procedures, it is frequently and unpredictably inadequate.  When acceptable comfort cannot be maintained under moderate sedation the doctor must discontinue the procedure (unless the resources needed to provide deep sedation are immediately available).

Deep sedation allows the level of sedation to be safely adjusted to a point of unconsciousness, when desired.  Deep sedation is often needed during brief portions of an endoscopic procedure.  When a sedation case is begun with preparations for deep sedation (specific staff, medications and monitoring), the doctor is able to adjust the depth of sedation continuously through the procedure, using light-moderate sedation when that is all that is needed, but rapidly increasing sedation from moderate to deep for periods during which a greater depth of sedation is necessary to maintain comfort. 

We have used deep sedation safely and effectively for years at the Southwest Endoscopy Center, where our experience using it exceeds 10,000 cases.  In December 2009 the federal government newly defined deep sedation to be "anesthesia" and required that it be administered only by an anesthesia provider when it is used in Medicare-certified facilities such as hospitals and ambulatory surgery centers.  In order to continue providing our patients with the high quality level of sedation we have historically used in a safe and effective manner we added a certified nurse anesthetist (CRNA) to our sedation team.  This addition incurs additional professional costs for which our anesthetist submits a bill.  In our facility, anesthesia services are provided by Animas Anesthesia Associates, LLC.

Insurance companies have varying policies regarding coverage for deep sedation.  Some companies choose to cover only moderate sedation (also called conscious sedation).  We believe that this position is outdated and fails to recognize both significant improvements in the safety and effectiveness of sedation practices and new regulatory contraints under which Medicare-certified facilities must operate.  The federal government's most recent finding with respect to the necessity of deep sedation for colonoscopy is reflected in this August 2010 statement of the FDA:

"For endoscopic procedures, particularly colonoscopies, a light-to-moderate level of sedation is needed for less stimulating parts of the procedure.  However, the anesthetic requirements often increase substantially during the more painful portions of the procedure (for example, when negotiating the colonoscope through the splenic and hepatic flexures).  Hence, a state of deep sedation is likely to be induced during the more painful parts of the procedure to manage pain and minimize patient movement and the concomitant risk of bowel perforation."  (emphasis added)
-August 11, 2010 - Statement of the FDA in FDA-2005-P-0059

You may choose to decline deep sedation and schedule your procedure either without sedation or with only moderate sedation if your doctor agrees to attempt your procedure under these conditions.  If you choose to limit your sedation to the moderate level you must accept the limitations of moderate sedation as discussed on our Sedation Options page.  Please review the moderate sedation consent form for your procedure on our Forms page.

Links to additional anesthesia resources and Anthem clinical guidelines


I had a procedure in the past with Versed (midazolam) and fentanyl.  It seemed fine.  Can I just have this same sedation again?

While upper endoscopy and colonoscopy can be performed successfully in a very high percentage of patients with traditional sedation methods using opioids-benzodiazepines (such as midazolam and fentanyl), which we used routinely at our facility until converting to propofol-based sedation in 2006, the intended level of sedation needed to achieve success (defined as that needed for patient tolerance of the procedure) often exceeds a level of moderate sedation (extending into deep sedation).  Federal regulations now specifically preclude the use of these drugs in this manner by individuals who are not qualified as anesthesia providers by statute.  Your doctor will consider this form of sedation only if he or she believes that it will be adequate based on review of your prior procedure records, including the doses of medications administered, to ensure that they conformed with the FDA-approved labeling for these agents.

Both upper endoscopy and colonoscopy can be performed without sedation when a patient is highly motivated to do this, and is willing to bear temporary discomfort, which in some cases can be significant.  Our experience is that most of our patients have a strong preference to experience as painless a procedure as possible.  In some cases, unsedated endoscopy can be provided to patients requesting it.  Please be aware that due to staffing limitations, if you request an unsedated endoscopy, and the procedure is not tolerable for you it may not be possible to provide immediate sedation, necessitating rescheduling of your procedure for completion under sedation/anesthesia at a later date.  This would incur additional charges.

See our Sedation/Anesthesia FAQs

Moderate Sedation
Offered selectively on patient request at the Southwest Endoscopy Center

We made the decision to discontinue moderate sedation (also called conscious sedation) as our routine sedation strategy in 2006, due to significant limitations in the effectiveness and adequacy of this technique for the procedures that we routinely perform.  Moderate sedation has recently been strictly defined in government regulations that control the manner in which sedation services are provided at health care facilities in the United States.  Moderate sedation is generally achieved through the IV administration of opioids and benzodiazepine medications titrated to the point of relaxation and sleepiness, though not to the point of sleep.  Patients under moderate sedation, by its regulatory definition, must remain purposely responsive on a continuous basis to verbal or light touch stimulation.  Recent regulatory actions have been directed against the "off-label" use of medications used for procedural sedation.  Physicians administering moderate sedation in a manner that is approved by the FDA must observe the FDA-approved package insert, which defines the "Usual Adult Dose" in the drug label.  Many patients are not adequately sedated for routine endoscopic procedures at the "Usual Adult Dose." 

While moderate sedation can afford effective sedation in many cases, it is frequently insufficient to allow comfortable completion of the procedure, necessitating either termination of the procedure or administration of additional medication to achieve a state of deeper sedation (which according to current federal regulations can only be administered in our facility by a CRNA or a second MD who is not performing the procedure). 

If you intend to avoid the costs of anesthesia services, are confident that you can complete a procedure under moderate sedation, are willing to bear discomfort, and are willing to accept the additional expenses of a failed procedure should your endoscopy be unsuccessful (and the costs of a rescheduled second procedure), moderate sedation may be offered if your endoscopist is willing to attempt moderately sedated endoscopy in your case.

In some cases, based on the medical complexity of your history, physical characteristics suggesting an increased risk for complications related to sedation, or the anticipated complexity of the planned procedure, your gastroenterologist may recommend that an anesthesiologist (a doctor specializing in the deliver of anesthesia care) provide sedation/anesthesia services.  You may also request sedation by an anesthesiologist as an alternative to having the gastroenterologist direct your sedation.  Anesthesia services are available to our patients undergoing endoscopic procedures at Mercy Regional Medical Center. 

Anesthesia services are professional services rendered by physicians who are highly trained and experienced specialists in the field of anesthesiology and are not directly affiliated with Digestive Health.  Charges for anesthesia services are separate from professional charges for endoscopy services rendered by Digestive Health's physicians.  These charges are generally covered by health insurance policy in accordance with the insurance contract, though some carriers may only provide for anesthesia services for endoscopy in special medical situations.

See our Sedation/Anesthesia FAQs

Your doctor is pleased to discuss sedation options in more detail directly with you prior to the scheduling of your procedure.

Special Concerns

Breastfeeding mothers undergoing sedation/anesthesia

Additional Information
You may read detailed professional-level information about endoscopic sedation at SedationFacts, a project of the American Society for Gastrointestinal Endoscopy, American Gastroenterological Association, American College of Gastroenterology, American College of Gastroenterology and Society of Gastroenterology Nurses and Associates.