Expert: Ronald Levy, M.D. - 10/4/2010

Question
Hi Dr. Levy:  I have to get frequent colonoscopies due to a genetic problem. During the first one I have an severe allergic reaction to midazolam so they tried propofol for the second one; and I had much more severe allergic reaction to the propofol.  Luckily an anesthesiologist was present; they said that I'm definately allergic to both and this is quite rare.  So I'm not going to tempt fate again with sedation; I finally got the exam with nothing and it wasn't bad.  The GI doc said that she would have an easier time finishing the exam if I got some painkiller (fentanyl) and since I had it before without issue we scheduled my next exam with fentanyl only.  When I went for the exam, I was surprized to find out that a CRNA would be administering the fentanyl; I understood that the GI nurses could give the fentanyl/midazolam combo but not the propofol and could not see why a CRNA had to give the fentanyl as a single drug.  I tried to explain that my insurance didn't cover the $700 for CRNA services for colonoscopy, but she insisted that a CRNA had to administer anything but the standard "cocktail" of fentanyl/midazolam.  The dose was not supposed to be unusual and allergies were not a factor.  The CRNA kept insisting that a CRNA needed to be involved in my case and that was that.  When I declined to sign the consent for her services, she questioned my decision and said that having a CRNA was essential for safety.   The GI doc spoke with her and told me that having a CRNA is always a good idea; but when I asked her if it was worth $700 out of pocket, she said "probably not".  I asked why the GI nurse could give the midazolam/fentanyl combo but a CRNA was "required" for just fentanyl alone and got no answer.  I cancelled the test.  A nurse later offered her opinion that the CRNA had been scheduled by mistake for my case (only one that day) and that she obviously wanted to get paid.   My question: is there any reason that a GI nurse can give fentanyl/midazolam but not fentanyl alone?   The GI doc said that the plan was to use 50-100mcg with the combo the first time and about the same as a solo agent.  I'm  never going back, but I'm curious if there is any reason for this situation.  Thanks

Answer
There is no reason. That CRNA was not being very ethical and while it is not a prosecutable offense (It is safer to have an anesthesiologist/CRNA), it is not required and if your insurance doesn't cover it, then you have the right to say no. Monitored sedation doesn't just cover Midaz/Fentanyl. It covers any combo of sedation meds (short of Propofol) that they want to give.


Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston