Expert: JM Starkman, MD - 8/25/2009

Question
What do you recommend for anesthesia (conscious sedation) for endoscopy screening procedure for a patient with pseudocholinesterase deficiency? We usually use fentanyl and midazolam, and this patient has a paradoxical effect to lorazepam due to the benzo class inhibition of cholinesterase. I've searched a few reference sites without answers. do they recommend smaller doses? Do they recommend diprivan instead of midazolam?

thanks for your help.
Corinne Rph

Answer
Propofol as the sole agent is reliable and quite safe in trained 'anesthesia' hands.  Its only contraindications are egg or soy allergies, but when I have test-dosed even these patients they test negative and proceeding has not presented any issue at all.   Trained anesthesia means all the usual things about being able to manage the complications of this drug---don't utilize propofol sedation or anesthesia unless you are familiar with its use!   The efficiency of any endoscopic screening service increases greatly when propofol is utilized and administered by an anesthesiologist who can also modify existing protocols to more effectively expedite admission and discharge from your location(s).

Effective doses of midazolam for many endoscopic procedures take too long to completely 'wear-off' to make them a standard-of-care any more. Please consider a "new millenium revamp" of your sedation/anesthesia protocol.