Is it dangerous to drink alcohol the same day I had twilight anesthesia? 

The standard advice is not to drink alcohol or take any other intoxicants for 24 hours after your anesthesia. Alcohol and other intoxicants can interact with anesthesia drugs to increase the effect of one or the other or both. If you've just had anesthesia, the effect of a drink of alcohol is likely to be greater than it would have been under normal circumstances. In other words you are more likely to become intoxicated. People who are intoxicated get into harm's way through impairment of judgment of normal motor function (movement) and other mental faculties. Extreme intoxication can affect breathing and even cause unconsciousness. Any medical facility that sent you home without the standard advice to avoid alcohol would be running a risk (medico-legal) for themselves and for you (health). The degree of impairment, and the resultant danger to you will depend on the amount of alcohol you have drunk, your individual susceptibility to the effects of alcohol, the amount of anesthesia you had, your individual susceptibility to its effects, the time that has elapsed since your anesthesia, and the effect of other medications you may be taking. There are many unpredictable factors involved here so perhaps you can understand why the standard advice is given. 

Who do they ask alcohol consumed in an average week will past alcohol consumed affect how you react to MAC anesthetic? 

Questions about alcohol consumption are part of the routine preoperative history. You will also be asked about use of tobacco and recreational drugs. Why do we want to know about alcohol consumption? First,ﾠexcessive drinking leads over time to a host of medical problems including liver disease, brain and nerve problems, bleeding disorders, problems with drug metabolism and excretion, and so on. These are serious and important problems thatﾠmay affect not only the anesthesia but the surgical procedure and the recovery from that procedure. Second, a patient who has recently drunk aﾠlarge amount of alcohol may still be intoxicated at the time of the surgical procedure. This may reduce the amount of anesthesia needed. A glass or two of wine the night before your procedure is most unlikely to be a problem. If you drink excessively orﾠcannot control your drinkingﾠthat is obviously a problem in its own right, affecting your health now and into the future,ﾠfor which you would be advised to seek help. 

I`ve been researching alternatives to conscious sedation during colonoscopy due due adverse events/reactions to IV sedation and found that, particularly in Australia, use of sevoflurane (nitrous oxide) is the standard. And, studies seem to show that it is cleared from the body faster than Versed or other drugs used here. Why is it not used in the U.S.? It is a cost or professional issue? 

Sevoflurane and nitrous oxide are anesthetic gases used in the United States, Australia, and everywhere else in between. It is certainly acceptable practice to administer sevoflurane and/or nitrous oxide for a colonoscopy. I am not sure which specific adverse events or reactions from IV sedation you are referring to but I am not aware of any scientific evidence that it has a better side effect profile than intravenous drugs like propofol and midazolam. Although sevoflurane is the least pungent of the inhalational (gas) anesthetics, some people still find it unpleasant. Like other inhaled anesthetics it often causes excitation and involuntary movement when used to induce general anesthesia so an IV agent is often needed in addition to the gas. Another problem is the pollution of the surgical or endoscopy suite that results from the use of gases, so that special gas scavenging and ventilation systems are required. And finally, use of sevoflurane often requires the insertion of an airway device, something which can usually be avoided during moderate IV sedation. 

I`ve beenﾠdelaying a colonoscopy due to previous complications from IV sedation (blood clots, painful arm swelling, waking up in pain and paralyzed during the procedure.) What are alternative pain control options? 

Colonoscopy without sedation can be a rather uncomfortable procedure. Colonoscopy therefore is generally performed with moderate to deep intravenous sedation, but not general anesthesia. 

Do you know what kind of anesthesia it was intended that you receive? If you really were paralyzed and unable to move during the procedure this would suggest that you received a general anesthetic, with a breathing tube in your trachea (windpipe). This is unusual but occasionally necessary. 

If you need to have a general anesthetic again you should talk with your anesthesiologist before the procedure, have her review the records of your previous procedure to help identify what happened, and make a suitable plan to avoid a repetition of your unpleasant experience. 

If you were intended to get moderate to deep sedation you should have been told that some degree of "awareness" is expected during certain parts of the procedure, although perhaps the majority of patients remember little to nothing of their experience afterward. 

Because colonoscopy does not involve cutting tissue, except of parts of the bowel (biopsies) which do not have pain receptors, there is usually not much, if any pain, during recovery. However there may be a certain amount of discomfort resulting from the blowing of air into the bowel to improve the ability to see inside the bowel. Where is the pain you have had? Did you have this pain before the procedure? In future you may have to ask your doctors to give you some strong pain-killer medication along with your sedation. 

Blood clots and a swollen arm are definitely unexpected! It sounds like you may have had a venous phlebitis or thrombophlebitis. Please browse my previously answered questions on this topic. This is a known, occasional, complication of your IV which hopefully will not happen again. 

My doctors have been pressuring me for several years to have a colonoscopy, but I don`t want any anesthetic that will induce amnesia. My doctors (and all of the media reports) keep insisting that "you won`t feel a thing". If that`s true, why do they insist on blocking out my memory? What is it they don`t want me to remember? I was the "designated Driver" for a friend`s colonoscopy, and while sitting in recovery at the outpatient gastroenterology center, heard a woman screaming in agony from the direction of the procedure rooms. When I asked the nurse what was going on, she laughed and said "Don`t worry, she won`t remember a thing". The thought of being that woman in pain horrifies me more than the thought of cancer. I have no symptoms, this is a screening colonoscopy, and I can`t convince myself that it`s worth the agony. Do I have any other choices? 

Thank you for your question. Questions similar to yours has been previously addressed whhich you can access through our search feature. Feel free to write back if you still have questions or need an explanation. 

I am scheduled for a colon exam soon. I am currently taking Lortab and Soma for back pain. Will this affect me when given anesthesia? 

The short answer to your question is no. The Lortab and Soma you are taking for back pain will not affect your anesthesia. Lortab (acetaminophen plus hydrocodone) and Soma (carisoprodol) are commonly prescribed medicines for pain. Lortab is a moderately strong narcotic. Soma is a muscle relaxant. If you are not currently having any side-effects or other problems you could safely continue to take these medicines up to the time of your procedure. You should check with your doctor on the rules for eating, drinking, and medications before your particular procedure. In most cases, pain medicines can be continued, including the day of the procedure itself, when they may be taken with sips of water. 

Is there any problem with asking for demerol and valium instead of demerol and versed since versed knocks you on your rear end for the entire day? If this sedation is good for our president`s colonoscopy, I guess it`s not too off the mark to ask for it for me. 

Valium (diazepam) and Versed (midazolam) are both benzodiazepine medications. Their effects are extremely similar except that midazolam has a shorter duration of action. Also, the regular intravenous preparation of diazepam is very irritant to veins so it hurts during injection. Most patients who receive midazolam for sedation are not knocked on their rear end for the entire day. If that were the case, the drug companies would not be making it and we would not be using it. What some people find hard to understand is that the surgical procedure itself may have profound effects on the body. There is sometimes an assumption that the anesthetic is responsible for any and all ill-effects after surgery. In fact, the trauma of surgery and the initiation of healing is both part of the problem and part of the solution. Your body is not like a car, that if properly repaired in the shop, can be immediately put back on the road and driven. 

I appreciate the prompt response to my question about IV sedation without memory impairment, although I`m very disappointed to learn that such a thing doesn`t exist. My reluctance to undergo IV sedation results from a very bad experience with it during a prior eye procedure. At that time the surgeon also declined my request for "local anesthesia only" without giving a reason. At the surgicenter, the only question the anesthesiologist asked me (before quickly disappearing) was "You healthy?" I woke up from surgery feeling euphoric. I ripped off my eye patch and tossed it across the room, although apparently none of the staff noticed. I was aware that this behavior was out-of-character but didn`t connect it to the IV drugs pumped into me. The only information/instructions that I received was a reminder to see my doctor in 3 days. I was feeling so good during the drive home that I had my friend drop me off at a movie theater. I gave him all my narcotic pain medication, because I felt certain that I wouldn`t be needing it. A coworker later informed me that I had undoubtedly been squirming in pain throughout the surgery but the IV drugs blocked my memories of it. This information left me with a vague sense of having been violated. So I was hoping for a better experience with my upcoming eye procedure (with a different surgeon). My online research about anesthesia led me to forums filled with postings from people who have also had very bad experiences with Versed and propofol. I`ve become convinced that very few patients are informed about the amnesia-producing and mood-altering effects of these drugs. (Whatever happened to informed consent?) On one website about anesthesiology for cosmetic surgery, it was suggested that the post-sugery euphoria produced by propofol could be advantageous for the plastic surgeon, since it might lead patients to return for additional procedures despite the mediocre results of their last one. My research also revealed that the surgery that I will be having (vitrectomy with removal of epiretinal membrane) is almost always done using local anesthesia without sedation in Great Britain, Europe, Australia and New Zealand; however, in the USA local anesthesia plus IV sedation is the norm. Is this because American patients are squeamish about pain and demand sedation? Or is it that American surgeons are uncomfortable operating on conscious patients who are capable of remembering their surgery? 

