Anesthetic may bring people to procedure they rarely relish
CROSBY — It’s probably not a stretch to say most people don’t enjoy the trip to the doctor’s office.
Add in a colonoscopy and watch that number drop out of the basement.
But what if the choice of anesthesia could make a difference? That’s what the hope is at Cuyuna Regional Medical Center (CRMC) in Crosby. Dr. Mark Gujer, chairman of the department of anesthesia, said previously when patients came for an endoscopy — where a tiny camera on a long, flexible tube is used to examine the upper digestive system — or a colonoscopy, they were sedated perhaps with drugs common for that task in the emergency room such as a sedative like Versed or with narcotics like Demerol or morphine.
Those drugs last four to six hours when a colonoscopy may last 15 minutes.
“So you have a minor procedure with no pain postoperatively yet you are done for the day,” Gujer said. “You are just wiped out from all those medications.”
Patients would go to the same-day surgery recovery room and maybe spend another hour before they felt clear-headed enough to leave for home. While the patient was out for the minor procedure, they could be left with hours of waiting for the drugs to sufficiently clear their systems to feel better. Some were nauseous. Others felt dizzy.
Gujer said patients could basically lose an entire day to have a colonoscopy. That time commitment may have added just one more obstacle to patients who hesitate to have a minor procedure that may just catch colon cancer early and ultimately save lives.
Gujer, medical director of perioperative services at CRMC, wanted to change that. He was working on a program to train nurses to administer an anesthetic agent called propofol. That anesthetic could only be used by people trained in anesthesia and was normally administered by personnel trained in delivering anesthesia, such as certified registered nurse anesthetists or anesthesiologists.
In Minnesota, nurses could be trained and certified to administer propofol sedation. The plan was to bring in a simulation lab and do the training.
“I wanted to do it for a couple of really important reasons,” Gujer said, seated at his desk at CRMC during a break between seeing patients and a leadership meeting. “The biggest one is patient satisfaction.”
Gujer said patients sedated with propofol remember talking to their doctors only minutes after the procedure is done because the drug is gone from their systems that fast.
“We can do that at a depth of anesthesia that provides patient comfort and surgical relaxation with just that one drug,” Gujer said. “We don’t give them anything else. They don’t get any narcotics so no nausea afterwards. So they feel better. They wake up. They are more alert. ... Some of our patients now are going out the door 15 minutes after they get out of the procedural room.
“Patients repeatedly tell nurses ‘wow I had this done four years ago; this is nothing like that.’”
For the hospital, using propofol is a way to eliminate a bottleneck. Having patients move through the recovery area more quickly instead of lingering because they feel groggy is a benefit to keep the system from bogging down, Gujer said.
“So we did it from a flow standpoint, too, but there are other added benefits,” he said.
Those benefits are coming from patients who have a better experience. Gujer said now they believe they will have much better compliance with the colonoscopy, a screening tool for cancer.
In 2005, the Institute for Safe Medication Practices, a nonprofit organization, reported using propofol for endoscopic and other diagnostic procedures was gaining momentum in hospitals, outpatient surgery centers and doctors offices. “In trained hands,” the institute reported, “propofol offers many advantages over other drugs used for sedation.”
So in 2009, Gujer was ready to start that training program at CRMC to use propofol. Then came the overdose death of Michael Jackson in acute propofol intoxication. According to a Scientific American article, the autopsy report found propofol in Jackson’s case was administered in a nonhospital setting and without the proper medical indication.
Gujer said the lesson from Jackson isn’t that propofol is dangerous. The message, he said, is not to have a cardiologist who is not trained in its use administer it improperly.
“In the hands of someone who is trained to use it, this is the safest anesthetic drug we’ve ever had,” Gujer said.
Believing there will be changes in how the drug is regulated by the Federal Drug Administration and the state of Minnesota, Gujer said instead of putting in the simulation lab and going through the expense to train nurses to administer propofol another option was suggested. Hire another nurse anesthetist and cover the procedures using anyone from the anesthesia department with its two anesthesiologists and five anesthetists.
CRMC kicked off that plan a year ago and reports cutting discharge times in half using propofol. It’s a little more expensive to provide the service, which the hospital is absorbing, but Gujer said they are gaining in patient satisfaction and the surgeons report better procedures. Patients are in a deeper level of sedation for the colonoscopy so surgeons have an easier time to perform the procedure, Gujer said.
At CRMC there area bout 5,000 surgical procedures in a year with 1,500 of them colonoscopies/endoscopies.
Peggy Forstner, patient care coordinator for same-day surgery and recovery, said prior to propofol patients woke up feeling groggy, hung-over, nauseous and sweaty. “Yuck feeling, I don’t know how else to describe it,” she said.
If the patient’s colon has some twists and sharp corners, it can be painful to have the scope move through it. She said it was tricky to provide enough sedation so the patient was comfortable, but not too much to cause a concern for their breathing.
“With propofol it’s much safer for the patient,” Forstner said. “Now there is a nurse anesthetist there monitoring the patient.”
Propofol has a mild amnesia effect, she said, so patients have no knowledge of the procedure. They sleep through it and because they are relaxed, it is easier for the scope to make the colon’s corners and they are not feeling that pain, Forstner said.
“If it was uncomfortable, they don’t remember it and it is very often not uncomfortable for them at all,” she said. With older patients the drugs previously used also created a concern for falling as drugs could leave people light-headed and drop blood pressure. Forstner said now patients wake and are sometimes ready to go home in 20 minutes. Recently a patient who had the procedure done years ago came in saying she almost canceled after not sleeping at all and anxious about the colonoscopy. This time, Forstner said the woman said she felt wonderful.
And that’s what health care providers wanted to hear especially for a procedure that patients may be reluctant to have but that could catch cancer in an early, more treatable stage.