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Yale Changes Anesthesia Protocol On Scopes: Propofol in, Fentanyl Out

CTBarristerCTBarristerMember
I have my annual scope at Yale next week and the nurse called me today for the usual pre-procedure battery of questions to update my chart. During this conversation she advised me that the anesthesia protocol has changed on colonscopies and pouchoscopies. The old standard of fentanyl/demerol cocktail is out and propofol is in. Not sure if this is related to COST or some medical decision that Yale made. Anyway if any of the medical professionals like Jan Dollar know what this is all about or can speculate in an educated manner I would like to hear their thoughts.

I know from PMs and other posts that several other posters treat at Yale Digestive Diseases so this is your heads up.

After I got off the phone with the nurse I immediately emailed my Doctor and told him in the past I had propofol, I had demerol/versed cocktail and fentanyl/demerol cocktails, and also had unsedated colonoscopies (been doing scopes for 42 years) and I do not want propofol and prefer conscious sedation. He emailed me back within a minute and said it was no problem and could be arranged.

Curious if anyone knows why Yale made this decision? I get that conscious sedation makes people groggy and they have to have others drive them to the exam whereas Propofol does not, but that is not an issue for me and I am likely to take the day off anyway. Is it this, or is this more of a cost related decision?

As a matter of interest, at last year's scope, my Doc was delayed while attending to another patient's emergency at the hospital, so they had to put me in the recovery room to wait for my procedure for about 2 hours. I then overheard a number of colonoscopy patients getting wheeled in post-procedure and speaking to their doctors in the recovery room. These were almost comical conversations as they were drugged out and their doctors were telling them about polyps and other bad stuff which 2 hours later they probably will not even remember being told any of that. It occurred to me that this could be a practical reason since with propofol you are not totally drugged out when you come to and can have a more meaningful immediate conversation with the Doctor. But to me it does not matter, as I will get his report and the pics and they, as well as the biopsy results once they come in, will all speak for themselves.

Anyone know anything more about what is behind this decision?
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ElmerFuddElmerFuddMember
Not sure the specific reasons at Yale. I do know I was usually given versed / ? to put me in a consciously sedated state.

I was surprised, then, to find that Children's Mercy hospital here uses Propofol pretty much exclusively for the kids' scopes. The reasoning is twofold: 1) Propofol does a good job of putting the kids out completely. Dealing with small bodies / colons, they don't want the kiddos moving around at all while being scoped. And 2) What you already referred to - the much quicker recovery time. And even with Propofol, my daughter was pretty funny afterwards Smiler

So I would guess both reasons play into their decision. Well, that, and the anti-narcotic movement that seems to still be present in the media and political worlds (which therefore affects decisions in the medical field).

Steve
Jan DollarJan DollarModerator, RN, retired
This seems like just a judgement call based on what they have learned over time.

Propofol is undoubtedly cheaper. The drug itself may cost more, but any time you can have faster induction and quicker recovery, that means less time in the OR or endoscopy room and in the recovery room. Time=Money. It does not mean you would be completely unconscious during the scope, as they often will have heavy dosing during insertion and the more painful parts, and lighten up before withdrawing the scope. It seems as safe as any other type of sedation. You just need to be monitored closely, as you would with any sedation.

And yes, for kids (and adults too) it is best if you are not squirming all over the table.

It is a hypnotic, so you still cannot drive yourself home after the procedure.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660799/

Jan Smiler
CTBarristerCTBarristerMember
Jan,

You kind of confirmed what I suspected, that propofol is more cost effective because of the time=money analysis. It is strange to me though, because my Doctor who is very well respected had a strong preference for using fentanyl/demerol combo which was made known to me in the past. However it is probably the bean counters that Yale employs to analyze stats on anesthesia that made this decision, and not my Doc or his colleagues. My prior GI Doc who was not at Yale and had his own private office had advocated a demerol-versed cocktail and not fentanyl and demerol, which had been advocated by my current Doc. Not sure why either one had those preferences in past years. I was always charged separately for the conscious sedation (it was a small component of the bill, less than $100).

The one year I had propofol it was by an anathesiologist who put me out cold, and then sent me a separate bill for $1500. However that was at a private GI doctor's office and I am sure Yale has their own staff anesthesiologist. I still worry that the bill for the propofol might be higher and Yale still ends up making money as it is more time efficient for them to use the Propofol and as long as insurance pays the bulk of it they will not care if they can justify using it based on some reasonable reason. On my insurance, I end up co-paying about $500 on Yale scopes after insurance pays what they pay, and something tells me the copay would be even higher with propofol based on past experience. Although I agree with you that for Yale it likely is more time and cost efficient to use propofol for reasons already discussed.
CTBarristerCTBarristerMember
quote:
Do most people get sedated I wonder?


The vast majority of people having scopes are colonoscopies and they need to be sedated. When I was in the RR for 2 hours waiting for my procedure to start, every single person they wheeled in was having their colon scoped.