Thanks again for your fascinating follow-up comments and questions. Now that I know a bit more about what happened to you after your eye surgery I can offer a few more suggestions and observations. I think it is unlikely that you were "squirming in pain" during your previous eye surgery. It would have been difficult for the surgeon to complete your procedure under those circumstances. Local anesthesia for eye surgery (actually more accurately termed "regional" anesthesia) is extremely effective and most patients do not experience pain until the block has worn off. I don't think that your friend's conspiracy theory, if I can use the term, is a useful one. I have worked in other countries where eye surgery is done with regional anesthesia alone. In other words, no sedation. This is extremely boring for the anesthesiologist, but seems to work perfectly well! Patients who seem unlikely to tolerate being awake are often given a general anesthetic. I think that cultural differences are at play here, and people in other countries may be far more stoic than Americans, and willing to tolerate discomfort (in fact, the most discomfort may be from having to lie on an operating table for more than 2 hours. These tables do not have sprung mattresses!). On the other hand, a stoic individual is also less likely to express the feeling, as you have, that he/she was "violated" by the surgery. He is more likely to be extremely grateful to the doctor for restoring or protecting his vision. The culture of medical practice is also a factor. Most doctors are inherently conservative and reluctant to change their practice especially if the particular style of practice is one they were taught by their respected teachers or peers, has worked well (from their perspective anyway) for years, and does not have a compellingly better alternative. Having said that, the practice of cataract surgery, for instance, has changed over the last few years, to the point where a large proportion of these very common operations is done with topical anesthesia (drops) and minimal, or even no sedation at all. The results seem to be just as good as the traditional approach with an eye block (needle) and IV sedation. This altered approach does not apply to retinal surgery unfortunately, which does require an eye block or general anesthesia. Unfortunately there is no perfect sedative agent - in other words a drug that causes sedation only, without side-effects such as respiratory depression, low blood pressure, disorientation, or dry mouth. Remember of course that the amnestic effect which you so wish to avoid is considered by many (most?) patients to be a desirable one. In your case, although you say you are trying to avoid the memory impairment, what I believe you are most interested in is a smoother postoperative recovery in which you do not fling off your surgical dressings and make very bad on-the-spot decisions about your medication management! It isn't true to say that IV sedation without memory impairment does not exist. For instance narcotic pain relievers (opioids), such as fentanyl, are not thought to cause amnesia directly. But narcotics are not very good sedatives - sedation is regarded as a side effect of these agents. There is one new sedative agent, called dexmedetomidine, that has certain very appealing properties. This interesting drug provides sedation without appreciable respiratory depression, making it a useful choice in patients in whom depression of breathing, or airway obstruction, are more likely or whose consequences are more problematic than usual. Although there is not a huge amount of experience with it yet, dex does seem quite a bit less likely to cause amnesia. The sedation with this drug also more closely resembles normal sleep. Dex does cause a dry mouth and has analgesic (pain relieving) properties. It is rather expensive. I am both amused and disturbed by your observations about informed consent, or the lack thereof, and by the very cursory preoperative evaluation performed by your anesthesiologist. Sometimes, anesthesiologists, surgeons, (and patients) are seduced into believing that little harm can be done by "a little sedation" for eye surgery, and that a comprehensive evaluation, and a full explanation of risks, is unnecessary. There are potential serious complications - although rare - and, as you have discovered, a variety of less harmful but nevertheless unsatisfactory, effects. Medical professionals are guilty of assuming that once their patients leave the surgical facility all is well, and the sedative drugs are without prolonged effect. The questions I receive in this forum suggest otherwise. 

I had oral surgery exactly a month ago, and IV anesthesia was used. About a week after surgery I noticed pain in my forearm distal to the insertion site (but no pain at the site). There was also a bruise running up my bicep proximal to the insertion site. It hurt (in my forearm) to extend my elbow and there were was an odd lump in my upper forearm. The pain lessened for a few days then came back only this time it was more distal and extended into my thumb. The pain is along my radius to about half way up my forearm and fairly superficial. The skin in the area is painful to light touch, and that pain is similar to that of a burn. Also, there is still a small lump and a vein seems to be protruding--though it is hard to tell if the lump is just part of the vein. I went back to my surgeon and they looked at it, but the nurse seemed like she had no idea what was wrong. Can you help me? 

Thanks for the very detailed description of your problem.ﾠ It sounds as though you may have some irritation of a vein together with thrombosis (clot), a condition called venous thrombophlebitis.ﾠ This is a relatively common condition resulting from the presence of an intravenous cannula ("IV") and/or the effects of drugs injected through the IV.ﾠ Thrombophlebitis is not usually associated with infection, is not life-threatening, and does not usually require treatment except to relieve the symptoms.ﾠ Is it getting better?ﾠ This is a condition that does get better over time and is treated with mild analgesics.ﾠ In the early stages of thrombophlebitis there is inflammation, which is seen as redness and warmth at the insertion site and along the course of the vein in which the IV has been placed.ﾠ Later, there may be a hardened area corresponding to where a clot was formed in the vein.ﾠ Although this diagnosis probably accounts for your symptoms, some aspects of your description don't correspond entirely.ﾠ The pain distal to the insertion site (further along your arm) would not be typical of venous thrombophlebitis.ﾠ Despite your excellent description you don't say exactly where in your forearm the IV was located.ﾠ Some locations would be close to nerves that supply the forearm.ﾠ It is possible that during insertion of the IV cannula a small peripheral nerve was injured.ﾠ Such an injury can cause heightened sensitivity to touch or pain from a stimulus which is not normally painful (allodynia).ﾠ Again, this type of nerve injury normally recovers over time (a few weeks or months) without treatment.ﾠ Was the insertion of the IV cannula very painful? - this would happen if the nerve was stuck directly by the needle.ﾠ A nerve injury resulting from the insertion of an IV cannula is uncommon but is probably something not entirely preventable.ﾠ Although your surgeon's nurse was not helpful, if you continue to have problems you should ask to see the surgeon directly, or perhaps the anesthesiologist or nurse anesthetist who took care of you during your oral surgery procedure.ﾠ These are the professionals responsible for your ongoing care in this situation, who are aware of the details of your medical history, which may contribute to a diagnosis or therapy, and who can conduct an appropriate, detailed physical examination. 

I am scheduled to outpatient surgery using an assisted local, what does that mean? I would much prefer to be put to sleep as I do not like needles. Thank you 

ﾠ"Assisted local" is not a term that I am familiar with but I will offer you an educated guess. "Local" usually refers to the use of local anesthetic as the primary form of anesthesia. An example is anesthesia for dental procedures, which is usually given by means of a needle to block the appropriate nerve(s). "Assisted" local may mean that an anesthesiologist has been asked to assist in your care. If this is the case, your anesthesiologist will monitor you during the procedure, and may provide additional anesthetic medications (intravenously or by mask) for your comfort, as well as perform a preoperative assessment and provide postoperative care during recovery. I suggest you check with your hospital or your surgeon to find out exactly what they mean by "assisted local". 

My neighbor had this procedure and suggested if I wanted to be aware of everything, to request fentanyl. My question is how much fentanyl is usually given and what is `in` to request to be pain-free? Thank you 

ﾠAll drugs given for anesthesia and sedation are best given in a "titrated" fashion. This means that a small amount is given, the response assessed, then additional amounts given until the desired effects is achieved. An average initial dose of fentanyl in an average adult is between 50 and 100 micrograms. If you don't want Versed (midazolam) tell your doctor. Alternative agents include propofol, which is sedative, and other drugs similar to fentanyl such as meperidine, alfentanil, sufentanil and remifentanil, which are pain-killers. These drugs have potential side-effects too - including nausea and suppression of breathing. 

I was told that for my scheduled colonoscopy I would be given Diprivan (propofol). I am on 45 mg Nardil (MAOI) and 10 mg of Lisinopril daily. In addition, I use a CPAP machine (100% compliant) for sleep apnea. Should I be concerned about any adverse reactions with the sedation Drug? Since the Lisinopril works with the Nardil in tandem to lower my blood pressure, if I am given too much Diprivan, should I be concerned with respiratory malfunction due to my sleep apnea? Is there another drug that would be better? What should I request to be in the procedure room and should I ask for an MD anesthesiologist? 

Thanks for your question. You are raising at least two, bright red flags. 1. Sleep apnea is a serious issue in any patient undergoing anesthesia. Airway obstruction is more likely to occur during and after anesthesia. Difficult tracheal (windpipe) intubation is also more common. 2. Nardil is an MAOI - a monoamine oxidase inhibitor. MAOIs can interact with certain anesthesia-related medicines, including meperidine (Demerol) and ephedrine, to cause severe reactions. In fact, until a few years ago it was standard practice to discontinue MAOIs before anesthesia. Although this is no longer routinely advocated, caution is still advised. In view of these two important and well-recognized anesthesia risk factors, it would be wise to request an MD anesthesiologist to provide your sedation for colonoscopy and to supervise your recovery. The anesthesiologist should advise you how to manage your medications before the procedure so ideally you will make contact beforehand. Finally, please note that in some centers, the use of lisinopril on the day of anesthesia is discouraged because in combination with general anesthesia (e.g. propofol) it can cause low blood pressure. This is one more reason to contact your anesthesiologist before the colonoscopy. 

Is it possible to have a colonoscopy with a painkiller but no added sedative? I truly hate the experience of IV sedation--for the same reason that I hate drinking to intoxication and then dealing with the hangover. I also like to remember my experiences. (I had to consult 5 cataract surgeons before I found one who would let me skip the Versed, but it was worth the effort. The surgery was painless with topical anesthesia and I felt fine afterwards, and I didn`t need to spend the rest of the day recovering from sedatives.) 

There are many possible combinations of drugs that are used to sedate patients undergoing colonoscopy. A typical combination is midazolam (Versed), which is a sedative, and fentanyl, a painkiller. Another approach is to use a sedative/anesthetic agent called propofol. Cataract operations are quite easily done without sedation because with modern surgical techniques there is little to no pain when topical anesthetic drops or a nerve block are used. Topical anesthesia is obviously not an option for a colonoscopy, so the intravenous drugs administered are more important. I believe it is possible to have a colonoscopy with painkiller only and no sedation. It might be a less comfortable experience. You might be given fentanyl, or similar drug only. You need to discuss this with the anesthesia provider. I suggest that you not limit the anesthesiologists options during the procedure. In other words you might start with the approach you are describing but allow the anesthesiologist to administer other drugs, including sedatives, if things don't go as well as planned with painkillers only. 

