Would it be proper to request an ankle block without sedation, perhaps a 5 mg. ativan to take the edge off any anxiety? I don`t want the amnesiac versed for my surgery since it does not provide any pain relief. 

You are correct that Versed (midazolam) does not provide any pain relief. So, is your request to not be given midazolam a proper one? It could be a mistake to tell the doctor, who is an expert in applied pharmacology, to avoid a particular drug without good reason. I believe the best approach is to discuss your concerns and your preferences with the anesthesiologist before the procedure. 

It sounds as though you would like to remain awake during the procedure - that is certainly a reasonable request for almost any orthopedic surgical procedure. Hammertoe surgery can be done with an ankle block, and a willing surgeon can supplement the block with infiltration of the field or digital nerve blocks if needed. If a tourniquet is required, placed on the leg or thigh, the ankle block will not cover that and a different plan will be necessary. 

I am wondering whether you might have read something on the internet or seen something on TV about the problem of awareness during general anesthesia, with or without the use of midazolam. This is a serious issue and a legitimate concern. However most anesthesiologists will tell you that the use of midazolam as part of the anesthetic, or as the premedication, does not create a problem in this respect. 

You should be aware also that Ativan (lorazepam) is a drug in the same class as midazolam (a benzodiazepine) and has the same effects. 

Benzodiazepines are sedative drugs that have other useful properties - they relieve anxiety, cause amnesia, relax muscles, and stop convulsions. So asking not to be given midazolam, while requesting lorazepam doesn't really make sense! 

If you have an ankle block, or other local or regional anesthetic, your anesthesiologist will generally try to respect your wish to be awake. If however you happen to become especially anxious or restless during the operation, midazolam is one of the main drugs used, in the United States anyway, to relieve that anxiety. If you are not doing well because the block is not completely effective and you are having pain, you would probably be given a drug like fentanyl (a pain-reliever), or given deep sedation (with a drug like propofol) or even general anesthesia (with a variety of different drugs). 

At the end of the day, it's your right to determine how you are treated, and by whom. As I've said before in this forum, it is also the right of the anesthesiologist not to administer treatment he or she believes to be unsafe or ineffective. Having said that, an anesthetic without midazolam certainly is not unsafe or ineffective. 

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. 

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`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`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. 

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. 

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 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. 

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. 

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 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. 

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.