With pouch scopes, the procedure is obviously less invasive and less uncomfortable, so it is a personal decision and sedation may be unnecessary for some or even most people. Because I am an IBD child of the 1970s when colonscopies were done unsedated and they did not believe in using sedation on kids, I had PTSD from these procedures and now I need the sedation. It is too long a story and only Jan, another IBD child of the 1970s, would likely be able to relate to this. Bottom line is it's a personal decision like deciding whether to donate organs or eat certain diets.
Jan DollarJan DollarModerator, RN, retired
Yes, not required or necessary in most cases, so it is a personal choice sort of thing for pouch scopes.

I had my first scope in 1972, but that was before they invented fiberoptics and there were no colonoscopies. Nobody was sedated for a rigid sigmoidoscope, pediatric or adult (they still don't sedate for those). Those were the ones they performed on that draconic tilt table with your ass in the air. Traumatic, yes. I was 15 at the time, so I at least was more of an adult than a pediatric case.

My first colonoscopy was probably mid to late 70s. I was sedated, but it was not the big affair that it is today. They did not even start an IV or put me on a cardiac monitor. The GI doc just gave me Valium and Demerol straight IV push and they put me in the break room to sleep it off after the scope. I never had a colonoscopy without sedation. With my HMO, the copay is the same, sedation or not.

As to why doctors have preferences that are different, it all depends on what they are used to. They are creatures of habit, same as anyone. They change based on professional standards or if the facility where they do their procedures have mandatory protocols. Opinions and standards are always in flux as new data emerges.

Jan Smiler
CTBarristerCTBarristerMember
quote:
I had my first scope in 1972, but that was before they invented fiberoptics and there were no colonoscopies.


I am using the term colonoscopy but that is a modern term and what I believe I had done was the rigid sigmoidoscope you describe. It was a very thick hard rubber tube, seemingly designed for giants, which was inserted at a harsh, unforgiving angle. I believe it was a one size fits all deal, like the NG tube was when I had it forced down, and I was a small kid with a teeny tiny rectum. I had it done, as I recall, throughout the 1970s with no sedation. My doctor did not believe in sedating kids- it was a grin and bear it situation. Like the old west/civil war days when bourbon was the best known anesthetic.

Modern IBD patients are spoiled now with soft, flexible narrow tubes, and even the NG tube now comes in a pediatric version, which was not available at the time I had it forced down.

These procedures were medieval type antics and the memories have never gone away.
Last edited by CTBarrister
Jan DollarJan DollarModerator, RN, retired
No, not a thick rubber tube in my case, but chrome steel always for me. When they described it to me, they said it would feel somewhat like a broom stick. Fortunately, it was not as long as a broom stick. They did not scope beyond the sigmoid colon back then. They used barium enema to examine the rest of the colon.

I probably misspoke about fiberoptics. They probably had been invented, but were not in use for endoscopy yet.

CT, please note that the rigid sigmoidoscope is still in use, and there are people here whose surgeon use it for their annual exam. While I do know that it has its place (some examinations require the rigid scope), a pouch scope is not one of them in my opinion. That doc could be God himself, and I would never consent to it.
skn69skn69Member
Yup, Mine were all without any sort of sedation, medication (other than that awful fizzy magnisium crap that I had to drink the night before (draino by any other name!) and that kept me in the toilet til 6am...they figured that I was groggy enough after that!)or anti-stress drugs...kids did not benefit from those niceities back then.
Yup, Huge, black rubber tube that I was pretty sure would come up my throat and out my mouth! Never screamed or yelled but more than one radiological orderly still has my nail marks in his writst.
Tilt table too...how awful, embarassing and traumatic can you get for an 8 year old,!
Did them most of my life pre-pouch and never benefited from any help, ditto for the pouch scopes (granted mine are abdominal and not anal now) and I want to see the darn screen and what is in there!
As for the prophenol, If I am not mistaken, that is what they have been using in Canada for years and here in France so maybe it is a trend? Quick in & out? No long stays in the recovery room, less risk of nasty side effects or need for 3rd party transportation?
Sharon
rachelravenrachelravenMember
I love Propofol. Sedated, but when turned off, metabolizes quickly and is out of your system. With our neuro vented patients, it's great, because you can turn it off and get good assessments, then turn it on and put them back to sleep.

I hate Fentanyl. Makes me nauseated and a groggy mess. I'm surprised you mentioned Demerol. That med is awful, and we never ever use it anymore. I tolerate Versed ok, but I hate feeling groggy after a scope, so I'll always vote for Propofol.

If the procedure requires pain meds, I request IV Tylenol. You'd be surprised, but IV Tylenol works pretty well.