I have had several cystoscopies into the bladder and up into the kidneys for kidney stones and on one occasion had a stuck stone scraped off the ureter wall and a prostate biopsy which made the procedure last awhile; therefore, the question: In all cases, I was given conscious sedation with Versed and perhaps other agents. These agents seemed to be able to "put one to sleep" (or in a twilight) almost immediately and allowed the anethesiologist to awaken me almost immediately. For a medical procedure, this method seemed excellent since there was no pain or nasea and everything seemed to be short acting -- what a wonderful expreience. Now, for what types of procedures and to what *extremes* (more difficult procedures) can this method be used? Thanks! 

Thanks for your question! Iﾒll start by giving you the ﾓofficialﾔ definitions of four different levels of sedation. These definitions were created by the American Society of Anesthesiologists, and were recently adopted by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), the most important agency that accredits hospitals in the United States. 1. Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. 2. Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. 3. Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. 4. Anesthesia consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The surgical procedures you describe (cystoscopy, removal of stones, prostate biopsy), if performed in an operating room, would usually require deep sedation or general anesthesia (levels three and four). The drugs that are used to provide minimal or moderate sedation are also used in many cases as part of the regimen for deep sedation and general anesthesia. Versed (midazolam) is one of the commonly used drugs. Propofol is another very useful agent. Higher doses of these drugs are obviously used to provide deeper levels of sedation and anesthesia. Modern anesthetic agents, given in a carefully measured fashion, with attentive monitoring, can provide patients with a relatively comfortable experience, with rapid onset, rapid awakening and a minimum of side-effects. This applies to all levels of sedation and anesthesia. The judgment about the most appropriate form of sedation or anesthesia for a particular surgical procedure is one best made by a qualified anesthesiologist, taking into account the needs of the surgeon and the preferences of the patient. 

I recently had to have an endoscopy; I was told that it would be done under conscious sedation. Despite receiving fentanyl 100mcg and midazolam (sorry, I don`t know the dose) I was wide awake through the entire procedure; it was very distressing, not to mention frustrating because the gastroenterologist got exasperated with me because I couldn`t stop gagging. The same thing happened to me about 15y ago when I had the same procedure. I am not taking any medications that would have interacted with the sedation. There was no anesthesia provider present during the procedure; the meds were given by an RN. Any suggestions for the future if I have to have a repeat endoscopy? I really would rather not go through that again. 

I'm sorry you had such an unpleasant experience with your endoscopy.ﾠ If you need another endoscopyﾠyou should have a good talk ahead of time with the doctor performing the procedure,ﾠso that you canﾠexplain what happened to you. ﾠIdeally, you will get a copy of the records of your recent procedure, including the doses of sedative medication that you received, and share those records with the doctor. There is a lot of variation in the amount of sedation that different people need for endoscopies and similar procedures. ﾠFor example, a skinny, teetotal, 80 year-old woman with heart problems will usually need a tiny dose of a drug such as midazolam to tolerate an endoscopy.ﾠ A robust, healthyﾠ20 year-oldﾠmanﾠwill probablyﾠneed several multiples of that, plus a drug such as fentanyl.ﾠ You are perhaps someone with a higher tolerance for these medicines, needing a larger dose to adequately sedate you thanﾠthe "standard" dose of, say, midazolam 2 milligrams, which you mention. Another anesthetic drug, propofol, can provide excellent sedation for endoscopy, and rapid recovery afterwards, but is best given by an expertﾠin the use of such drugs -ﾠan anesthesiologist. Propofol-based sedation is probably the "gold standard" for sedation for minor procedures. The great thing about well-performed sedation is that its a win-win - the patient has a comfortable experience, and the doctor has ideal operating conditions and can concentrate on the task at hand, instead of trying to complete the procedure as quickly as possible on a squirmy, anxious patient.ﾠ It has even been shown that the rate of detection of abnormalities during endoscopy is higher in patients who receive this kind of sedation/anesthesia. Of course the reason why you may have received only a standard dose of sedative medication is that these drugs can produce an over-sedated, even unconscious patient who then requires resuscitation.ﾠ This is the reason why hospitals are require to "credential" non-anesthesiologists to provide sedation - making sure that they have the skills necessary to "rescue" patients who become inadvertently sedated to excess.ﾠ The RN providing you with sedation may have been concerned about giving you too much. One option for your next endoscopy is to have it in a facility that uses an anesthesia professional, who will tailor the sedation to your needs, and do it safely. ﾠIf this is not available to you, you could simply explain to the doctor what happened, and suggest that additional sedation beyond "standard" doses be used.ﾠ At the end of the day however, your doctors, who understand your medical condition,ﾠare the ones that must be trusted to make appropriate medical decisions with your input and your assent. 

I am having hammertoe surgery and wish to avoid the amnesiac affect versed provides. Can I request that the conscious sedation be used without versed? 

The amnesia you get with Versed (midazolam) is not "retrograde" amnesia - in other words, you don't lose your memory for events occurring before you are given the drug. All the drugs, not just midazolam, that are used to depress consciousness will also affect memory. If you are sedated or unconscious you are not registering new memories. Most patients do not wish to be aware of what is happening during surgery and that is why drugs such as midazolam are in common use. If you are to receive moderate or deep sedation for your surgical procedure it is possible to avoid the use of midazolam. But, what are your goals? Have you had a bad experience in the past? It is best to discuss what you are trying to achieve with your anesthesia provider rather than directing her to avoid the use of a specific drug. 

Two days ago I underwent a colonoscopy under sedation. I woke up during the procedure and was aware that I was in extreme pain, although I didnot actually feel this pain, which was a very weird experience. They gave me some more painkillers and I cannot remember anything of the rest of the procedure nor for 3 hours afterwards. But when I went to sleep the night after the colonoscopy I relived this waking up experience over and over again and now I could feel the pain as well, or so I imagined. And what`s more I cannot seem to stop crying. For two days I have been doing nothing but cry. Is this normal? Is this a side-effect of the sedation and how long will this last? 

Awareness of pain, while not actually feeling it, is something termed "dissociative" anesthesia.ﾠ There is a combination of drugs, once commonly used (but now muchﾠless so), which can produce this type of experience.ﾠ This combination of drugs - usually a medication called droperidol,ﾠplus a pain relieving (narcotic) medication (such as fentanyl) -ﾠis less popular now because many people, although able to undergo the procedure without apparent problems, find it overall to be unpleasant. I suggest that you contact the anesthesiologist, or other doctorﾠ responsible for giving you the sedation.ﾠ You should try to find out whatﾠyou were given, and also to explain in more detail how you are feeling.ﾠ Your doctor may then be able to offer you a better explanation.ﾠ Assuming there is not thought to be a physical reason forﾠany ongoing pain (and it would be very important to check that out) it might even be helpful to refer you to someone for counseling. Keep in mind that a colonoscopy does not usually require general anesthesia.ﾠ That is, one should not expect to be completely unconscious during the procedure, and there may unfortunately be periods when discomfort is experienced. 

I am having eye lid surgery in two weeks. Is it OK to take a 2mg of diazepam at 7:30AM and surgery then will be at 9AM. I have been told that I will be in twilight state, and that it was makes me nervous. they say I need to be somewhat awake to aid in the surgery. 

ﾠDiazepam, also known as Valium, is a medication that decreases anxiety. In larger doses (generally more than the 2 mg that you intend to take) diazepam causes sleepiness. If you are accustomed to taking diazepam for nervousness or anxiety it is unlikely that this will be a problem during your surgery. Hopefully it will help you get in a more relaxed frame of mind beforehand. During the procedure you will be given intravenous sedation (ﾓtwilight stateﾔ) to keep you nice and calm. This is usually very successful and safe, and allows a rapid recovery and return to daily life. The surgeon does not want you to be too sleepy however because you must be able to cooperate - for example by blinking - during the operation. You should always check with your doctor before taking any medication on the day of a surgical procedure. In most cases you will be advised to continue taking your usual medicines, but there are exceptions. In your particular case it is likely that your doctor will agree to letting you take the diazepam, but you should definitely check with him/her or the office to make sure. 

What is the difference between conscious sedation, MAC and LMAC. 

Thanks for your question. I am not familiar with the abbreviation "LMAC". "MAC" (Monitored Anesthesia Care) and "conscious sedation" are some of the many terms that have been applied to the various levels of sedation that can be achieved when general anesthesia is not required. These terms are poorly defined and are best replaced by the official terms, "mild sedation", "moderate sedation", and "deep sedation". For more information please refer to other answers on this site. 

I`ve raised, and notice many other questions, regarding problems with IV sedation. We`re always told the phlebitis, blood clots and bruising are "rare" -- obviously this is not the case. What is the most constructive way to get our care providers to listen to our concerns? I don`t want to be confrontational, but I`m too often made to feel like I`m a nuisance if I ask for anything outside of "this is the way we always do it." Do you have any thoughts on how we can best be partners in our health care? And thank you for your service to this site. 

