Expert: Ronald Levy, M.D. - 3/3/2008

Question
QUESTION: Hi, I know that most people are happy with the amnesia caused by sedatives such as midazolam (why would you want to remember a colonocopy???), but I won't go ahead with the procedure if these drugs are used. I NEED to be aware of what's going on, and to remember it.

My gastroenterologist has offered me iv ativan instead of versed on the grounds that it's less sedating. A quick internet search suggests that isn't true.

I know that many people can tolerate colonoscopies without sedation. I suffer from anxiety and IBS, so can't guarantee I'd be OK.

I would be getting a narcotic painkiller anyway. Do I need sedation on top of that? Can you recommend anything? Can I trust my doctor not to give me something which will knock me out???

Thanks.

ANSWER: The first question is "Why do you NEED to remember your colonoscopy??" Ativan also causes sedation and can cause amnesia as well and I would suggest some sedation for this procedure. IF you don't want it and your doctor agrees then you can trust that he won't go against your wishes. Understand however that if the mild sedation is not enough, he would have to abandon the procedure if you don't want deepewr sedation.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: PS I just read the coincident posting regarding sedation for colonoscopy. Likewise, I have researched the topic and found study results such as:
a) 17% of Europeans and most Norwegians do not have sedation;
b) 20% of GI nurses and 0% of non-GI nurses did not want sedation;
c) in many studies of having the procedure without sedation, the majority, largely the vast majority, of procedures were completed satisfactorily (cecal intubation).
I've read a couple of accounts (from the UK) where the patients decided not to have the analgesia even, and were fine with the procedure.

I've also read individual accounts of people not knowing that the sedation causes amnesia until after the event, at least one other account of signing consent forms after the drugs had been administered, and also of someone asking to be lucid for the procedure then being amnestic for the event.

The concept of colonoscopy without sedation seems to be a particular problem for doctors in the States. I'll ask the allexperts gastroenterologist about it when he's back in March.

I would prefer mild sedation. My "trust issues" mean I will be at least as anxious about not being given too much as about the procedure itself. I thought that before I read the experiences described above!

Just to confirm, you don't think the narcotic analgesia would have sufficient sedative effect and "mild sedation" would involve a small amount of an additional sedative?  

Answer
What they do in Europe is not necessarily what is best for the patient but might be what is less expensive. This is not true in all cases but England does have a socialized system. I can tell you that whn I was in medical school in Israel (another socialized system) they did not give laboring women epidurals and the urologist did cystoscopies with just lidocaine jelly. I doubt it was because they weren't requested or warranted. Yes you certainly can have a colonoscopy without any sedation or analgesia and you will do fine. It may be extremely uncomfortable, but if you're willing to put up with that, no problem.To answer your question, narcotics do not have sedative effects, per se. They can make you sleep but you will be arousable. I suggest that you discuss your concerns and wishes with your anesthesiologist who will do whatever they can to make your experience tolerable.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston