Colonoscopy using propofol for "enhanced sedation"?

[StJills360]

Hi - has anyone managed to successfully request this from the NHS?

I have been called for a colonoscopy following a positive FIT test - they seem to be offering only 3 choices to manage my anxiety of the process: nothing, gas and air or midazolam/fentanyl. I have avoided anything invasive medically for many years (inc. the dentist) due to extreme anxiety so wish to be unaware of the process, hence the deeper sedation request. According the BCSP guidelines, a small majority of patients need enhanced sedation using propofol and the BCSP provider should make reasonable efforts to provide this. It all seems to hinge around whether an anaesthetist is present or not as propofol cannot be administered by the endoscopist.

I don't feel I can proceed with the test with what they are offering so will cancel the screening appointment. As I have no symptoms, I feel there is no rush here and can see if I can find a private service.

I know the vast majority of people are fine with what's being offered - but unfortunately, feedback from several colleagues has highlighted that when this doesn't work, the lack of an anaesthetist means you just have to grin and bear it as they can't give you anything else. I don't want to take this risk, especially as to get me into the room into the first place will be challenging enough (hope the GP can help with that). You'd have thought with the modern medicines available that having mentally endure a procedure a process that documents how well it was "tolerated" was a thing of the past.

I fully understand the importance of this and the risk if I don't proceed - but the primitive part of my brain wont let me. It is worrying my DH (he has found this a breeze by comparison) but this has not changed my decision.

Hopefully someone else has experienced the same and can offer some advice!

I too have had colonography. The trouble with that is if anything such as polyps are found they then have to go in with a scope to remove them.

Onewelbeck have responded with a positive message - none of this "try our way first and then if that doesn't work, we will try your way" shenanigans. I am taking great comfort from that. I know it's expensive, but for the me the value is huge!

Due to it's location, it's a couple of days way from home for me - but that's a minor issue. I would most likely ask my mother to accompany me as my DH and I don't really see eye-to-eye on this. He hasn't said it directly yet but I can tell he considers this a huge waste of money. I am still terrified beyond belief - but at least I have an option to consider that is more gentle.

I'm in the US and get annual colonoscopies as I have ulcerative colitis. I've always had propofol with no other choices except perhaps nothing. I'm surprised the NHS so tightly controls it. It's a very safe drug when administered properly.

I had a colonoscopy with gas and air and fentanyl and miza ( can’t remember the rest). I can now understand why fentanyl is so popular as a street drug. I was vaguely aware of what was going on but didn’t care at all. I wasn’t best pleased they woke me up afterwards either.
The bowel prep is by far the worst bit but I wouldn’t have on without sedation

It’s more the cost of an anaesthetist available to do it. It’s cheaper for them to do with IV sedation or without anything at all.

All about cost. No person centred care here.

there are barely enough anaesthetists in the UK to cover lists that actually need an anaesthetic - that's why it can't be routine to have an anaesthetist on every sedation list too. Propofol is great, but is very easy to stuff up (Michael Jackson's cardiologist being the most famous stuffer-upper) and needs a skillset that isn't necessarily needed so much with some of the other drug combos.

OP word of advice, very important advice. Please check your chosen private endoscopist is an accredited bowel cancer screening endoscopist. That means they have passed the bowel cancer screening program exam. They are the best colonoscopists.

You've obviously got yourself a plan in place for the colonoscopy so I won't comment on the sedation. I just wanted to say there are different doses of diazepam and this might be worth exploring with your GP in the (hopefully unlikely) event that you need further procedures.

DH has a really high level of anxiety about a number of medical things and found that while like you the normal dose of diazepam did nothing for him, a higher dose allowed him to tolerate an extraordinary amount of needles, enclosed spaces, nurses rolling their eyes at him, etc.

My mum has really significant anxiety around healthcare. And her way of dealing with it was just to live in denial of any health concerns and not seek medical attention. She went to extreme lengths to hide what was happening and it almost killed her. I’m not sure what I could have done differently under the circumstances but I do know that being dismissive would have only made her lie and hide more. Fortunately we did find out in time and got her medical care.

I wish my mum had been as honest and brave as you because then I could have helped her earlier. I hope your DH can realise that and support you.

I had sedation - privately- midazolom and something else - but I was still awake and didn’t feel it made much difference. It was uncomfortable but not painful - I’ve had worse smears.
I was sedated properly for endoscopy - I did not want to be awake for that, no way.

I had propofol, but I'm not in the UK. When I came round I looked at the staff in disbelief and said: Have you started yet?
It was all over and I hadn't noticed a thing. Somebody had to pick me up from the clinic though.