That is an excellent question! I've learned that problems and concerns about IV sedation are more common than I thought. Exactly how common is not clear. Obviously, the people who write in are a self-selected group and I only hear from the ones with concerns and problems related to their anesthesia care or health care in general. What is the denominator? I think there are a lot of satisfied customers out there too! Part of the problem may be a lack of data on actual outcomes, as we anesthesiologists are often guilty of not following up on what exactly happens to our patients. Of course, the fact that a complication is "rare" is not helpful if you are the one who experiences it. Also, the acceptability of a particular complication rate varies widely among different people. Appreciating that involves having long discussions with each patient. And time is often short. The culture of health care is changing and definitely becoming more responsive to the types of concerns you bring. But culture takes a long time to change. In many settings, the old paternalistic, doctor-knows-best, approach reigns. That is certainly true of many countries outside the United States. I assume you are based in the US. You would be even more disappointed I suspect were you to be a patient somewhere else where physician autonomy is still very strong and patient empowerment correspondingly low (although they are not always inversely correlated!). One suggestion is that you always try to keep the big picture in mind. The big picture is - your best shot at getting better from your illness, or surgery, is by creating the conditions for your medical team to do their best for you. Accept they have limitations and that treatment methods are not perfect. Try not to be hostile, even though your anger may be justified based on your previous experiences. Also accept that perfect outcomes are not always possible, that complications do occur even in the best hands. Try to have an extra pair of eyes and ears with you - a family member - because errors do occur. When you see a problem or a potential problem, an error in the making, you need either the right kind of doctor who can respond appropriately to your directives or preferences, or to evoke your most profound emotional intelligence, on a case-by-case basis in your interactions with less than responsive caretakers. Take your medical records everywhere with you - physicians like data. If you've had complications before, have the documentation with you to avoid getting labelled as simply a neurotic or troublesome patient. Find out whether your hospital has a patient advocate or ombudsman - these people are not emotionally invested in your care the same way the doctors and nurses are, and can often help if they are good at their jobs and not perceived by doctors are being on "the other side". I hope these few ideas help! 

My urologist has recommended a transvaginal sling, which will require a small vaginal incision and two small punctures in the lower abdomen. Because of a prior very bad experience with PONV from general anesthesia, he has recommended local with deep sedation. Will the drugs used for the sedation allow me to feel the pain of the local injections, but blot out the memory? 

With modern anesthetic techniques you should not have to trade a benefit - that is, a lower risk of side effects - for a risk, that is, a lot of pain during your surgical procedure. The goals of general anesthesia are to make the patient sleepy, eliminate or at least minimize pain or discomfort, provide good conditions for the surgeon to do her work (and that includes no patient movement), amnesia ("blot out the memory" as you put it) and preserve homeostasis (that means keeping vital organs functioning). Oh, and all of this must be accomplished efficiently and at a reasonable cost. For the surgical procedure you mentioned (vaginal sling), skillfully administered local anesthesia plus appropriately judged deep sedation are likely to give you a fairly comfortable experience with a low risk of nausea or vomiting (PONV). A lot of the responsibility for a good experience is in the hands of the surgeon, because it takes time and effort to achieve a good local anesthetic. Sometimes the surgeon may have to pause if the patient is experiencing discomfort, administer extra local, and wait for it to take effect. Among the most common drugs used for deep sedation are propofol, midazolam, and fentanyl. Fentanyl is a strong analgesic (pain-killer). So fentanyl is a key drug in this mix. Propofol is an anesthetic drug which causes sedation or unconsciousness. If you are unconscious can you experience pain? A difficult question to answer. Certainly general anesthesia for painful procedures can be administered without the use of a pain-killing drug during the procedure itself. Patients appear to have no short or long term harmful effects as a result of that particular approach, provided that pain killers are given prior to awakening to cover any persistent (postoperative) pain from the surgery. 

Do you think Entonox (50%Nitrous Oxide/50%Oxygen) is a good alternative for people who do not want the side effects associated with amnesia causing drugs used in conscious sedation especially in non-surgical out-patient procedures? It`s been used at the Mayo Clinic apparently with good results for procedures like colonoscopy. 

The effects of anesthetic drugs on memory, cognition, and sedation is an active and complex area of study. Although neuroscientists believe that sedation and amnesia are separate processes, in reality the drugs used in everyday clinical practice are usually both sedative and "amnestic" agents. The benzodiazepines, like midazolam (Versed), have prominent effects on memory acquisition and retention as well as being useful sedatives. The inhalational agents (gases) have similar effects on memory. Amnesia during a surgical procedure is considered by most doctors and patients to be a desirable state. In fact, "awareness" during general anesthesia is a feared event. However a number of people, including several who write in to this forum, seem to be concerned about this, looking for ways to avoid amnesia and retain memory acquisition during the procedure, while at the same time being comfortably sedated. I am not sure that this is possible. Nitrous oxide causes loss of consciousness at levels above 70% concentration. Entonox (50% nitrous oxide, 50% oxygen) causes sedation, usually without loss oc consciousness. Does Entonox cause amnesia? The short answer is YES. In fact, a very careful recent animal study, in a model that seems to correlate well with the effects in humans, showed that nitrous oxide, compared to the equivalent sedative dose of other gases (halothane, isoflurane, desflurane) is the MOST potent amnestic drug in this class! The effects of nitrous oxide on memory have been recognized since 1799, described in Britain by Humphrey Davy! Propofol, often used for patients undergoing colonoscopy, causes amnesia too. Just about the only drugs commonly used in anesthesia that do not affect memory are the opioids - drugs such as fentanyl, meperidine and morphine. Unfortunately you get sedation only as a side-effect of opioids, and you also get respiratory (breathing) depression. 

I am having surgery on bunions and hammer toes. I will be undergoing the MAC procedure. I am very concerned that I might feel pain if I am not completely asleep. Is this procedure suitable for my type of surgery? thank you 

You may wish to browse this site for other questions I've answered covering the issue of "MAC" and its suitability for various surgical procedures. In brief, MAC (Monitored Anesthesia Care) is another term for mild or moderate sedation. The level of comfort (or discomfort) you experience during the operation on your feet will relate to the effectiveness of the local anesthetic administered by your surgeon (or anesthesiologist), and to the amount of sedative medication you are given. You should be pretty comfortable. Sometimes the hardest part of these kinds of procedures to tolerate is the injection of local anesthetic itself. For a brief period you may given an amount of sedative medication that is enough to make you unconscious for a minute or two, then the rest is plain sailing. 

Two weeks ago I had oral surgery and had light sedation via IV in the arm, in the inside of the elbow area. During the surgery I was awake, in and out of sleep but I could still feel that my arm at the IV site was burning on and off, which I thought was odd as I`ve had the same sedation before and didn`t have the burning at the IV site. I also noted that their was no bleeding from the vein after they took the IV out, the bandaid was clean. After about two days the vein was hard, it feels like a plastic tube under the skin, and it spreads about 3" above the IV site. There is only occasional pain, usually at night before bed but I wouldn`t say it is painful and at no stage has it been tender, red, swollen etc. The only concern I have is how hard it feels and the fact it extends up my arm. I understand there are certain conditions you can get after IV such as superficial phlebitis, do you think this is what I have? Also would you suggest to see a doctor at this stage? 

It certainly sounds like superficial phlebitis. None of your symptoms are warning signs and this condition normally improves without specific treatment. Please keep in mind that this is not an emergency service. We provide information only so you should always ask your doctor for advice about whether to go in and be seen. 

For this minor outpatient surgery, the anesthesiologist wants to administer Versed, which in the past has knocked me out for a day and a half. I asked for remifentanil, just a short dose to not feel the pain from the needle insertion. He seems to be against any disruption of his 'usual routine`. Is my request outlandish? 

ﾠThis is a tricky one. Would you tell your surgeon how he should be tying his knots or where exactly to cut? Anesthesiologists are experts in applied pharmacology and, like surgeons, develop ways of doing things that work in their practice and that, presumably, have some grounding in science. Drugs are their tools. Telling the anesthesiologist that you want a particular drug will sometimes create difficulties because you are presuming to have better professional knowledge than he or she does. On the other hand, you do have the right of autonomy. You should not be pushed into accepting a drug, or surgical procedure, with which you do not have confidence or where you don't fully understand the risks, benefit and consequences. Sometimes all that's needed is a quiet chat between you and your anesthesiologist, outside the hurly-burly of the surgical suite, to explain his perspective and your concerns. If you've had a bad experience with Versed, or any other agent, there is almost always another way to do things. 

I noted two questions where patients asked about colonoscopy without sedation. It is possible - I had it done that way. I had a small dose of Demerol. I was fully awake and watched the entire procedure, which was very interesting. I do wish to state that there is discomfort - particularly as the scope followed the last corner of the colon and also from inflation used to open up the colon. The worst discomfort was somewhat intense, but brief. I would agree that there should be an IV so that if you say `Uncle` sedation can be quickly administered. Why did I do this? 1. I am a total techie and simply found the process and the technology very interesting. 2. I have never reacted well (mentally) to sedation. Two weeks after my colonoscopy I was having laparoscopic hernia repair which required general anesthesia. I did not want to have to deal with my own severe mental reaction from two back to back anesthesias - I could write a lot about that but that would be a separate question. My doctor was very understanding and worked with me the way a physician should. He said he does about 3 colonoscopies per month this way. He has also done upper GI endoscopies without sedation. I might add that assuming I am still healthy I am perfectly willing to go through this again although without sedation, although I might ask for a slightly higher dose of demerol. 

Thanks for your interesting comments which I think will be useful to other readers. I believe your desire to experience the colonoscopy while awake probably puts you in a small minority. But it's nice to know it can be done! The most pain comes when the bowel is inflated with gas and at the point where the scope must navigate around the "bend" - the splenic flexure. You described this well. Having an IV in place is like having a lifeline. If things are not going well with your chosen approach of minimal or no sedation then you can be "rescued" with pain-killing or sedative medication. As I've said before, it is important that you have a comfortable experience. It's also important not to lose sight of why you are having the procedure in the first place. The gastroenterologist is most likely to do a good job of examining your insides if you are quiet, immobile, and pain free! 

