Sunday, March 2, 2014

Colonoscopy - Knock 'em Out or Not?

Colonoscopies and Sedation

In the United States, individuals remember the prep much more than the procedure.  This is because, unlike most of Europe and Asia, colonoscopies are done under sedation.  What is sedation, and what are the pros and cons of having a colonoscopy without the sleepy-time option?

First, many individuals don’t understand what it means to be sedated.  Sedation is often confused with general anesthesia – and rightfully so.  The main source of the confusion is that sedation and general anesthesia can be induced by the same drug – one is just a deeper state than the other.  In colonoscopies, drugs like midazolam and Propofol (yes, the same drug that was found in Michael Jackson’s system) are used.  Because sedatives are not analgesics, they are frequently paired with drugs like fentanyl to reduce the pain associated with the procedure.  Basic IV sedation does not require substantial airway management and is generally done using a skilled nurse and does not require an anesthesiologist. 

The level of sedation used varies by practitioner – it can go from mild conscious sedation, where the patient is “awake” but not completely aware to full anesthesia (no responsiveness to even painful stimuli).  Because amnesia is one of the side effects, the patient may not even know how “deep” they were under.  Not remembering a colonoscopy can be a positive thing, but is it necessary?

Anesthesia has become much safer since the days of ether in the operating room.  The rates of death due primarily to anesthesia are now believed to be along the order of 1 in 100,000 (back in 1950 the rate was closer to 1 in 1,000).(1)  With 15 million colonoscopies a year in the US, this would mean an average of 150 deaths per year due to the application of anesthesia, but only if anesthesia didn’t prevent other risks.(2)  Unfortunately, the data shows that anesthesia also increases the risk of splenic rupture and other fun things – this is believed to be due to the sedated patient not being able to communicate when things go wrong.(3,4)
Despite the potential for complications, the primary driver for not using anesthetics isn’t safety, but cost.  A typical Propofol administration can add anywhere between $600 and $1,000 to the cost of a procedure.  When screening colonoscopies are recommended for the masses, this may mean an increased healthcare cost of over $1 Billion per year.(5)  Given finite health resources, the societal question becomes one of the greatest application of funds.

Most patients, when provided the opportunity to have sedation free colonoscopies, are able to tolerate the procedure fairly well.  Only 2.3% of patients rated the pain “moderate” or “severe” when provided a sedation-free procedure.  Most rated it as non-existent or mild.(6)  The population used, however, was the screening colonoscopy population – individuals less likely to need extensive polyp removal or navigation through strictured areas.  A recent study looked specifically at this issues facing IBD patients and found that those with intestinal inflammation required more sedation (and analgesic application) than those without inflammation.  This may suggest a bifurcated approach – using sedation with IBD patients and no sedation for screening colonoscopies.(7)  Or, perhaps, a hybrid approach that allows for patient-directed sedation.(8)

There are other intangible benefits to the non-sedation colonoscopy as well.  These include less time spent with the procedure and the ability to drive oneself home afterward (a major benefit for those of us that are single and have to rely on friends).  These may outweigh the discomfort factor for some individuals.

The use of sedation is largely a personal choice in the US.  Since most health plans will pay for it, there is minimal individual cost.  The small amount of increased risk may be a consideration for some, but the increased pain likely with those suffering from IBD (and increased duration) may counteract that.  Ultimately, it comes down to personal choice.

Bottom Line

·         There is an increased risk of death and complications in sedation colonoscopies, though it is not large.
·         The costs associated with sedation are large for the healthcare system overall, but not for the individual patient.
·         Those with IBD may have more severe and longer pain when having colonoscopies performed than those having a screening colonoscopy.
·         Sedation is an individual choice – it can always be added (as long as an IV has been started) if a patient begins to feel too much pain.

1.       Lienhart, Andre, Yves Auroy, Francoise Pequignot, Dan Benhamou, Josiane Warszawski, Martine Bovet, and Eric Jougla. "Survey of anesthesia-related mortality in France." Anesthesiology 105, no. 6 (2006): 1087-1097.
2.       Seeff, Laura C., Thomas B. Richards, Jean A. Shapiro, Marion R. Nadel, Diane L. Manninen, Leslie S. Given, Fred B. Dong, Linda D. Winges, and Matthew T. McKenna. "How many endoscopies are performed for colorectal cancer screening? Results from CDC’s survey of endoscopic capacity."Gastroenterology 127, no. 6 (2004): 1670-1677.
3.       Eckardt, Volker F., Gerd Kanzler, Thomas Schmitt, Alexander J. Eckardt, and Gudrun Bernhard. "Complications and adverse effects of colonoscopy with selective sedation." Gastrointestinal endoscopy 49, no. 5 (1999): 560-565.
4.       Cooper, Gregory S., Tzuyung D. Kou, and Douglas K. Rex. "Complications following colonoscopy with anesthesia assistance: a population-based analysis." JAMA Internal Medicine 173, no. 7 (2013): 551-556.
5.       Fleisher, Lee A. "Assessing the Value of “Discretionary” Clinical Care The Case of Anesthesia Services for Endoscopy." JAMA: The Journal of the American Medical Association 307, no. 11 (2012): 1200-1201.
6.       Takahashi, Yuuichi, Hideaki Tanaka, Mitsuyo Kinjo, and Ken Sakumoto. "Sedation-free colonoscopy." Diseases of the colon & rectum 48, no. 4 (2005): 855-859.
7.       Kale, V., C. Dunne, M. Ahmed, S. Lee Chun, G. Cullen, H. Mulcahy, and G. Doherty. "PATIENTS WITH INTESTINAL INFLAMMATION REQUIRE MORE SEDATION DURING COLONOSCOPY." Gut 62, no. Suppl 2 (2013): A9-A10.

8.       Leung, J. W., S. Mann, and F. W. Leung. "Options for screening colonoscopy without sedation: a pilot study in United States veterans." Alimentary pharmacology & therapeutics 26, no. 4 (2007): 627-631.

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