Ok, I managed to talk to the BCSP - as expected, I imagine you need to go through a few hoops to get anywhere near the enhanced list. They did admit that it's difficult for anyone else to appreciate your own level of anxiety so did understand. I turned down the appointment offered next week as it was far too soon for me at this stage and they agreed that was sensible. I mentioned I needed to see what my GP can do for me medication wise just to get me into the room - but the next appointment offered I will also have to cancel as I can't get an appointment with my own GP for 3 weeks or so. I got the impression they would help me if they could but they are constrained by protocol. They have suggested the midazolam/fentanyl, gas and air AND whatever my GP can through at me - that's either good news or admission that it's not that good depending on your point of few.

I spoke to a private a clinic and yes they can offer enhanced sedation - but the before and after isn't quite the velvet glove I was expecting. I haven't wrote them off just yet as I suspect (for instance) I can ask the anaesthesiologist to use gas induction etc. - it's just that that isn't the normal process as so isn't mentioned by default.

It seems that the system just isn't quite joined up enough - if you request a procedure a certain way due to fear then they literally deal with that request aspect only - you then need to research things yourself and ask if not offered - no one else is joining any dots.

I am hoping my GP is willing to help as per some PM suggestions have made else I will keep kicking this into the long grass.

If you have had a positive stool test under the BCSP please do not "kick this into the long grass". You need this colonoscopy.

I recently had a colonoscopy at One Welbeck and would highly recommend. I was very anxious. The propofol totally knocked me out I didn’t hear or see or feel anything. One thing to be aware of you go through to the prep room alone and I was waiting there a while. But the nurses were amazing. I totally understand anxiety (panicked and gave up in an mri even with benzos) but this really was manageable and I was impressed by One Welbeck. Best of luck.

can't you just ask for general anaesthetic? I was put under for mine at my own request

General anaesthetics for colonoscopies aren't routinely offered on the NHS in the UK - too expensive.

There are safety issues too, it's not just about money. Apart from the fact that not every patient is suitable for G.A , there is very good evidence that the quality of the colonoscopy performed depends on being able to turn the patient at several points dirng the procedure. Thats unlikey to happen if they are under GA. It's very easy to miss something important in the bowel if you dont have the best views,moving the patient assists with better views.

Agreed, GA is too much of a risk - but we do have loads of other options that aren't GA - it's just that a anaesthesiologist (rightly) needs to administer it.

I read somewhere that someone was offered a spinal block as a solution. For me, that totally misses the point - you're still fully aware of what's happening, but you can't get away if you need to - double torture!

I am glad that midazolam/fentanyl was enough for most of you. The fact that for some (and it's probably a small percentage) it didn't is what scares me (as well as anything invasive really...).

Some good news - my GP is referring me so I can talk to a consultant re: enhanced sedation, and rather than diving in at the deep end, talk the issue through beforehand, away from any medical rooms. They were extremely helpful and understood this as a issue which has been there a long time . Once I get the paperwork through I can stand down the BCSP appointment. I still have the private option up my sleeve if needed though. This has all been done via an email this morning and a follow up call to me this afternoon - amazing!

That’s great news @StJills360! Really happy for you.

Sorry to be dim, but surely patients are turned fairly regularly during operations performed under GA? I have seen it done on the TV, and I know my father was moved several times for a serious orthopedic procedure. Do you mind explaining further please MissyB1? I find it quite interesting!

Usually the anaesthetist takes over ventilation with bag and mask with propofol so not sure how easy that would be positionally wrt colonoscopy access PR

Midazolam + Fentanyl knocks most people out and are potent anxiolytics. You can just ask for a higher dose.

midazolam/fentanyl IS by all measures an enhanced sedation. It is certainly powerful.
Propofol is a general anaesthetic with all that that entails: respiratory and cardiac depression, which is why it needs to be used under anaesthesiologist supervision.
You are talking yourself into a much more dangerous procedure because you are anxious about possibly remembering the diagnostic procedure that you are afraid of. Colonoscopy is unpleasant and usually uncomfortable but is just a stranger putting a soft tube up your bum. No-one is going to tell you that it's pleasant, but it isn't dangerous. A general anaesthesia is much more serious and dangerous.
I understand that you know what you want and are vociferously advocating for your own medical choices, but (gently) in this case you are advocating for your fears over your best health choices.

Consider spending your available funds on therapy to overcome your anxiety rather than paying for more risky procedures because of that anxiety. I hope that things work out for you.