I had a colonoscopy yesterday, which involved mild intravenous anesthesia, enough to put me to sleep during the procedure, but immediately afterward I was awake and alert. However, I soon began having hay fever-like symptoms such as sneezing, watery eyes, and runny nose that lasted throughout the day and into the next. I have no allergies that I`m aware of (including latex), and I`ve had this procedure before, as well as two hernia repairs with intravenous anesthesia, with no such effects. Is it possible that I am reacting to something in the anesthetic? 

It seems unlikely that your symptoms are due to the anesthetic. During your colonoscopy you were probably given propofol, fentanyl, midazolam or some combination of those or similar agents. Allergy to these drugs is rare, and would not usually present with hay fever-type symptoms, but rather with a rash, low blood pressure or breathing problems. I think its more likely that you reacted to something that was inhaled. The most obvious candidate is latex, which is often present in measurable concentrations in the air of procedure and operating rooms, and is derived from rubber gloves and other medical items. You probably had an oxygen mask on your face during the colonoscopy so I wonder whether there was something (possibly latex) in or on the mask to which you reacted. You sound fairly certain that you do not have latex allergy (why?) and I can't think of any other inhaled allergen likely to be present in a clinic or hospital setting. Latex allergy is relatively common in individuals who use rubber gloves frequently (e.g. healthcare workers) and causes hay-fever symptoms and a rash, progressing sometimes to severe problems with blood pressure and breathing. Have you ever had hay fever before? Perhaps it's just a coincidence that you had your colonoscopy and the hay fever on the same day! 

I had an IV inserted and removed 3 months ago which was used for versed and NS only and I have a bruise that follows my vein up my forearm still. It is yellowish in color and still tender to the touch. The vein was a little hard feeling also. How long is this supposed to last and/or is this common? 

This question has been answered previously. 

I`m scheduled for a colonoscopy but would prefer not to have versed as it has no benefit to relieve pain and takes away one`s memory for the entire day. What can I request instead and what is customary? Thank you. 

Versed (midazolam) and fentanyl are customary. Propofol is popular. You are correct that midazolam does not relieve pain but your statement that this drug takes away one's memory for the entire day is not true. Millions of patients have received midazolam for various medical and surgical procedures and appear to have been satisfied with the experience. A pain-killing drug and/or local anesthetics are usually used together with midazolam. The amnestic (memory suppression) effects of propofol and other sedative drugs, including midazolam, thiopental and dexmedetomidine are approximately the same. However, the amnesia begins when the drug is given. Memory preceding the administration of the drug is not lost. There are a number of analgesic (pain-killing) drugs that can be given for a procedure like colonoscopy. These include meperidine (Demerol), fentanyl, alfentanil and remifentanil. These drugs do not produce amnesia. 

I recently underwent an incomplete colonoscopy under "moderate sedation." Although I had two previous incomplete sigmoidoscopies due to intolerence to pain, I was not given any information on the sedation--just that it would be much better than a sigmoidoscopy. Only after the failed prcedure was I told that the sedation was not meant to relieve pain. The doctor claimed not to know why a person would fail under mild/moderate sedation. Am I some unusual case? Can you tell me what % of colonscopies have to be done over under heavier sedation? Since the chart notes stated the previous sigmoidoscopy was incomplete, shouldn"t the doctor have known the average amount of sedation might not be enough? Any good reason why the doctor automatically used mild/moderate sedation? I have a $2000 bill and no cancer screening. 

It sounds as though you have had a very difficult time with your colonoscopy, but it is hard to comment specifically on your experience without knowing more details. Who was responsible for administering the sedation? What drugs were given? Nevertheless, even without knowing the specifics, I can assure you that your unpleasant colonoscopy experience is entirely avoidable and should not happen again. The fact is, with proper anesthesia care almost anyone should be able to undergo a colonoscopy in comfort and safety. In most cases, mild/moderate sedation produces acceptable results in patients undergoing colonoscopy. Unfortunately there are always going to be individuals for whom an arbitrary amount of sedative medication is inadequate, and does not in fact take them to the appropriate level of sedation. The trouble is, in many cases, that sedation is given based on a preset protocol, which allows for a certain amount of medication to be given over time. By contrast, anesthesiologists giving sedation for colonoscopy will provide mild, moderate or deep sedation, or even general anesthesia if warranted, based on the needs of the patient and of the practitioner doing the procedure. There is no preset maximum, and everything is done based on the response of the individual patient. One reason why an anesthesiologist can do this is that she is trained to ﾓrescueﾔ patients from the effects of excess sedation and is therefore not bound by any theoretical maximum dose of medication. In addition, anesthesiologists may use a full array of drugs and techniques, under careful monitoring, to ensure comfort. This includes a particularly useful drug called propofol. The really critical thing about sedation for this type of procedure is that, if successful, it allows the doctor doing the colonoscopy to focus entirely on his main job, which is to methodically examine the entire colon and take whatever other action is necessary to diagnose or treat disease. Ideally, the doctor should not have to worry about the sedation. When this task of sedation is delegated to a qualified expert in sedation ﾖ i.e. an anesthesiologist - the doctor can perform the colonoscopy in ideal conditions. In fact, recent studies have shown that more polyps can be detected when excellent sedation is offered. If your insurance plan does not cover the cost of an anesthesiologist it may be worth pursuing this directly with the insurance company. Your gastroenterologist may be able to help. After all, he was unable to perform the procedure you need, presumably for cancer screening, and there needs to be another attempt to do it, this time in a way that you can tolerate, and in safe hands. Good luck next time! 

I`m scheduled to have a colonoscopy in early March and my doctor talked to me about a drug called "Diprivan" which will be used to sedate me. I`ve never heard of it before. How long does it take for this medicine to start working? Does the doctor have to wait a certain amount of time after the medicine is given before he may start my surgery? (I want to make sure I`m asleep.) Will I wake up soon after it`s stopped or will its effects linger? Thanks... 

Diprivan is propofol, a milky white intravenous anesthetic and sedative drug. This is a medicine that works very quickly indeed after intravenous injection. Like all anesthetics and sedatives, the effect depends on the dose. A little bit will produce light sedation. When a higher dose is given, general anesthesia (unconsciousness) will result. A colonoscopy does not require a very deep anesthetic - moderate or deep sedation is usually sufficient. This means you may not be completely unconscious during the entire procedure. Recovery from a procedure done with propofol sedation is usually rapid - that is why it is favored for a variety of outpatient surgeries and medical procedures. It is also a drug that does not have much in the way of unpleasant after-effects. In fact, propofol has anti-nausea properties and occasionally produces euphoria and a pleasant dreamlike state. Despite the rapid offset of the drug's effects, current practice is to prohibit patients from driving, operating machinery, or making important decisions. Propofol often causes a burning sensation at the intravenous site. In common with other anesthetics, it is a depressant. In the hands of unskilled practitioners, propofol can cause severe depression of the cardiac and respiratory systems. Don't try this at home! 

I`m scheduled for a colonoscopy (no problems, just a routine screening) and I don`t want to be sedated as I have never been sedated for anything including two chilbirths (for which I also did not receive pain medication) and I don`t want an IV. My Mother and both sisters had a lot of bruising and pain at their injection sites that lasted for weeks and I refuse to go through that. I want to be aware of what is happening to my body through the entire procedure and be able to convey to the doctor if I want to stop the procedure. I can`t do that if I`m sedated. I also want to be able to leave the hospital afterwards without any residual medication affecting me. In other words I don`t want to leave in a drugged stupor as my husband did after his procedure. If I go through the procedure the way the doctors have outlined it to me then they will be taking all of the decisions about what happens to me out of my hands. I am trying to retain as much of my dignity as I can in this wholely undignified experience. So the question is, is it possible to have a colonoscopy done with no IV or sedation? 

ﾠDuring the Civil War, men had their limbs amputated without anesthesia. As you've mentioned, women may endure childbirth without medication. I am sure it is possible to have a colonoscopy without sedation. I guess it is your right as an autonomous patient to request this. Before you make your request, you should consider these questions: - Why are you having the colonoscopy? - What are the rights of the physician? These are my suggested answers: You are having a colonoscopy to screen for asymptomatic abnormalities. Such abnormalities can be polyps or even cancer. You want the physician to have the best possible chance of detecting these because their detection could save your life. You give the physician the best chance at detecting abnormalities by lying absolutely still so she can concentrate on finding abnormalities. If you are not sedated you are likely to have significant discomfort, with which the physician will be concerned, and find difficulty being immobile. Your physician may be distracted by your discomfort and be pushed into completing the procedure as quickly as possible. As a result the abnormality may be missed. This would be a very unfortunate outcome for both you and the physician. I imagine that in the US it might even be grounds for a lawsuit against the physician! Your dignity is important. How important is your life? Your dignity may be best safeguarded by not having to endure a procedure that is difficult for both you and the physician to complete. An IV doesn't have to result in prolonged bruising and discomfort. Ask for someone who has had lots of experience putting them in. I suggest you discuss this issue with your physician, and the sedation with the anesthesia provider, who may or may not be an anesthesiologist. I suspect that both will be willing to give it a try without sedation provided you agree they can step in and provide this if necessary to ensure a good outcome. 

