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What are My Options for Sedation During My Upcoming Colonoscopy?

What are My Options for Sedation During My Upcoming Colonoscopy?

By Benjamin Krevsky, MD, MPH | May 23, 2017

Many people are nervous about getting a colonoscopy performed. The most common concerns are the preparation, the need to take time off from work, finding out that they might have cancer, embarrassment, and pain during the procedure. This prevents many individuals from having the very procedure that could save their lives.

While most people know that there have been great improvements in the cleansing preparations (less volume, better taste), and less time off from work (open access colonoscopy eliminates the office visit needed prior to the examination), very few people know much about the types of sedation that are available.

First, it will be helpful to define the various levels of sedation that are possible. 1) None. That means that no medications are given. ‘Nuf said.  Very few people choose this option. 2) Light sedation. This is just what it sounds like. Although one is sleepy, the patient can still respond to verbal commands and can feel pain. There is no effect on breathing or cardiovascular function.  3) Moderate sedation (also called Conscious Sedation). This is a little deeper than light sedation, yet the patient can respond purposefully to verbal or physical stimulation. There is usually little or no effect on ventilation or cardiovascular function (low risk). Most patients will have no memory of the procedure while under moderate sedation.  4) Deep sedation. This is deeper still, and patients will respond to repeated painful stimulation, but usually non-purposefully. Breathing may be impaired, as may cardiovascular function. The patient will have no memory of what happened while under deep sedation (amnesia). 5) General anesthesia. In this case, the patient does not respond to painful stimulation at all. Breathing is usually impaired, and airways support and ventilation are usually needed (e.g., a tube placed in the lungs and a ventilator machine providing air). Cardiovascular function may be impaired as well.

The level of planned anesthesia determines who will be administering the sedation. For example, light or moderate sedation are usually administered by the Gastroenterologist performing the procedure. Deep sedation and general anesthesia are administered by a nurse anesthetist or anesthesiologist.

Most patients tell me that they want to be totally asleep during the procedure (“Just knock me out, Doc.”) That would mean general anesthesia. But this level has a higher risk for a complication, so when I explain the options, most patients are agreeable to a lower level of anesthesia.

Pros and cons of different levels of sedation for colonoscopy

None. I perform totally unsedated colonoscopy about once or twice a month. This is in patients who – for various reasons – do not want any sedation. The big advantage is that the patient recovers immediately after the procedure and can go to work or drive right away. They do not need anyone to accompany them home. It also eliminates the possible complications that can occur with any form of anesthesia. While the procedure itself can cause some cramping or gassy abdominal pain, this can be minimized through the use of carbon dioxide to inflate the colon and special techniques to advance the scope. If you want this, make sure that the gastroenterologist has experience doing unsedated colonoscopy. You don’t want to be the doctor’s first one!

Light sedation. This is rarely done. Since medications are administered, the risk of complications is present. Also, the patient will need to be accompanied home and should not do regular activities until the next day. But since the sedation is light, there is no effect on pain –the patient feels and remembers everything.

Moderate sedation. This is one of the most common forms of sedation used. The medications are usually midazolam and fentanyl – a mild sedative and a pain killer. This is a nice, safe combination, and usually causes amnesia for the procedure. The risk is if too much is given. To avoid this, it is given slowly, with appropriate monitoring. At Temple University Hospital, the doctor and a nurse are with the patient the whole time. The vast majority of patients are satisfied with this sedation.

MAC. This stands for Monitored Anesthesia Care. It is administered by an anesthesia professional who is in the room with the gastroenterologist and a nurse or technician. This is usually selected when there are concerns about the patient’s lungs, heart, or tolerance to midazolam or fentanyl.  The medicine used for this type of sedation is propofol - yes, the same medicine that was abused by Michael Jackson. However, unlike Michael Jackson, the propofol for colonoscopy is given by a trained professional under constant supervision and monitoring. The depth of sedation with MAC is sometime moderate sedation, but is usually deep sedation.

General anesthesia. This is almost never used for colonoscopy. General anesthesia is usually reserved for patients with severe lung disease, unstable airways, and particularly long procedures.

So how do I decide what type of sedation I should get for my colonoscopy?

It’s simple – talk to your doctor. If you are meeting with the gastroenterologist before the procedure, simply ask what type of sedation is planned. Discuss the pros and cons, and of course, your preferences and concerns.  If you are scheduled for open access colonoscopy, you can call the office of the gastroenterologist prior to the procedure to see what is planned. If you want to discuss the sedation further, you should be able to speak with a nurse or doctor prior to the procedure to allay your concerns.

While we can’t make the bowel preparation more pleasant, we certainly can make the actual procedure a comfortable one.   

About the Author

Benjamin Krevsky, MD, MPH is a Professor of Medicine at the Lewis Katz School of Medicine at Temple University in the Gastroenterology Section. Dr. Krevsky is regularly listed as one of the Best Doctors in America and has been selected as a Top Doctor in Philadelphia Magazine for 2017. He is an active clinician and educator, having published over 200 papers, audiotapes and books. His clinical interests include colon cancer screening and treatment, anorectal disorders, motility disorders, and endoscopic treatment of gastrointestinal diseases. He has been honored with selection as a Fellow of the American College of Physicians, American Society for Gastrointestinal Endoscopy, American Gastroenterological Association, and American College of Gastroenterology.