Prior to a breast or bone marrow biopsy, intravenous sedation is typically offered to, and accepted by, patients.
But, what if some don’t really need such heavy sedation?
Over at Better Health, Harriet Hall wonders if some patients would do just fine with a simple local anesthetic: “Has it become a knee-jerk reflex to sedate everyone as a general principle? Why? To avoid complaints and keep patients more cooperative during procedures? Are we paternalistically deciding that it is better if the patients don’t remember the procedure? I wonder: if minor procedures are not remembered, might the mystery increase anxiety and fear of the unknown for future procedures? We must ask seriously whether IV sedation is done more for the patient’s benefit or the doctor’s.”
There’s something to be said about a cooperative patient during a procedure. Movement due to discomfort or pain can make a biopsy or minor surgical operation more difficult.
But that said, recovery time is longer with heavier forms of sedation, and the patient is exposed to a greater potential of side effects and complications.
Ultimately, the choice is up to the patient, and it should be an informed one. Although I can envision most opting for intravenous sedation for many elective procedures, physicians shouldn’t assume that’s always the case.
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- The dynamics between the surgeon and anesthesiologist in the operating room
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{ 13 comments }
All of my patients prefer heavier sedation than less sedation. It is not a pleasant feeling to remember a colonoscopy! I think less sedation is tantamount to torture.
I think it depends on the patient and on the procedure. For my colonoscopy, I did prefer the sedation. It wasn’t something that I cared to remember.
But I’ve also had a core needle biopsy of an abdominal tumor. The tumor was right underneath the fascia, so pretty close to the surface. There was one nurse who really wanted to sedate me but the doctor let me choose. I chose not to and it was fine. I got some local anesthetic and the whole thing was over within 15 minutes. It wasn’t an uncomfortable or unpleasant experience and I was happy to be able to go home that much sooner.
I had IV sedation for a breast biopsy 15 years ago and wish I’d had just the local anesthesia. Holes in the memory are especially disturbing for survivors of child abuse.
I asked for and got the lightest possible sedation for my colonoscopy and remember the whole thing. It hurt when the scope turned the “corners” but no more than having my drains removed after bilateral mastectomy, and no one offers you so much as a baby aspirin for that.
Heavier sedation gives an opportunity for medical students to be involved without scaring the patient. What patient wants to hear during the procedure “I’ve never done this before”, “oops” (or worse) or from the attending, “don’t worry, we can fix it”.
Thank-you, Dr. Kevin, for clearly stating that the decision rests with the patient and the consent must be INFORMED.
Support of informed consent by doctor-mentors has far reaching value.
Hope your readers are listening carefully.
This is a sensitive issue for me – I’ve had a lot of procedures – including colonoscopy – and a few years ago I began refusing consent for Versed – for the very reasons recounted here – the retrograde amnesia is far more disturbing than the discomfort from the procedure. I never connected my feelings with history of child abuse – but I think it may apply in my case as well.
Last time the anesthesiologist called me a control freak. Yeah, I felt comforted and trusting with that attitude.
I've had lots of procedures done with only local anesthesia or nothing, including D&Cs, a tubal ligation and a colonoscopy. Although sometimes uncomfortable, I much prefer that to not remembering parts of my life. I always have a vein open so that I can "opt out" at any point, though!
I think it's the result of being forcibly restrained before my tonsils were removed, just before I was 3yo. I do remember that part and it is not a good memory.
Plus, I only have to recover from the procedure, not from the sedation. I left the GI clinic within 10 minutes of finishing the colonoscopy. Just had to get dressed and leave.
Bone marrow biopsies are incredibly painful. Often time, time restraints with trying to get many blood products in, get a central line placed, leukophoresis, and start chemo on our new leukemia patients prevents use of conscious sedation for bone marrow biopsies. I’ve only seen one patient agree to have a 2nd without IV sedation. It’s downright barbaric that we do them ever without conscious sedation in my mind. The patients squirm, cry, and even yell. Why do that to someone when there’s alternatives, generally accepted as safe?
As a patient and a CRNA and a clinical hynotherapist I have been in all 3 worlds.
I REALLY think the best way to go is with Hypnosis sedation via iPod. I had 2 1/2 hours dental surgery with just local and shocked the surgeon. He said I was more sedated than his sedated patients.
One can be relaxed and cooperative with hypnosis. It works. The iPod can stay out of the way with just little ear buds and the volume can be set and controlled so the personnel don’t have to worry about that issue.
I have a CD for pre-op anxiety that I give my clients and then the CD specifically for intr-op surgery use
I had a bone marrow biopsy ( I did it as part of a study, for money, when a poor student) and it was done with a local shot and it was nothing very bad, and I knew to expect discomfort. So I guess YMMV.
On the other hand, I know I’d NEVER have a liver biopsy unsedated.
Informed patient choice is the better approach and I’m suspicious, frankly, of the “should we routinely offer” approach.
I think it’s a money-saving measure in guise of concern for patients. The side-effects are not nothing, but I suspect what matters more to the kindly concerned voice, is procedure time, monitoring, staffing – well, cost.
And announcing sedation is not routinely necessary is the first step to saying “we don’t do that routinely and no you can’t have it, unless you want to pay for it on top of your health policy.
Sedation for colonoscopy is safe, if you want it fine, but a lot of us don’t. Unsedated colonoscopy is far safer (you can’t perforate an unsedated patient’s colon, they will get up and smack you) and all sedation drugs carry some risk. Many people find the amnesia caused by sedation drugs haunting. I needed a colonoscopy because of symptoms and had a heck of a time geting one without sedation. Once after agreeing to do the exam unsedated (after I told them of my horrible Versed experience), a CRNA tried to “force” me to agree to Propofol at the last minute! It’s obvious that a lot of gastros use sedation just to make their job easier and faster. Finally I found a real doc who agreed to do my colonoscopy unsedated; she listened to my Versed horror story and literally said: “holy s**t” I guess that you don’t want Versed! She mentioned propofol in passing as the drug that killed Michael Jackson and we agreed that was a bad choice for me also. It was so nice to have the exam done by someone who wasn’t rushing, watching the screen and remembering what she told me. No chemical lobotomy from sedation. I guess that I was tired after the exam (which was painless) because the doctor said that I looked tired; the nurse took me into a room with a real bed and told me to take a nap. After about an hour of sleep (and farting), I was surprized that someone was watching me sleep and offered me food when I woke up. What treatment!
ToolBoxMD-you have a terrible attitude; why don’t you tell patients the truth about colonoscopy sedation; that it’s the most dangerous part of the procedure and that most patients who had had an unsedated colonoscopy actually prefer it that was? And that MANY doctors and nurses get unsedated exams? I’ll tell you why: because the sedation if for YOUR benefit, not the patients; with sedation you can do the exam quickly and roughly and get the amnesia patient out the door, only to suffer PTSD-like reactions and depression when their temporary drug-induced amnesia wears off. But by then, they are home and you really don;t care, do you? A good doctor would offer unsedated colonosocpy to patients. Sorry if this offends, but it’s true.
I just had a bone-marrow biopsy because of a severely depressed platelet count; luckily it was ITP not leukemia. The oncology doc who did the biopsy was honest about the pain of the test..the needle for the local anesthetic burns like a bee sting for a few seconds and the biopsy causes pressure…but she said that the sedation is often no bargain…you are awake and conscious but may or may not recall the procedure due to the amnesic drugs……I decided not to do the drugs; it wasn’t too bad and I’m not screwed up mentally from the amnesia which sometimes happens. And the sample wasn’t processed right, so it has to be done again and I will skip the sedation again……..it’s not worth it
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