I will be having outpatient vitreoretinal surgery with local anesthesia and IV sedation. My goals for anesthesia are: (1) no post-surgery nausea/vomiting, (2) minimize pain, (3) avoid feeling "drugged" post-surgery, (4) avoid any drugs that produce amnesia--I want to remember the surgery! My surgeon opposed my suggestion of only having local anesthesia. Please suggest possible drugs for IV sedation that would meet my goals. 

Thanks for your question. You seem to be very clear about your goals! But perhaps you are losing sight, if youﾒll excuse the pun, of the real aim here. I think you should focus on a fifth, and most important, goal. That goal should be for you to have a successful surgical outcome ﾖ the recovery or preservation of your eyesight. And in order for surgical success to occur the surgeon should have absolutely optimal conditions for operating on your eye. In our institution, vitreoretinal surgery is usually done with a ﾓblockﾔ. A block is local anesthesia injected into the orbital cavity to render the eye temporarily motionless, and insensate (pain free). The block is usually accompanied by IV sedation using any or all of the following drugs ﾖ midazolam, fentanyl and propofol. With the limited amount of medication used there is seldom a hangover (ﾓdruggedﾔ) effect, however both the midazolam and the propofol can produce amnesia. Most patients have minimal or no pain during the procedure. The incidence of nausea with this technique is low. If your surgeon opposes only local anesthesia I suggest that you take this seriously. Has he explained why? Have you consulted with your anesthesiologist? It may be because of the concern that you will be unable to remain motionless during the operation. Sudden movement during retinal surgery can be very upsetting to the surgeon and could even prevent the safe completion of the surgery. Every surgical team has customary ways of doing things and although everyone tries to accommodate the wishes of individual patients, itﾒs not always possible to do this and still achieve the primary goal ﾖ safe anesthesia and surgery with a good outcome. Your wish to avoid the amnestic effect and remember the surgery, while a bit unusual, is understandable. However in this case you may not be able to have it all. Perhaps you should let your desire for a ﾓmemorableﾔ experience take a back seat. Allow your surgeon and anesthesiologist do things in the way with which they are most comfortable and which maximizes your odds of safe, successful eye surgery. 

I am having lacrimal duct surgery performed for a blocked tear duct. The surgeon is using monitored care anesthesia with sedatives. He said I would be very drowsy and possibly asleep. This is unclear to me. I would like to be prepared to ask the anesthesiologist a few questions regarding this type of anesthesia. Any light you can shed on the topic would be helpful. Will I need to be intubated? Will I be monitored? Is this type of anesthesia suitable for this surgery? What is the recovery like? Will I remember the procedure? How is the anesthesia administered? 

ﾠThe following detailed definition of "monitored anesthesia care" (MAC) is from the American Society of Anesthesiologists: "Monitored anesthesia care is a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Monitored anesthesia care includes all aspects of anesthesia care - a preprocedure visit, intraprocedure care and postprocedure anesthesia management. During monitored anesthesia care, the anesthesiologist or a member of the anesthesia care team provides a number of specific services, including but not limited to: monitoring of vital signs; maintenance of the patient`s airway and continual evaluation of vital functions; diagnosis and treatment of clinical problems which occur during the procedure; administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary to ensure patient safety and comfort; provision of other medical services as needed to accomplish the safe completion of the procedure. Monitored anesthesia care often includes the administration of doses of medications for which the loss of normal protective reflexes or loss of consciousness is likely. Monitored anesthesia care refers to those clinical situations in which the patient remains able to protect the airway for the majority of the procedure. If, for an extended period of time, the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic." The choice of a particular anesthetic technique (MAC, general anesthesia, regional anesthesia) is normally a decision made by the anesthesiologist, taking into account the type of surgery as well as the needs and preferences of both the patient and the surgeon. A monitored anesthesia care technique usually involves the administration of intravenous anesthetic drugs, oxygen (given with a nasal cannula or face mask), and standard patient monitoring procedures similar to those used during a general anesthetic. MAC implies that the trachea (windpipe) is not intubated. Because MAC usually entails the administration of lower doses of anesthetic drugs than with a general anesthetic, the recovery period tends to be shorter. The drugs that are used definitely affect one`s ability to remember the procedure, but periods of awareness can occur. Please consult your anesthesiologist before your surgery to establish what is planned for you and to answer any other specific questions. 

My mother just had outpatient surgery for a blocked tear duct, and had MAC anesthesia. She was told point-blank before going into the operating room that she would be asleep, yet she states that she was aware and awake during the whole thing. She remembers bones crunching (or a sound like it), pulling, pushing, suturing, etc., and stated that time went very slowly. The promised state seems MUCH different that the reality. What`s going on? I had a colonoscopy under MAC, stated beforehand that I did not want to be aware, and only woke up when it was done. This sure makes me not want to ever have MAC again if it is not dependable for comfort during surgery. 

This is a really good question because it raises a very common concern - thank you! MAC anesthesia is a term which stands for Monitored Anesthesia Care. What does that mean? Well, rather than "just putting you out", the use of anesthetic medications results in a range of anesthetic states, or "levels of sedation". Which level you get to depends on a number of things, including the age and general condition of the patient, genetic factors, and the choice and amount of anesthetic drug. The American Society of Anesthesiologists (ASA) has defined four levels of sedation: (1) minimal sedation, (2) moderate sedation (conscious sedation), (3) deep sedation, and (4) general anesthesia. Official definitions are reproduced below. As sedation is increased, or deepened, the patient becomes progressively more sleepy (less easily roused) and more able to tolerate painful or uncomfortable procedures, (in the definitions this is assessed by the response to stimulation or verbal command), ending in the state of unconsciousness known as general anesthesia. What is not always realized by the lay public is that as sedation becomes deeper, the patient also gradually loses the ability to breathe normally. This is usually accompanied by a depression of heart function and blood pressure. You will notice that MAC does not appear in this classification. It is a term which has fallen out of favor somewhat, but probably corresponds most closely with levels 2 and 3 - moderate and deep sedation. Given that most patients prefer to be unaware during their surgery, one may ask why a lesser or lower level of sedation is desirable. The answer is that recovery is quicker, and, as I have said above, that there is less depression of the heart, blood pressure and breathing from the anesthetic agents at these lower levels of sedation. Problems arise when patients do not understand the type of anesthesia they are to receive. It is important for the anesthesiologist to clearly communicate the intended level of anesthesia and sedation, and for the patient to anticipate what is likely to happen. It is also important to offer an explanation, as the ASA points out, that "because sedation is a continuum, it is not always possible to predict how an individual patient will respond". Problems occur when patients do not respond in exactly the way intended or expected. That is, they get either too light (less sedation) or too deep (too much). In the case of anesthesia that is too light, the patient may become aware or awake, as you so vividly describe. (What is surprising to many is the fact that recent studies show that even with general anesthesia, there is an incidence of unintended awareness of around 2 per 1000 cases). If a patient wants to be unconscious during a procedure (general anesthesia) this may be possible but there are trade-offs - more drugs, slower recovery, more risk of nausea afterward, need for a breathing tube, greater risk of depression of the heart. For a procedure such as a colonoscopy, what is typically offered is minimal or moderate sedation. The drugs used, such as midazolam, have the happy benefit of causing amnesia. In other words, patients forget almost the entire experience, despite having been awake enough during the colonoscopy to respond normally and purposefully to commands or conv ersation. This perhaps was your experience. For your mother on the other hand, undergoing a more invasive procedure, the results were less desirable. It sounds as though she experienced no pain during the surgery but was distressingly aware of certain unpleasant aspects of what the surgeon was doing. The outcome could have been different perhaps if your mother had been told that during the anticipated state of moderate sedation she was likely to feel some of what the surgeon was doing, but would experience no pain. Your mother may then have been more willing to accept what she was experiencing in the knowledge that she would, in return for her tolerance, be able to leave the facility more quickly, recover with fewer side-effects, and have less risk of heart or breathing complications. Finally, if during the procedure she was really uncomfortable she could have expressed this to the anesthesiologist who may have been able to administer more medication to increase her comfort. Perhaps this vital aspect was not explained to her before the procedure took place. I hope that your mother has no need of further surgery. But in the event that she does undergo another procedure lets hope she has a more satisfactory experience with anesthesia. Be sure to discuss your concerns with your anesthesiologist who will be glad to explain all of this in more detail and to tailor your anesthetic to your needs, always with safety in mind. American Society of Anesthesiologists Definitions of Levels of Sedation 1. Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. 2. Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. 3. Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. 4. General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable even by painful stimulation. 

I recently had a surgery in which they used MAC (monitored anesthesia care, I believe?). I found out two days later that I am in the very beginning stages of pregnancy. This procedure was done before my first missed period. What are the risks to the fetus or chances of spontaneous abortion with this type of anesthesia? 

Any risk of abortion (miscarriage) or of harm to your developing fetus is much more likely to be related to the condition which prompted the surgery, and to the surgical procedure itself. Conditions that are associated with fever, or that affect the pelvic organs, may lead to miscarriage. There is not a lot of data from scientific studies about the effects of anesthetic agents in early pregnancy in humans (how would you get anyone to sign up?!). So the information we do have comes from anecdotal reports, and from animal studies (which often don't translate to humans). The good thing is, even this scanty and indirect evidence suggests that standard anesthetic agents have few if any effects on the developing fetus, assuming the condition of the mother during the anesthetic and surgery is satisfactory. In other words, the mother's oxygen levels, blood pressure and heart output, temperature and other metabolic functions are in the normal range. This doesn't mean that an anesthetic during pregnancy is a good thing, or something to be undertaken lightly, but it does suggest that the risk is low. In fact most centers have policies or practices intended to avoid your scenario. It is our practice to inquire of any female of child-bearing age about the possibility of pregnancy. Where there is even the slightest possibility, a pregnancy test is done, with the patient's consent. In some centers, pregnancy testing is routine in all cases. 

