Expert: Ronald Levy, M.D. - 5/16/2011

Question
I just had my first screening colonoscopy at age 40 since my mother had colon cancer.  My discharge paper stated I was given 11 mg of Versed and 75 mg of Demerol for the procedure.  Starting 6-8 hours after the procedure, I began feeling agitated and restless -- to the point that work the next 2 days was difficult.  My first day back to work (the day after my procedure) was very difficult.  I work with the public all day, and I had to mask my agitation (I'm expected to be professional).  By the end of the day, I felt terrible.  I got home and broke down (I cried for an hour); I'm not normally an emotional person.

I called my doctor the next day.  I had read online that the standard dose of Versed is 1 - 2.5 mg initially, with additions up to a total of 5 mg.  I asked my doctor about my side effects and my concern over my apparently high dosage of Versed.  The doctor was very nice and listened to my list of symptoms.  He said that what's listed on a package insert (ie, what I'd read online about Versed) isn't always what's practiced in a 'real world' setting.  He said I was given a 10 mg initial Versed dose (along w/ 75 mg Demerol), and I was given an additional 1 mg later in the procedure because I was moving and talking (which he interpreted as my being uncomfortable).  He said that while my reaction to Versed is unusual, it can happen in a small percentage of patients.  He suggested using propofol (+ a 'very small' dosage of Versed) for my future colonoscopies.  Over the course of 3-4 days, my agitation and fragile emotional state improved, although I remained mentally 'foggy' and somewhat depressed for about 10 days.  Now, 2 weeks later, I'm finally feeling basically normal.

My concerns are the following:

Was 10 mg of Versed too high of an initial starting dose?  Nowhere have I read that intial dosages should be this high (I am a 135 lb. male).  My concern is that the drug wasn't given long enough to take effect.  I was also told by a nurse when I called back later that they frequently use 10 mg Versed in patients.

Do you agree that propofol is the best option for me in the future?  Is it necessary to give any Versed at all (even a much lower dose), given my bad reaction to it?  If propofol needs to be given with another agent, are there other good options besides Versed?  I do not particularly like the thought of amnesia.  If I'm truly 'out' from the propofol, is an amnesia-producing drug necessary?

A final concern is whether to choose another doctor in the future.  I don't expect you to specifically say yes or no.  While I think I received a good-quality colonoscopy (I have many good pictures!) and I was pleased with how my doctor responded to my concerns when I called 2 days later, I have some lingering concerns with his overall judgment.  I don't blame the doctor for my 'paradoxic reaction' to Versed; he had no way of knowing since it was my first time being sedated.  What I do question, however, is the high initial dose of Versed he used.  Even though I may have had a reaction to a lower (standard) dose, I truly feel that the degree of my symptoms was related to my high dose/overdose.  Bottom line:  if I'm uneasy about the doctor's judgment with regard to the drug dosing, how comfortable should I be with his judgment on other things (ie, the quality of the colonoscopy)?  Asked another way, was this initial dose outlandish or somewhat common?
Thank you.

Answer
I can only speak in generalities as I don't know the specifics. In general, an initial dose of versed for a person your age and weight would probably be 4-5mg. That being said, I would continue to titrate it up based on your comfort level. talking is not an indication of discomfort and as long as you are not moving so much as to impede the procedure, I would not give more. I would also use a narcotic, like Fentanyl, which takes care of the pain aspect. The Versed is primarily for relaxation, sedation and amnesia. Giving a standard starting dose of 10mg to allcomers is not reasonable to me but I imagine that you did not have an anesthesiologist doing your sedation, rather a nurse or the doctor himself.
As for Propofol, most endoscopists are not trained to use it so you would likely have an anesthesiologist or nurse anesthetist providing that. It does not put you completely to sleep (when used as a sedative) and works best in conjunction with Versed (although it can be used alone). Propofol also causes amnesia. As for whether you should change doctors, I cannot say. If you have your next procedure with him, make sure he remembers the reaction you had and he should tailor your sedation accordingly or get an anesthetist to provide the sedation.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston