Physiology Q - conscious but unable to speak

[Dustbunny]

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I guess you can label me a pre-med if you wish, but my background is pharmacy. My question is related to a phenomenon that I've noticed first hand as a patient while sedated, and I've often wondered about it.

1) Many times when I was a kid, I was sedated so tubes could be put in my ears. I always opted for IV anesthesia because I hated the smell of the mask over my face. One time in the recovery room my blood oxygen levels were low, so they wanted to give me oxygen through a mask. My eyes were closed, I could hear and understand, and I was able to move. I resisted the mask, because again, I could smell it when it got close. After a few minutes they gave up trying to put it on. Perhaps due to my valiant efforts, my blood oxygen levels came up. Who knows. I was five at the time.

2) More recently (age 22) while having an ileocolonoscopy, I was consciously sedated. Aware of what was happening when I wasn't sleeping. When they hit my ileum, there was searing pain which naturally woke me right up. I started squirming, trying to get away. (Imagine a hot knife twisting in your small bowel.) The GI doc asks "Why is he moving?! Can we give him more fentanyl?!?" and my thought was "Because I'm f'n dying, you @sshole." I tried to speak, but I could not. I think I might've managed a groan. Maybe.

Anyway the nurse jumped on me, because I was trying to get up. So I bit her. (She was a good sport about it, though, and I apologized after.)

What is the physiology of not being able to talk? Motor functions are fine, olfactory works just great. Hearing is not impaired; cognition fine. Nociceptors, five-by-five.

But why can't you speak? Is there an explanation or is it just me? Both times, I wanted to speak, but nothing would come out. Is this common?

 

[Lizard1]

Anyway the nurse jumped on me, because I was trying to get up. So I bit her.

that made me laugh.... 😉

anyways, about this episode you experienced of not being able to speak....if they were only doing a colonoscopy (and not an endoscopy - camera down your gullet) then you were likely just experiencing a twilight phase of anesthesia. you don't have all of your motor and cognitive function working at 100% so hence the disorientation of being in a haze. you were not paralyzed by muscle relaxants as you were spontaneously breathing so it can't be chalked up to that.

 

[Noyac]

I'll bet they gave you that old drug. The one that we used in the ER to shut up the drunks and the psych pts.

Propamuteafol

 

[Heeed!]

I'll bet they gave you that old drug. The one that we used in the ER to shut up the drunks and the psych pts.

Propamuteafol

Ha Ha !

 

[rmh149]

There probably wasnt any kind of anesthesia provider in the room. They more than likely gave you a combination of fentanyl and versed (no propofol)....this is called conscious sedation. Fentanyl for the pain, versed for the anxiety and the benefit of the amnestic effect. Although, if anyone drinks at all, versed can be worthless in standard doses. Many people move around and wake up (heaviy drugged of course) during a colonoscopy. Although most dont rembember it. Too bad you did.....next time you go for a colonoscopy let them know about your experience so they can pile on the versed.

 

[Noyac]

There probably wasnt any kind of anesthesia provider in the room. They more than likely gave you a combination of fentanyl and versed (no propofol)....this is called conscious sedation. Fentanyl for the pain, versed for the anxiety and the benefit of the amnestic effect. Although, if anyone drinks at all, versed can be worthless in standard doses. Many people move around and wake up (heaviy drugged of course) during a colonoscopy. Although most dont rembember it. Too bad you did.....next time you go for a colonoscopy let them know about your experience so they can pile on the versed.

What?

Are you sure?

 

[Lizard1]

Although, if anyone drinks at all, versed can be worthless in standard doses.....next time you go for a colonoscopy let them know about your experience so they can pile on the versed.

i don't know about that....that sounds like a recipe for disaster in a GI lab with a nurse and an GI doc 😉

 

[Dustbunny]

What?

Are you sure?

Hah. I don't drink. And yes, it was fentanyl and midazolam for the ileocolonoscopy; I looked through the paperwork before the procedure. There were two nurses and a GI doc. I suppose one of them might have been a CRNA, but I honestly don't know. I don't think either of them were.

I still want to know the physiology of the phenomenon...

 

[militarymd]

Sounds to me like you got some DROPERIODOL in your mix.

droperiodol can cause that "locked in" sensation.

 

[Planktonmd]

Sounds to me like you got some DROPERIODOL in your mix.

droperiodol can cause that "locked in" sensation.

Yes,

Good old Droperidol, it can go either way: some patients became so calm and obedient that you could do whatever you want to them, others got scared and literally ran away.

 

[VolatileAgent]

I still want to know the physiology of the phenomenon...

go to med school.

 

[rmh149]

What?

Are you sure?

Well, I cant say that I am sure about this case...I wasnt there. But it sure sounds like it. Just the idea that the surgeon asked for more fentanyl....instead of propofol. RN's can do fentanyl and versed but not propofol. There are many GI labs that do not have anesthesia support for their cases.

We frequently try to negotiate contracts with GI labs for anesthesia support. Many of them only want us to do the difficult ASA III's...of course this is not good for business. The GI docs make more money if they do the procedure without anesthesia support and the RN giving fentanyl and versed (whole other thread). I think its a bad idea....its just a matter of time before someone loses their airway.