I am going to have a cyst removed from my flexor tendon sheath. They are going to use MAC sedation. I am extremely terrified of this. After reading several reviews on this type of sedation, I am now worried that I will be aware of what is going on, and if this happens, I know I will freak out. I want to tell the anestiageoligist (sp?) that I want him to knock me out before the surgeon even touches my hand. I am so scared. Can you tell me if he will do that. I just don`t think I can go through with this if he doesn`t. The cyst is so painful and restricting that I need to get it removed though. Any advice on this MAC would greatly be appreciated. If you could tell me around about way I will feel when I am on it. I know everyone is different. 

Clearly you are very frightened about your upcoming surgery. It's natural to be somewhat anxious but I do wonder what you've been reading and why you are so scared. I'm sure you realize that a cyst removal from your tendon sheath is a pretty minor procedure. If it's pain you are worried about you can be sure that the combined efforts of a competent surgeon and anesthesiologist together will ensure you are pain free during the procedure. If it's done under "MAC" - that is moderate or deep sedation - you may be "aware of what is going on" in that you may feel the surgeon touching, moving or applying pressure to your hand. You might be correct about that alone being enough to freak you out, but I doubt it because in my experience even the most anxious of patients manage just fine, given lots of reassurance and the correct amount of sedative medication. After discussing your anxiety with the anesthesiologist I'm sure he or she will give you some anxiety-relieving sedation - such as midazolam - before you reach the operating room. That will probably be enough to calm you down. During the procedure itself you will probably receive additional midazolam together with intravenous sedation - e.g. propofol. These drugs in high enough doses can produce general anesthesia - unconsciousness - but the aim is usually a state of sedation short of general anesthesia. If you are absolutely unwilling to have the procedure in the way it has been planned you should speak with your surgeon and anesthesiologist, preferably ahead of time. It is likely that they will be rather understanding of your fears, reassure you that all will go well, but offer you the option of general anesthesia if that is what you desire. A necessary condition however is that facility in which you are to have the procedure done must have the capability of providing general anesthesia including the appropriate after-care. There might be additional out-of-pocket cost to you. 

I recently had a colonoscopy. I was given a white milky medication via IV to sedate me for the proceedure. When I awoke a short time later in the recovery room, I felt GREAT. No side effects. I would like to know the name of the medication used. 

That's an easy one! The milky white medication is propofol (trade name Diprivan in its original formulation). Propofol has become, worldwide, the intravenous anesthetic agent of choice. When used for sedation, propofol often produces the experience you describe. A few individuals even have pleasant dreams. 

I had a colonoscopy on Monday morning at 8am. I was given Versed and Fentanyl for the conscious sedation. I "woke up" a couple of times in severe pain. I was told after that I required a lot of one or both of the drugs. I slept the rest of the day. Next morning, I was still very weak and dizzy, unable to go to work. I also proceeded to get a migraine. My BP is in the normal range, but low by 15points for me. I also began crying uncontrollably Tues morning. Dr. thinks it is the anesthetics... It`s now Tues night and getting a little better, but I`m still not myself. Any ideas? I was told I`d be fine right after the procedure. I could hardly sit up to get in the wheelchair to leave! 

This is not a diagnostic service, so my comments are general. If your weakness, dizziness or headache persists you should see your doctor. It's true that colonoscopy is usually advertised as an easy, "drive-through" sort of procedure. Sometimes it just isn't that way. You're not the only one! In a certain number of patients, pain is experienced during colonoscopy despite "usual" doses of midazolam (Versed) and fentanyl. Individualized sedation - a little for some, more for the people who need more, is the ideal. Many anesthesiologists prefer the use of a sedative/anesthetic like propofol, but propofol can cause significant decreases in blood pressure and breathing. (There is controversy over whether non-anesthesia providers, like surgeons or gastroenterologist, should be allowed to administer propofol). You might have a received fairly large amount of midazolam. Although this is a fairly short-acting drug, you can expect some hangover effect with large doses. This should go away within hours to days. Anesthetic and sedatives are often blamed for almost all of the after-effects of surgery. The truth is we don't know exactly what the contribution is of surgery and the accompanying stress of manipulating and/or cutting tissues, versus the effects of the anesthesia. It is likely in most cases to be a combination of both factors. And let's not forget the psychological stress of undergoing a medical procedure, with uncertain outcome and associated worry. That form of stress will surely contribute to feelings of physical unwellness. 

My last menstrual period was July 5th andﾠI had a colonoscopy performed on Aug 9th withﾠIV sedation of MidazolamﾠI just found out today that I`m pregnant how much harm is my baby in? Please help. 

ﾠMidazolam seems to be a very safe drug during pregnancy. It is such a commonly used drug that many women have probably been in your situation, accidentally exposed to midazolam during early pregnancy, without any corresponding reports of harm to the developing fetus. However no controlled studies of high scientific standard in pregnant women have been conducted to confirm this. (It is impossible ethically to do such a study). Studies in rats and rabbits have been reassuring, but nobody can give you an absolute guarantee on this basis that your baby has not been harmed. The odds though are strongly in your favor. Good luck! 

Three weeks ago today I had a tooth pulled by an Oral Surgeon and they ended up having to give me an IV to knock me out. The Oral Surgeon put the IV in the back of my hand. I have been having pain in my hand ever since I had the IV. Two week after the IV I noticed that the vein in my hand was swollen and it hurt up into my wrist. I did call the Oral Surgeons office and I did go see her. She said that there could be a possibilty that it could be phlebitis or a blood clot. She told me to use an anti-inflamatory and to put warm compreses on my hand and to come back to see her in 3 days. I have another appointment with her today. I would like to know if something like this normal after having an IV. I did contact my Internal Medicine doctors office and they told me to see the Oral Surgeon today and see what she says and then to call their office back. Is this something that is normal or could it be a serious problem. Thank You 

Thanks for your question. Phlebitis is a term that means inflammation of a blood vessel. Phlebitis occurs quite commonly after the insertion of intravenous catheters ("IV"). The exact frequency of phlebitis is anywhere from 2.5 to 45% or more. The frequency depends on how phlebitis is defined, the site of IV insertion, the duration that the IV has been in place, the type of material that the IV is made of, the length of the IV catheter, and on the existence of other disorders as diabetes. Phlebitis can also be associated with the formation of a blood clot in the vein. In more serious cases the site can become infected. If infection develops, the infection can be spread throughout the body. It would be very unusual for an IV placed in a hand, for a short period as you describe, to develop a serious infection. One sign of infection is the presence of enlarged lymph nodes under the arm on the affected side. Because of the risk (though small) of serious complications, you should definitely make sure to see your surgeon for the follow-up appointment. Hopefully the standard conservative treatment you mention will be successful.ﾠ 

I had a colonoscopy done on 9/19/06, all was well, no polpys, no cancer, etc. However the doc discovered 3 large hemorrhoids which he banded.ﾠ Since 9/20 /06 I have a loose bowel movement, EVERY HOUR ON THE HOUR. I am at my wits end and cannot take my stool sample to the lab until 9/25/06. Could I have a reaction to the anesthesia? 

You had a procedure done on your bowel and now you have a bowel-related symptom - diarrhea. It is interesting that you would think that the anesthetic, rather than the procedure, would somehow be responsible for the diarrhea! Please contact your gastroenterologist for advice. I don't think the anesthetic has anything to do with your current problem. I wonder whether the bowel preparation medicines you might have received prior to the colonoscopy may be causing the loose stools. 

After 24 hours I still have some vision distortion. Experienced Chills, sick to stomach/not vomiting, blurred vision, malaise after dental work. Is this considered allergic reaction? Does it affect the liver functions? 

The symptoms you are describing are not at all typical of an allergic reaction. I suggest that you seek attention from a physician as soon as possible, especially if your symptoms worsen. 

What is the difference between MAC sedation and Conscious or Twilight sedation? Which is preferred for the above procedures? Are these two basically the same? 

The problem is that these terms - MAC (Monitored Anesthesia care), Conscious Sedation, and Twilight Sedation - are poorly defined. Although still in widespread use, the preferred way to describe the different levels, or "spectrum" of anesthesia is the following: 1. MINIMAL SEDATION (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. 2. MODERATE SEDATION (perhaps synonymous with conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. 3. DEEP SEDATION is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. 4. GENERAL ANESTHESIA is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. For a procedure like colonoscopy, the goals is usually to provide sedation at levels 2 or 3. However, this is not a mechanical process in which you can select an exact dose to give you an exact level of sedation. The level of sedation can and does vary between individuals getting the same doses of the same medication, and also in the same individual depending on the level of stimulation produced by the procedure. The practitioner administering the sedation must be able to "rescue" the patient who unintentionally progresses into a deeper level of sedation. 

I am soon to undergo surgery and understand I will be under twilight anesthesia for about 30 minutes. First, is this the same as MAC? Also, Do patients ever "talk in their sleep" while under this and/or say/do things that could be embarassing to them after coming out of this state of sedation? The amnesia that occurs from this is a bit disconcerting . 

