Expert: Ronald Levy, M.D. - 4/12/2011

Question
I'm high risk and quite late (10 years) getting a colonoscopy; mainly because of the seadation required....I had outpatient ortho surgery and the "conscious sedation" administered by a nurse was a nightmare and several friends who have had the same for colonoscopy swear that they will never have any procedure or surgery with conscious sedation again.  I understand that I'm an exception to the rule that most people have great seation experiences, etc, but mine was awful.......twice actually.  Anyway, I'm bleeding and my PCP is insisting that I get a colonoscopy.  The anestheisa that sounds good to me would be nothing; I'll gladly endure the pain rather than risk the sedation, but my PCP is reluctant to agree.  The endo doc told me about patient-administered drugs (PCA) and this is fine with me..but the CRNA told me that they didn't have the pump (?) for this really great option...she agreed that PCA (remifentanyl/propofol mox) was great and appropriate, but that they didn't have the pump so I had to let her administer the stuff. Sorry, I have herad this before and the outcome was terrible.  Question: whay can't the CRNA be the PCA pump?  I mean, can't she mix the remi/fent mix, run it via infusion pump (which they do for bolus administration all the time) and I tell her when and if I want sedation?  The endo doc agrees that this is a viable idea, but the CRNA says it won't work.  Any reason that this won't work?  I'm sorry that I'm asking the CRNA to spend a few more minutes on my case, but it's for a good reason.  thansk

Answer
First of all, I have never heard of a PCA pump for giving sedation as you describe. That being said, the anesthesiologist/CRNA (by definition) is your PCA pump. The role of the anesthesiologist is to provide sedation, pain relief and amnesia and the primary way we do that is to check the patient and find out if they are comfortable or need more sedation. I'm sorry you had a bad experience but if your sedation was administered by an endoscopy nurse and not an anesthesiologist/CRNA then the next time I would have the latter. Sedation nurses have a limited arsenal of what they can administer and when they max out on that, they either push through or cancel the procedure. An anesthesiologist has a wider selection and can take you all the way to general anesthesia if necessary.

I would talk with your anesthesiologist and explain the problems you had in the past and let them choose an appropriate sedation. I would certainly not recommend doing it without sedation.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston