anesthesia/colonoscopy/side effects

[penmark]

The facts: routine colonoscopy, 50 yr old man, no known allergies; Gastroenterologist suggests that anesthesiologist administer deeper sedation (versed plus propofol), as opposed to twilight sedation (versed plus fentanyl), which he would have administered without need for anesthesiologist. Pt. advised anesthesiologist that he experiences "heartburn," for which he takes Rolaids 2-3 times per week.

After some discussion, deeper sedation is agreed to. Patient is given: fentanyl, 50mcg; versed, 1mg; and propofol, 200mg. Not sure why the fentanyl was given, since it was not part of the plan that had been previously discussed. Sedation with 15 seconds upon injection; patient awakens about 20-25 minutes later; procedure complete; coughing. Gastroenterologist advises patient was also coughing during procedure. (note: patient asymptomatic prior to procedure.)

Patient complaints immediately after procedure: upper chest tightness; chest pain when inhaling; persistent cough. Cough not as persistent after 45 minutes, but continued for 6-10 hrs. Chest/lung exam deemed normal. Underside of one side of tongue had large black and blue mark, which disappeared within 36 hours. Pt. had chills 2-3 hrs after procedure; then threw up; then slept soundly 3-4 hours; then woke up overheated. Second day after procedure, cough almost gone, but still has "chesty" cough, with some clear phlegm.

Advised that nothing was in patient's mouth, except for routine suctioning during procedure.

Question: Is fentanyl/versed/propofol a typical cocktail for this type of anesthesia? Could the anesthesia be responsible for causing any or all of the the coughing, tight chest, continued "chesty" cough, black and blue tongue? If so, which? Could the suctioning have caused the black and blue tongue? Does any of this constitute an allergic reaction to any of the administered meds?

Mark

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[VolatileAgent]

coughing is a realtively common side effect of fentanyl administration, even in small doses.

 

[penmark]

thanks, how long would the coughing typically last?

 

[jwk]

The facts: routine colonoscopy, 50 yr old man, no known allergies; Gastroenterologist suggests that anesthesiologist administer deeper sedation (versed plus propofol), as opposed to twilight sedation (versed plus fentanyl), which he would have administered without need for anesthesiologist. Pt. advised anesthesiologist that he experiences "heartburn," for which he takes Rolaids 2-3 times per week.

After some discussion, deeper sedation is agreed to. Patient is given: fentanyl, 50mcg; versed, 1mg; and propofol, 200mg. Not sure why the fentanyl was given, since it was not part of the plan that had been previously discussed. Sedation with 15 seconds upon injection; patient awakens about 20-25 minutes later; procedure complete; coughing. Gastroenterologist advises patient was also coughing during procedure. (note: patient asymptomatic prior to procedure.)

Patient complaints immediately after procedure: upper chest tightness; chest pain when inhaling; persistent cough. Cough not as persistent after 45 minutes, but continued for 6-10 hrs. Chest/lung exam deemed normal. Underside of one side of tongue had large black and blue mark, which disappeared within 36 hours. Pt. had chills 2-3 hrs after procedure; then threw up; then slept soundly 3-4 hours; then woke up overheated. Second day after procedure, cough almost gone, but still has "chesty" cough, with some clear phlegm.

Advised that nothing was in patient's mouth, except for routine suctioning during procedure.

Question: Is fentanyl/versed/propofol a typical cocktail for this type of anesthesia? Could the anesthesia be responsible for causing any or all of the the coughing, tight chest, continued "chesty" cough, black and blue tongue? If so, which? Could the suctioning have caused the black and blue tongue? Does any of this constitute an allergic reaction to any of the administered meds?

Mark

The "plan" is up to the anesthesia provider, not the gastroenterologist. We don't tell them how to do a scope, they don't tell us how to provide sedation (and if they don't know that, we're glad to inform them how things are).

 

[VolatileAgent]

thanks, how long would the coughing typically last?

minutes to hours.

 

[zippy2u]

Penmark, Sniff, Sniff...Ya startin' to smell like a ratty ass barrister to me. Ise only got $250,000/$750,000 mister, please be easy on me... Regards, ---Zip

 

[jwk]

Penmark, Sniff, Sniff...Ya startin' to smell like a ratty ass barrister to me. Ise only got $250,000/$750,000 mister, please be easy on me... Regards, ---Zip

I had the same thoughts...

