We are using gastroenterologist-directed intravenous propofol sedation for most procedures performed at the Southwest Endoscopy Center and Mercy Regional Medical Center. Our doctors and staff now have over 2 years of experience with this technique in over 5,500 cases.
The following questions come up frequently in our preprocedure discussions. The answers reflect our experience with both traditional sedation and with gastroenterologist-propofol sedation. Please let us know if you have a question which is not addressed here.
What does sedation feel like?
Most patients sedated either with midazolam-fentanyl or propofol have little recall of "going under." Those who do typically remember pleasant and relaxed feelings. Patients sedated with midazolam-fentanyl usually have complete or near-complete amnesia for their procedure, and for a period of time after the procedure, which occasionally lasts for a few hours. While this is not unpleasant for most of our patients, some complain that they felt "drugged" after their procedure. Patients sedated with propofol often report quite vivid dreams, which are typically pleasant in nature. Propofol also causes complete or near-complete amnesia for the procedure, but memory and most cognitive functions typically return nearly to normal prior to discharge. Patients sedated with propofol rarely complain of feeling "drugged" and more often remark that they feel as if they had a great nap. While fentanyl and other opiate-type drugs commonly cause nausea, this is rare with propofol.
Is sedation needed in every case? I'm afraid of sedation and want to be awake if possible.
Our goal is to provide you with a safe, complete and comfortable endoscopic procedure. There is considerable variation from patient to patient with respect to tolerance for these procedures. Some motivated patients may be able to tolerate an unsedated upper endoscopy well but not colonoscopy, and vice versa.
The ability to tolerate an unsedated upper endoscopy depends largely on the sensitivity of your gag reflex and your anxiety level about the procedure in general. If you are highly motivated to avoid sedation and can wiggle two of your fingers in the back of your throat for a few minutes without gagging or retching you may be a good candidate to try unsedated endoscopy. On the other hand, if even the thought of fingers in your throat makes you gag it is unlikely that you will tolerate the exam without sedation.
The ability to tolerate colonoscopy depends on factors relating to your sensitivity to anal and rectal manipulation, manipulation of the colon and its supporting tissues, and to the amount of manipulation of the colon necessary to complete the exam, which is quite variable from patient to patient and difficult to predict before the procedure. Additionally, the need for sedation in colonoscopy depends on the technical difficulty of the exam, which also is variable and hard to predict. In general, thin woman tend to be more difficult to examine than overweight men, though this is not universal. A prior hysterectomy also seems to predict a more difficult exam.
Propofol provides much more flexibility in meeting sedation needs than traditional sedation with midazolam and fentanyl because of its rapid onset and short duration of effect. With propofol it is possible for your doctor to take you "deeper" for one to two minutes during what might otherwise be a painful insertion of the colonoscope through the left side of your colon (the part of the exam most often associated with discomfort) and then "lighten you up" for the remainder of the examination. If desired, propofol sedation can be discontinued on reaching the highest part of your colon (the cecum) and you can be allowed to wake up during the instrument's withdrawal, which is generally not uncomfortable.
Will I remember anything? I am scared of feeling pain and I want to be "out."
Most of our patients prefer not to remember their examinations. Sedation with propofol is more likely to succeed in providing a pain free examination than traditional endoscopic sedation with midazolam and fentanyl, but even traditional sedation is effective in accomplishing this goal in most patients. It is very unusual at our center for patients to report the recall of any significant discomfort at the completion of their procedure. It is important to discuss your preferences regarding your sedation with your doctor, who will work with you to incorporate your wishes into your sedation plan.
Can I drive home after sedation?
While the medications we use are very short acting there is not adequate data in the medical literature to confidently determine when psychomotor function returns sufficiently to allow safe driving. We instruct you not to drive or operate potentially dangerous machinery until the day after your procedure.
What if I want to see my colon...is that possible?
Just as some patients ask not to remember anything, others want to see some or all of their exam. You should discuss this with your doctor before the examination. In most cases patients sedated with propofol can be allowed to awaken during the withdrawal of the colonoscope, once the cecum has been reached. Colonoscopy is not usually uncomfortable once the cecum has been reached.
I always vomit after anesthetics...sometimes for hours. Will the drugs you use cause this reaction?
Virtually never. Low dose midazolam and propofol do not cause nausea.
Will I say something I shouldn't or divulge a private secret during sedation?
This seems to be a common worry. It is not unusual for patients to become talkative when under the influence of sedative drugs, and they often are surprised to hear things that they chatted about as they were "going under," during the exam itself, or as they recovered. Personally speaking though, in 24 years of endoscopy practice none of my patients have divulged a personal secret or anything else that they in retrospect thought was inappropriate during the examinations I have performed.
I had sedation for endoscopy or colonoscopy this morning and now I have fever, chills and muscle aches. What is going on and what should I do?
These symptoms are not expected and should be reported immediately to your physician. If you also have throat, neck, chest or abdominal pain or tenderness, an endoscopic complication such as perforation must be assumed to have occurred until proven otherwise. Early diagnosis and treatment is key to achieving the best outcome. If you have no other symptoms your fever, chills and muscle aches may be due to the sedative administered for your procedure, particularly if you received propofol. The FDA and CDC are currently investigating clusters of propofol-associated fever from around the country, as discussed here. Evaluation and treatment for bacterial sepsis is recommended if this problem is suspected.
I read about the Las Vegas outbreak of Hepatitis C related to nurse anesthetists reusing syringes and propofol vials. What are your injection practices?
We use only single-dose 200 mg vials of propofol at our facilities, which are not shared. If a patient needs more than 200 mg of propofol for their procedure a second new vial is accessed with a new needle and new syringe and the entire 200 mg is drawn into the syringe. Whatever amount is not needed to complete the procedure is then discarded. We do not reuse needles or syringes, or use single-use medication vials for multiple patients.
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If you need specific medical advice, please contact our office for an appointment.
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