Thanks for your questions about sedation and its effects. There are several terms used to describe the anesthetic "state" in which the patient is sedated but not under general anesthesia. Among the most commonly used terms are the ones you've mentioned. "MAC" or Monitored Anesthesia Care is "a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure." A rather vague definition. In fact, MAC is often used to describe a state of "moderate" or "deep" sedation (more on that later). "Twilight" anesthesia has no official definition that I am aware of but is often used to describe the same type of sedative or anesthetic state that "falls short" of general anesthesia. The official terms and definitions, developed by the American Society of Anesthesiologists, and adopted by other national organizations, involves a "continuum" of sedation. The continuum starts with "minimal" sedation, and moves through to moderate and deep sedation, and, finally, general anesthesia. Along the continuum, with increasing doses of sedative or anesthetic drugs, a patient becomes less responsive, but also gradually loses the ability to keep the airway open, breathes less well, and experiences more depression of cardiovascular function. Moderate sedation is also known as "conscious sedation" - a bit of a misnomer really. There is a common misconception that sedation acts like a "truth serum" and that patients are compelled whilst in this twilight zone to divulge secret and embarrassing personal details. If only it were that exciting! In more than 15 years of anesthetic practice I have yet to take care of a patient who has revealed to me any juicy secrets! It is true however that sedated patients sometimes become a bit disinhibited, much as an inebriated person under the influence of alcohol might behave. This could be an embarrassing experience, however the amnesia effect means that you are unlikely to remember what you said. Whether this is a good or bad thing depends I suppose on your perspective. The goal of the anesthetic state is to allow the surgical procedure to be accomplished quickly, safely and effectively. A patient who is behaving in a disinhibited, drunken state will very quickly be given more anesthesia (or, sometimes, less) in order to create better conditions for the surgical procedure to take place. Unfortunately, the treatment of medical and surgical conditions sometimes involves the inevitable loss of one's physical dignity for a period of time. Hopefully the highest ethical standards surround the care we deliver. Let's recall that doctors and other healthcare providers are meant to observe the highest levels of respect for a patient's privacy. We all become patients at one time or another in our lives, and hopefully we learn to accept the occasional embarrassment or loss of physical dignity with humor, in return for the benefit of excellent and compassionate care. On a final note, I always encourage our readers to engage their anesthesiologist (and surgeon) in a discussion of risks, benefits and alternatives of anesthesia care. It is possible that the procedure you are about to undergo can be accomplished with minimal or even no sedation, using local or regional anesthesia techniques. This approach will help you to avoid the problems that you have raised in your question. 

After a colonoscopy procedure during which I was diagnosed with colon cancer I began sneezing in recovery and am still doing it hours later after antihistimines. Is this normal? What can I do to avoid this during my surgery in the coming weeks? 

It does sound as though you may have reacted to something in the environment. I think it's unlikely to be the anesthetic medications though. For a colonoscopy, in the United States, the most common medicines used are propofol, fentanyl, and midazolam. These drugs very seldom cause allergic reactions but when they do the reaction may include a rash, swelling, difficulty breathing, and low blood pressure. Sneezing is not typical. Another possibility is that you are allergic to latex and have responded to rubber gloves, or some other latex-containing medical item that you came into contact with. Individuals with latex allergy often have a background of other allergic conditions, such as asthma or hay fever, and of previous exposure to latex in the workplace (gloves, usually). There is a blood test for latex allergy available. A final possibility is that your symptoms are completely unrelated to the colonoscopy procedure and you came into contact with something outside, or were just in the early stages of a respiratory infection. In any case, I think you are unlikely to have similar problems during your forthcoming procedure. It's a good idea to tell your anesthesiologist about your experience too she can be on the lookout for allergy-related problems during and after the surgery. 

Is it okay to have a glass of wine 13 hours after your twilight sedation? 

My guess is that you're planning to drink some wine after your procedure, or you already did so. If you already drank your wine - did something bad happen? (This is my suspicious nature coming through!). Most guidelines recommend that patients avoid alcohol for between 12 and 24 hours after any form of anesthesia or sedation. At 12 hours it is likely, assuming you are healthy and short-acting agents were used, that your body will largely have eliminated the drugs. The real question is, what activities are you going to undertake after drinking your wine? There's not likely to be a problem if you're sitting at home and watching TV. If on the other hand you're going to drive, operate machinery, or make important decisions, it is conceivable that even one glass of wine, plus any lingering effects of the sedation, could combine to make you more intoxicated than you would otherwise be after a single glass, and a danger therefore to yourself or others. Please follow the advice given to you by your doctors. 

Is it okay to be sedated 2 times with this anesthesia within one month? 

ﾠThere is usually no reason to worry about receiving "twilight sedation" - also known as moderate sedation - twice in one month. There is a fair range of responses to anesthetic drugs, dependent on age, general condition, genetics, interaction with other medicines, and other factors. Despite these factors, modern anesthetic drugs are rapidly broken down by the body and excreted and recovery is usually rapid. 

I have an upcoming colonoscopy and was told that I have several choices as to the type of "anesthesia" that I can get....first was some sort of "conscious cocktail" of painkiller and amnesia drug that is usually effective,and a second, "deeper" drug "diprivan" administered by an anesthesia person and thirdly nothing at all. The doc says that choice one works well on "most people" but not on all, choice number two (the diprivan) is great but expensive, and choice three (nothing) is only the choice of a small percentage, but the "safest" option.....This is just a screening test due to bad history, no emergency...just from a safety standpoint, is there a significant difference of risk between the three choices? I`m scared to death of the idea of any anesthesia and am leaning towards nothing if the first two are at all risky. Thanks 

Thanks for your question. Your doctor has provided a not unreasonable summary of the choices except that he is not balancing risk against benefit. Options one and two are very safe in the hands of any well-trained clinician using appropriate monitoring and clinical judgment. Option three (no sedation at all) is the safest from the point of view of side-effects from anesthesia (obviously). But here's a question. Do you want the doctor to have the best possible chance of giving your colon a thorough going-over? I assume the answer is yes - else why bother having the colonoscopy? The best possible conditions for the doctor doing the colonoscopy are: 1. The patient is asleep (immobile and not wriggling around) 2. The endoscopist does all the time needed to complete the procedure with thoroughness There is at least one study showing that in patients who get the deep sedation technique, more polyps are found in the colon than those who get the usual "cocktail". There are certain parts of a colonoscopy, such as when the scope gets to an area called the splenic flexure, that can be really very uncomfortable. 

I`ve been told that versed has to be given in small amounts and why is this necessary? I was given 9mg of versed total for my esophageal endoscopy, so how many doses would have been made? Thank you. 

Midazolam in large doses can actually induce general anesthesia, a state in which the patient is unresponsive to stimulation and has decreased blood pressure and breathing. So midazolam, and other similar agents, are usually given in small amounts. The response of the patient is then assessed over the next few minutes, and more is given as needed. The usual dose of midazolam given to an adult patient is 1 - 2 mg at a time. So, an amount of 9 mg of midazolam administered over a half hour or so would not be excessive. 

I was told to have a breast biopsy, but the doctor said it could not be done with a local anesthetic, but she would have to use MAC. I have multiple chemical sensitivity, and am allergic to many medications, as well as plastics, all contrast dyes, ester anesthetics, etc.etc. etc. I had a very negative reaction to Versed (severe brochospasms for over a month) following a colonoscopy in 2001. I would like to know which drugs are used in MAC. The doctor said it couldn`t be done with a local, because it`s "easier on the doctor" if the patient is not awake. Apparently, the patient`s allergies/sensitivities are not as important, but I have not found any other doctors in my area willing to do it with a local anymore. Thank you. 

MAC is not a specific medication, or set of medications. In fact, MAC (Monitored Anesthesia Care) is a difficult term to define (see previous questions on this topic) and refers to some level of sedation, accomplished usually with intravenous drugs, plus local anesthetic injected by the surgeon. Most "MAC" anesthetics in the United States probably involve some combination of propofol, midazolam (Versed) and fentanyl. However, there are other drugs that may be used, especially in other countries. 

Sedation can certainly be administered without the use of midazolam, and some people find that a propofol-only technique is well tolerated. A potent opioid like fentanyl is needed to "cover" discomfort that is not entirely blocked by the local anesthetic, limit the pain of injection of the local anesthetic itself, and to provide some degree of pain relief once the procedure is over. 

A recent article in the British Journal of Anaesthesia may be helpful. It suggests that in patients with your kinds of problems usual anesthetic practice should apply, while obviously avoiding drugs which you are known to be sensitive to. 

For a routine colonoscopy, my doctor is letting me decide between twilight and total anesthesia. But she says that total anesthesia is safer (anesthesiologist present) and has fewer after effects. I forgot to ask her why, in that case, any one doctor offers twilight sleep or any patient chooses it. What are the tradeoffs? 

Twilight anesthesia and total anesthesia are not standard terms, so I can't really tell you exactly what your doctor means. The official classification of "levels of sedation" goes as follows: 1. Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. 2. Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. 3. Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. 4. Anesthesia consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.ﾠMy guess is that your doctor is offering you either a Level 1-2 experience in which you are given small amounts of intravenous sedation, administered by a nurse, or a Level 3-4 experience involving an anesthesiologist. With the latter you have the benefit of greater comfort for you during the procedure, and possibly better conditions for the doctor doing the colonoscopy. This usually comes at a higher cost, (although you may not be the one paying) but with perhaps a slightly longer recovery time. An intravenous infusion of a drug called propofol is very often used for deeper sedation, however propofol is not the only drug that can be used for this. The key issue is safety. There is probably no significant difference between the two approaches as far as safety (the risk of harm) is concerned, assuming you've got competent professionals doing the work. Anyone permitted to administer lower levels of sedation must have the ability to "rescue" the patient from deeper levels that may occur unintentionally. In the United States anyone providing general anesthesia or deep sedation is likely to be an anesthesiologist or nurse anesthetist, although some gastroenterologists are seeking special permission, through legislation, to allow them to administer propofol for colonoscopies without an anesthesia provider.