 

[CanGas]

Sure smells like someone is fishing for something too.

But besides:
Midaz - 1mg = baby dose
Fentanyl - 50mcg = baby dose (same as 2 tylenol #3 but only lasts 30-45 min)
Propofol - 200mg = was likely not given as a single bolus but titrated in over the 20 min based on pt's response.

As for the other symptoms:
Blue under tongue - the guy just had a garden hose going down his throat and needed some suctioning. Bruising would NOT be surprising.
Cough - normal with fentanyl, duration can be easialy explained by a small amount of oral secretions leaking into lungs = normal. See above comment on garden hose going down throat.
Sleepy after - well of course, he just got a bunch of happy drugs
Chest pain - see again comment on garden hose down throat. Think that does not cause some discomfort after? The esophagus is in the chest too.

My vote, all normal responses to a normal G-scope. The guy is probably a hell of a lot happier than if he was fully awake for it

 

[zippy2u]

Penmark, Make sure ya blow up the photo of that black and blue tongue 10 feet by 10 feet so the jurors can see it and wheel your client into the courtroom in a wheelchair in discheveled clothing with his tongue hanging out of his mouth and drooling copious amounts of saliva-- could getcha an extra $50,000. Regards, Zippy---the jaded one

 

[penmark]

Thanks for the info, especially CanGas. For those of you with suspicious minds, the guy was me, and I was trying to learn if i might need to avoid any of the administered meds in the future. Why didn't I ask the anesthesiologist, you might wonder. Well, when I did, she simply stated, "oh you're fine, go home." Also, you'll be interested to know that I had the twilight sedation five years ago, with no discomfort (to me or the gastroenterologist), so I wondered why I would suddenly need the deeper sedation. I actually read some ideas about that in this forum, but I am not drawing any conclusions. Nevertheless, I appreciate the info you folks provided, will ignore the snide remarks, and I won't even add any of my own.

 

[jwk]

Thanks for the info, especially CanGas. For those of you with suspicious minds, the guy was me, and I was trying to learn if i might need to avoid any of the administered meds in the future. Why didn't I ask the anesthesiologist, you might wonder. Well, when I did, she simply stated, "oh you're fine, go home." Also, you'll be interested to know that I had the twilight sedation five years ago, with no discomfort (to me or the gastroenterologist), so I wondered why I would suddenly need the deeper sedation. I actually read some ideas about that in this forum, but I am not drawing any conclusions. Nevertheless, I appreciate the info you folks provided, will ignore the snide remarks, and I won't even add any of my own.

OK, I'll add mine.

First, a little honesty up front goes a LONG way.

Second, I'd at least consider finding both a different anesthesia provider and gastroenterologist next time, based solely on your description.

Third, I have a sneaking suspicion that your anesthesia might have been provided by a CRNA, and possible just an RN, not an anesthesiologist (not flaming - no shooting from the gallery please), since it appears that possibly, and again based solely on your description, that the gastroenterologist was directing at least some of the sedation part of the procedure.

And finally, it's quite possible that you recieved a very thorough explanation of what happened while you were in the PACU after your procedure, and simple don't have any memory of it - versed has a big amnestic component to it's effect. I have patients ask me five times if they had cancer - all in the three minutes it takes me to check their vital signs and give a report to the PACU nurse.

 

[penmark]

First, a little honesty up front goes a LONG way.

I apologize if anyone felt misled, but it never occurred to me that a simple question (not posed dishonestly) would be interpreted the way it was. Thanks for your insight.

 

[joncmarkley]

fentanyl causing cough?

I would think if anything it would supress cough?

where did you read that?

 

[DropkickMurphy]

fentanyl causing cough?

I would think if anything it would supress cough?

where did you read that?

It's listed on the side effects on every package insert I've ever seen for fentanyl.

 

[dhb]

"anesthesia/colonoscopy/side effects"
colonoscopy with suction in the mouth?? someone must of gone too far know we have a case $$

 

[cchoukal]

It's listed on the side effects on every package insert I've ever seen for fentanyl.

I've had 2 patients start to cough just seconds after giving midazolam/fentanyl for premedication. My attendings blamed the fentanyl. Apparently this is fairly common.