I can tolerate a quick pouchoscopy without meds, though, but I often require some dilations, so I'm cool with the Propofol route.
Scott FScott FMember
I can't speak to the relative cost of propofol vs. alternatives, but in general these decisions are not made based on small cost differences. While people might disagree about how to prioritize the various factors, I think they're selecting what they honestly believe is best clinically, at least in their environment, with their staff.
CTBarristerCTBarristerMember
Rachel,

Demerol was always given to me as part of the conscious sedation cocktail, either with versed or fentanyl, every single year from 1992 through 2013. My doctors during that span of time were the top GIs in NYC and Connecticut working out of Mount Sinai in NYC and Yale New Haven Hospital in CT. I understand that some patients can get sickened by these meds but it never happened to me. Is that the only reason why you believe demerol is "awful"?

Regarding propofol, I have no doubt it is more time efficient, but I know the following as well: (1) unlike the conscious sedation cocktails, propofol MUST be administered by an anesthesiologist, which suggests to me that more things can go wrong with it (and you can check with Michael Jackson's mother on that one); and (2) I know for a fact I got a separate anesthesiologist bill with propofol which was much higher than what I paid for conscious sedation, when I had these procedures done in NYC and insurance was not covering it. I am sure Yale is only looking at the cost of buying these meds- they are not looking at the labor cost because the anesthesiologist who administers it is a staff anesthesiologist who will be getting paid the same amount of money whether they use propofol or not.

Most of you guys are focused on the cost to Yale, my interest is what is the cost to the patient. I do not doubt it may cost less to Yale to buy propofol but the labor cost is already borne and what I want to know is what is the difference in cost to the patient????????? How can it possibly be cheaper for the patient when Yale utilizes an anesthesiologist to administer propofol and you are billed for that anesthesiologist service, but anyone, perhaps even a properly trained monkey and certainly a nurse, can run an IV and inject demerol and versed, and you only pay extra for the cost of the drugs themselves?
Last edited by CTBarrister
Jan DollarJan DollarModerator, RN, retired
CT, my understanding is that propofol does not require an anesthesiologist for administration. However, it does require a dedicated staff (doctor or nurse) to monitor the patient. Obviously, requiring an anesthesiologist really increases the cost of a procedure. Protocols can vary by the facility, but that does not mean it is a blanket standard of care for the state or country.

Jan Smiler
CTBarristerCTBarristerMember
Jan,

That may be correct as to the standard of care varying with propofol, but when I had it administered in New York City, I was told very unequivocally that it MUST be administered by an anesthesiologist and that is why I got a bill for the anesthesiologist. The only reason for the existence of that anesthesiologist at the GI's office, I was told, was to administer propofol on the day he did scopes. No anesthesiologist ever gave me conscious sedation, but propofol was given to me by an anesthesiologist.

It was a year or two later that Michael Jackson died from self administering excessive propofol under the watch of Dr. Conrad Murray, who was not an anesthesiologist. In the news reports I read at that time, I heard or read that he had committed malpractice by not having an anesthesiologist administer the propofol. Although allowing Jackson to self administer the drug as he pleased was likely itself malpractice.

I am going to discuss this further and dig more into this issue because I am certain I was told in NYC that it had to be given by an anesthesiologist. It's true that may be due to New York law. And my scope is being done in Connecticut, where I never had propofol before for any procedure.
Last edited by CTBarrister
Jan DollarJan DollarModerator, RN, retired
It certainly is possible that there are local laws governing how propofol is administered, but it probably was just hospital protocol. However, what you were told and understood to be true before, could now be obsolete. Medical standards and protocols are constantly changing.

Here is a Gastroenterology position statement from 2009 that pretty much tells all you need to know. http://www.google.com/url?sa=t...vm=bv.69411363,d.cGU

You really cannot compare propofol administered by doctors and nurses specifically trained for it, to the off label use by Michael Jackson and his doctor. He was left unattended! Obviously, a sign of someone untrained in its administration.

Jan Smiler
rachelravenrachelravenMember
I administer Propofol to ICU patients daily without an anesthesiologist, though the amounts I can give are lower than what anesthesia can give, and we don't "push" the med any longer, unless an MD (not necessarily an anesthesiologist) is present (we can give in a continuous titratable drip).

But no way would you want what they push given in a conscious sedation scope! They'll push 200mg without blinking an eye during an intubation.

Demerol has fallen far out of favor in the opiate world. It is shorter acting as an opiate, it metabolizes into toxic metabolites. Granted, a one-off dose from a scope is less likely to be problematic, but MDs have been taught and advised to use other opiates. We don't even stock it in our Accu-doses anymore, just because there are better and safer opiate choices these days.
CTBarristerCTBarristerMember
Jan and Rachel,

Thank you for your posts, they are very informative and they make a lot of sense to me. I can understand now why Yale likely made the decision to use propofol as their "standard scope anesthesia", but I am still going to reject it in favor of conscious sedation. I will go with either fentanyl or demerol and versed - neither combination was ever a problem in the past. I have never done a pouchoscopy without sedation, for reasons already discussed, and the grogginess post-procedure is not a big deal since it is an off day for me anyway and I am being driven to and from my home.

I have had 3 different scope sedation protocols (really 4, if you include the no sedation procedures of the 1970s) and I am always curious to know the reasons for the changes, and your posts have helped me understand where they are coming from.

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