 

[core0]

Well, I cant say that I am sure about this case...I wasnt there. But it sure sounds like it. Just the idea that the surgeon asked for more fentanyl....instead of propofol. RN's can do fentanyl and versed but not propofol. There are many GI labs that do not have anesthesia support for their cases.

We frequently try to negotiate contracts with GI labs for anesthesia support. Many of them only want us to do the difficult ASA III's...of course this is not good for business. The GI docs make more money if they do the procedure without anesthesia support and the RN giving fentanyl and versed (whole other thread). I think its a bad idea....its just a matter of time before someone loses their airway.

Two wrongs. Nurses are administering Propofol. It depends on the particular nurse practice act. There is actually a fair amount of poorly done studies that show that it is safe. As far a Fentanyl and Versed, if you carefully select the patients there is not much danger. There is a lot of data that this is very safe. We do more than 6000 cases per year and have never had to reverse a patient. Anesthesia for GI labs is not covered by insurance in most cases unless you want to jump through a bunch of hoops. GI docs make more money without anesthesia because they don't have to pay anesthesia out of their AEC fees. There is some anesthesia that does cases in California on a cash basis (you want anesthesia, you hand the nice anesthesiologist $400 and away you go). There is also a lot of anesthesia done in the New York and Boston area. Outside of that you really don't see much.

Now nurse administered propofol - that is a dog of a different color.

David Carpenter, PA-C

 

[mille125]

go to med school.

hahahahahahaha

 

[Mman]

Two wrongs. Nurses are administering Propofol. It depends on the particular nurse practice act.

I believe this also depends heavily on the particular hospital/health system that this is affiliated with. At many centers, propofol use is restricted to the domain of anesthesia or ventilator sedation. The only places in our hospital or outpatient clinic it can be used outside the OR are for intubations (in the ER or ICU) and vent sedation. The GI docs cannot use it for sedation by hospital policy.

 

[rmh149]

I believe this also depends heavily on the particular hospital/health system that this is affiliated with. At many centers, propofol use is restricted to the domain of anesthesia or ventilator sedation. The only places in our hospital or outpatient clinic it can be used outside the OR are for intubations (in the ER or ICU) and vent sedation. The GI docs cannot use it for sedation by hospital policy.

Coreo, you are right about RN's able to administer propofol...I did many times in the ICU, but it always involved someone on the vent. But as Mman said, in the GI lab they cannot...or shouldnt. I should have said "push propofol". RN's can do conscious sedation (no propofol).

I have never done a colonoscopy without propofol...maybe versed and fentanyl works. For this poor guy that started this thread, obviously it didnt.

Am I wrong...do you know any GI clinics that administer propofol without an anesthesia provider?

 

[Noyac]

Am I wrong...do you know any GI clinics that administer propofol without an anesthesia provider?

Um yes, ours .

Our GI nurses are trained (by us ) to give propofol for sedation. No anesthesiologist present.

 

[rmh149]

Um yes, ours .

Our GI nurses are trained (by us ) to give propofol for sedation. No anesthesiologist present.

Are you not affraid of them taking your job? I'm totally kidding....I had to say it.

Interesting....do they run the patients on the pump, or push the propofol?

 

[Noyac]

Are you not affraid of them taking your job? I'm totally kidding....I had to say it.

Interesting....do they run the patients on the pump, or push the propofol?

Both

And if my job is sedating people for GI cases, they can have it.

 

[rmh149]

Both

And if my job is sedating people for GI cases, they can have it.

I agree, very boring. I never liked it. I dont think they will ever go for that here....but I will ask around...out of curiosity.

 

[jetproppilot]

Two wrongs. Nurses are administering Propofol. It depends on the particular nurse practice act. There is actually a fair amount of poorly done studies that show that it is safe. As far a Fentanyl and Versed, if you carefully select the patients there is not much danger. There is a lot of data that this is very safe. We do more than 6000 cases per year and have never had to reverse a patient. Anesthesia for GI labs is not covered by insurance in most cases unless you want to jump through a bunch of hoops. GI docs make more money without anesthesia because they don't have to pay anesthesia out of their AEC fees. There is some anesthesia that does cases in California on a cash basis (you want anesthesia, you hand the nice anesthesiologist $400 and away you go). There is also a lot of anesthesia done in the New York and Boston area. Outside of that you really don't see much.

Now nurse administered propofol - that is a dog of a different color.

David Carpenter, PA-C

Nice post.

My opinion on the huge controversy of non-anesthesia-providers giving propofol:

My mom, who works in a school cafeteria, could give a GI patient fifty milligrams of propofol.

The patient would be OK, my mom would pee-pee her pants, GI dude slips in the tube, patient may become apneic but my mom would resort to violently shaking said patient which would provide enough stimulation to make the patient breathe which is cool since my mom just did her first anesthetic.

I think the propofol controversy is comical.

Limit the dose a non-anesthesia dude/dudette can give, make sure they know how to do a chin lift correctly.

Recruit GI RNs that can manage an airway commensurate to the experience level of a PACU nurse.

