Expert: JM Starkman, MD - 7/16/2011

Question
Hi Dr. Starkman,

I will apologize in advance for my lengthy post; my question really isn't that complicated, but I wanted to make sure I gave you as much information as possible.

I had my first screening colonoscopy recently (I just turned 40) since my mother had colon cancer.  I was sedated with 11 mg of Versed and 75 mg of Demerol (I am a male and weigh about 140 lb.).  On numerous websites I’ve read, this dose seems quite high for someone of my weight.  Apparently I was stable and everything was fine for my procedure, but the degree of amnesia I experienced was unexpected and upsetting.  Of course I had been informed about amnesia, but I only have partial memory even of events that took place 4-6 hours after I arrived home.  I have zero memory from just after watching the doctor inject my IV with the sedatives until about 1 hour after arriving home.  Starting the evening of my procedure, I began feeling agitated and restless.  I could not sleep the first night.  The next two days at work were really difficult.  I felt so agitated, but had to keep everything bottled up so I could function as normally as possible.  I was also much more fragile emotionally than usual, and my mental processes were foggy and slow (I half-heartedly joked with colleagues that I felt like a computer that needed an upgrade).  I had to think about my next words when speaking with someone – even just about simple everyday things.  I experienced a period of depression/PTSD that lasted about 8-10 days.  I just wasn’t myself for about 10 days after the procedure.

I did call my GI doctor (who administered the sedative agents himself) 2 days after my procedure, and he was very receptive and listened to my concerns.  He showed respect toward me, and I certainly plan to use him again for my future procedures.  He said that while my reaction/side effects were not common, they can happen.  He advised propofol + ‘a very small dose’ of Versed for future procedure(s) under the direction of an anesthesiologist.  Since I don’t have to worry about another procedure for another 5 years, I didn’t ask many questions beyond that, and we certainly did not go into specifics.

In researching the propofol option, I’ve come across the following protocols: 1) single-agent propofol, 2) propofol + Versed, 3) propofol + opioid, 4) propofol + Versed + opioid.  Apparently, the various options each have their pros and cons.  The addition of other agents can lessen the dose of propofol required, but the additional agents can have side effects of their own.

Here are a few of my thoughts and questions for you:

1)  I don’t mind being completely “out” during my procedure, but I would prefer to remember at least some of the recovery room events, the discussion with the doctor afterward, my discharge, and the trip home.  Is this an unreasonable request?  My concern is that any Versed (even a much lower dose like 0.5 – 1 mg) would still cause amnesia and potentially some of the agitation and depression I experienced with the higher dose.

2)  If you were in my situation, would you opt for single-agent propofol, or would you choose one of the cocktail protocols?  To me, single agent propofol sounds best (or maybe even propofol + opioid), but I am hoping you can educate me on the pros and cons of the various options.

3)  I have some anxiety toward what options I will be given with regard to propofol.  Since the propofol option is “on the table,” (my GI doctor was the one who suggested it) would you expect that there would be options regarding the use of other adjunctive drugs as well?  While I plan to talk with my GI doctor at the time I schedule my next procedure (to make sure it gets scheduled at a hospital with propofol given by an anesthesiologist), I doubt I will speak to the anesthesiologist until the morning of my procedure.  My concern is that my wishes/preferences may be dismissed by the anesthesiologist.  While I want to be involved in the decision-making process (after all, the drugs will be going into ME), I don’t want to come across as a difficult patient who mistrusts my doctors.  I hope they see me as a patient who had a prior negative response to a drug who wants to ensure a smoother procedure this time.  Are there any suggestions you have for how to get everyone on board, yet not be viewed as another difficult patient who reads too much on the internet?

Thanks for your time.

Answer
Dear Al,

Thanks for writing--but I've covered almost every issue about which you have written in other answers/posts previously. Read them. Bottom line:  If you want a properly administered anesthetic, then an anesthesiologist is the one who ought to be doing it.  Gastroenterologists have a 'speck' of anesthesia training compared to anesthesiologists.  Of your next anesthesia experience request a board certified anesthesiologist and no cocktail but a 'straight propofol' anesthetic.  I've administered the anesthesia this way for thousands of colonoscopies with no side effects, esp prolonged amnesia.  And please do not ask me to perform your colonoscopy.  Good luck.