Case closed.

Remember, administrative types get paid to schedule meetings and create BIG DEALS so then they have something to follow up on in another meeting, and between the two above meetings, a meeting will be scheduled to make sure the followup meeting has been scheduled.

Even though on this subject, way-too-many meetings have eaten up our ASA dues.

 

[core0]

Coreo, you are right about RN's able to administer propofol...I did many times in the ICU, but it always involved someone on the vent. But as Mman said, in the GI lab they cannot...or shouldnt. I should have said "push propofol". RN's can do conscious sedation (no propofol).

I have never done a colonoscopy without propofol...maybe versed and fentanyl works. For this poor guy that started this thread, obviously it didnt.

Am I wrong...do you know any GI clinics that administer propofol without an anesthesia provider?

I would agree. If that person ever showed up at our clinic we would schedule the case in the hospital with Anesthesia. Anesthesiologist would choose what kind of sedation/anesthesia is used. The last thing we want to do is listen to someone screaming in our endoscopy center. However for most people Versed and Fentanyl works just fine.

As far as Nurse Administered Propofol. There are two issues here. One is will the BON let it happen. Interestingly in several states you get the CRNA's saying it is anesthesia and the RN's saying the CRNA's are restricting nursing practice. There are a couple of proponents with Doug Rex probably being the leading proponent:
http://www.ingentaconnect.com/content/bsc/ajg/2002/00000097/00000005/art04039
http://www.drnaps.org/index.htm
http://gastroenterology.jwatch.org/cgi/content/full/2003/701/1


Here is the ASA position:
http://www.asahq.org/Newsletters/2005/02-05/whatsNew02_05.html

Finally here is a medscape article with a link to all the different position statements.

http://www.medscape.com/viewarticle/518218

Most of the people in our area use bolus dosing. Interestingly no one is doing this in an AEC. This is all happening in the hospital. Equally interesting is that the hospitals that we have worked in restrict Propofol to CCM, Anesthesia and ER docs. The same system which the other group works in has no such restrictions. Our doc's don't think this is a good idea. The idea of a non reversible agent scares them. You guys deal with airways all the time. If you had a problem then bagging them or tubing them wouldn't be a problem. The average GI doc hasn't intubated someone since residency. Their only real airway management is when you do ACLS every year.

While proponents claim that you have quicker discharges and turnovers which is what you want in an AEC, the only study done on this shows they are the same. The other factor is the cost. I am not sure how much Propofol is, but I would guess that it is more than Fentanyl and Versed. AEC's watch their costs. If is more expensive then it will probably not be used unless you can decrease turnover time. That's why we don't use Zofran (had to recently find a substitute for Tigan).

David Carpenter, PA-C

 

[jetproppilot]

I would agree. If that person ever showed up at our clinic we would schedule the case in the hospital with Anesthesia. Anesthesiologist would choose what kind of sedation/anesthesia is used. The last thing we want to do is listen to someone screaming in our endoscopy center. However for most people Versed and Fentanyl works just fine.

As far as Nurse Administered Propofol. There are two issues here. One is will the BON let it happen. Interestingly in several states you get the CRNA's saying it is anesthesia and the RN's saying the CRNA's are restricting nursing practice. There are a couple of proponents with Doug Rex probably being the leading proponent:
http://www.ingentaconnect.com/content/bsc/ajg/2002/00000097/00000005/art04039
http://www.drnaps.org/index.htm
http://gastroenterology.jwatch.org/cgi/content/full/2003/701/1


Here is the ASA position:
http://www.asahq.org/Newsletters/2005/02-05/whatsNew02_05.html

Finally here is a medscape article with a link to all the different position statements.

http://www.medscape.com/viewarticle/518218

Most of the people in our area use bolus dosing. Interestingly no one is doing this in an AEC. This is all happening in the hospital. Equally interesting is that the hospitals that we have worked in restrict Propofol to CCM, Anesthesia and ER docs. The same system which the other group works in has no such restrictions. Our doc's don't think this is a good idea. The idea of a non reversible agent scares them. You guys deal with airways all the time. If you had a problem then bagging them or tubing them wouldn't be a problem. The average GI doc hasn't intubated someone since residency. Their only real airway management is when you do ACLS every year.

While proponents claim that you have quicker discharges and turnovers which is what you want in an AEC, the only study done on this shows they are the same. The other factor is the cost. I am not sure how much Propofol is, but I would guess that it is more than Fentanyl and Versed. AEC's watch their costs. If is more expensive then it will probably not be used unless you can decrease turnover time. That's why we don't use Zofran (had to recently find a substitute for Tigan).

David Carpenter, PA-C

Thanks for your contribution here.

FYI, propofol is generic now so it's cost shouldnt be a determining factor in it's use or non-use.

 

[rmh149]

Thanks for your contribution here.

FYI, propofol is generic now so it's cost shouldnt be a determining factor in it's use or non-use.

How much is it ber 20cc vial...$30 or so?

 

[Noyac]

How much is it ber 30cc vial...$30 or so?

I think the hosp cost at my facility is under $5 for 20cc vial.