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Is IV Sedation Over-Used?

We criticize alternative medicine for not being evidence-based, and they criticize conventional medicine in turn, saying that much of what conventional medicine does is not based on evidence either. Sometimes that criticism is justified. I have run across a conventional practice that I suspect began because it sounded like a good idea, but that never was adequately tested and is not carefully thought out for individual patients.

I recently had a bone marrow aspiration. The written instructions said not to eat or drink for 6 hours before the procedure, to bring someone to drive me home, and to expect an IV. I suspected from these instructions that they were planning to use IV sedation, and I was right.

I questioned the need for sedation. I am prejudiced about bone marrow aspirations. I observed several and did one myself during my internship. When I had finished, the patient asked me when I was going to start. We did the procedure at the patient’s bedside in a multi-bed ward with no sedation, only local anesthesia. So my prejudice was that the procedure was no big deal and was not terribly painful.

I can imagine that some patients may be terrified by the idea of a needle going into their bone and may want to be sedated and not remember the experience. But I was not anxious about it, and I saw no need for the fentanyl and Versed they wanted to give me. I figured it would only prolong my time in the hospital, produce amnesia, expose me to a small risk of adverse effects, and leave me groggy; so I asked to opt out. They readily agreed – although they did keep asking me if I was really sure I didn’t want it. They would not have offered the option of no sedation if I had not known to ask.

The pathologist doing the procedure told me the injection of local anesthetic into the skin was the most painful part of the procedure. He was wrong. It was the ONLY painful part of the procedure. The penetration of bone and the aspiration of marrow produced only a pressure sensation.

This study reported that 85% of non-sedated patients had intense pain. I find that hard to believe, based on my personal experience and the experience of the pathologist that the local anesthetic was the worst part of the procedure. I wonder if those patients were anxious and were expecting intense pain. At any rate, I think giving me IV sedation would have been the wrong thing to do.

I had a similar experience with an excisional breast biopsy. They offered me general or local anesthesia and I chose local as presumably the safer option. Then they said they would use IV sedation along with the local. I asked why. They said to relieve anxiety. I told them I wasn’t anxious so if that was the only reason for sedation, I didn’t want it. I finally prevailed. I was comfortable, alert, had a good time chatting with the anesthesiologist, and was able to leave the recovery room much sooner than sedated patients.

I’m not saying that IV sedation is not indicated for some patients, but I am convinced it was not indicated for me. Has it become a knee-jerk reflex to sedate everyone as a general principle? Why? To avoid complaints and keep patients more cooperative during procedures? Are we paternalistically deciding that it is better if the patients don’t remember the procedure? I wonder: if minor procedures are not remembered, might the mystery increase anxiety and fear of the unknown for future procedures? We must ask seriously whether IV sedation is done more for the patient’s benefit or the doctor’s. The answer will vary with the procedure and the patient.

Rather than sedating every patient, why not use some judgment? Even if the patient is anxious, perhaps a non-drug option could relieve that anxiety without risking the side effects of drugs. Surely some anxiety is due to fear of the unknown. Would it help to show patients a video of someone comfortably undergoing the procedure without sedation, with an explanation of exactly what was happening? Would simple reassurance or personal attention from a patient advocate be helpful? Worth looking into? I think so.

Doctors are frequently accused of prescribing unnecessary drugs out of habit or reflex. I suggest that IV sedation for minor procedures is an example of over-prescription that is based more on custom than on good evidence.

Posted in: Pharmaceuticals, Surgical Procedures

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46 thoughts on “Is IV Sedation Over-Used?

  1. Jules says:

    Overused? I think there’s something to be said for the overwhelming fear of lawsuits, too. Patients being capable of winning overly huge sums of money for “pain and psychological torment” or something along those lines has got to contribute something to the “dope ‘em all up” mentality.

    My boyfriend works in an ICU, and he regularly sees patients who haven’t been given enough sedation or painkillers. He sincerely believes that adequate sedation/pain relief or slightly-over-adequate sedation/pain relief is infinitely preferable to the alternative.

    IMO, if you’re capable of arguing for not being sedated, then it’s probably true that you don’t need it. But if you can’t, then it may be true that you do, and it’s even more likely that the physician can’t afford to find out if it’s the case.

  2. tommyhj says:

    First of all, personal observation and experience shouldn’t form a basis for recomandation or prejudice. That aside, I totally agree. I never use anestesia of any kind at the dentist either, and although it’s painful, it’s no big deal to me.

    But pain is mostly a psychological phenomenon, and there are meny ways to relieve the anxiety and expectation of pain instead of using sedatives. Sadly, one of them is acupuncture.

    If we could devise a test to show how susceptible people are to real, unexpected pain and to fake expected pain, we could aim anesthetic treatment individually. We don’t however, and the best solution is to give the same treatment to everyone, even if it is based on studies of subjective experience of pain.

  3. caoimh says:

    “I suggest that IV sedation for minor procedures is an example of over-prescription that is based more on custom than on good evidence.”

    That’s an empirical claim that you bolstered with some anecdotal evidence whilst providing a study which demonstrates the opposite claim.
    You may be correct in your assertions, but you have no evidence.

  4. marmic says:

    Thanks for the post. I was hoping someone would eventually post something about the existing modalities in “traditional” medicine that are not really evidence-based, whether they’re not backed by research or they ignore the known evidence. I encourage the writers on this blog to consider doing it from time to time. Doctors and nurses can be almost as superstitious as CAM practitioners.

    However, I’m disappointed by the arguments used. This post is based on anecdotal evidence. Period. And then we accuse CAM advocates of doing the same thing?! Not only is the only evidence anecdotal, but when a study is mentioned, it’s only to question its validity based on … personal experience!!!

    Sorry. No cigar. This is not science based medicine. Please provide solid references to bolster your argument.

  5. weing says:

    It sounds like it’s overused but I suppose it has to do with patient preference. A poll in the community regarding IV sedation for various procedures might be worthwhile in setting up a protocol.

  6. Peter Lipson says:

    I did dozens of bmb’s as a resident (busy cancer program and i was thinking about doing heme-onc). Most were done without sedation, some with. The ones without were tolerated, and were quick, but they were never comfortable. The core wasn’t bad, but the aspiration always make people very, very uncomfortable.

  7. DevoutCatalyst says:

    As a patient I just want honest information on when I can opt out of sedation for any given procedure, and what the reality of my choice might be.

    I found out concretely that upper GI endoscopy without sedation can be, for a short time, extremely unpleasant, but the advantage of being able to drive myself home and continue with my day unimpeded was too compelling to ignore. Would do it without sedation again.

    I was told if I suddenly got religion and wanted sedation, they would give it to me. Don’t know to what extent this would have complicated the doctor’s day.

  8. Dr Benway says:

    caoimh, you are correct that the information presented by Dr. Hall is largely anecdotal, based upon her experience as a patient and as a doctor doing bone marrow biopsies, and the experience of another doctor she mentions.

    If she had asserted that IV sedation is unnecessary for patients generally based upon the above, your criticism would have been warranted. However, she didn’t go so far. She merely questioned the current standard of care, suggesting that the distress of patients undergoing the procedure might be more from anxiety than physical pain.

    Quality anecdotal data help us decide where to focus future research efforts.

  9. weing says:

    BTW Harriet,
    I hope the results of the biopsy were to your liking.

  10. TsuDhoNimh says:

    I saw and helped make the smears for dozens of bone marrows (busy, BIG hospital) and bone marrows were almost always done under local anaesthesia.

    Part of the training for the physicians who did them was some intense “bedside manner” training in preparing the patient and the choreography it takes to make it happen smoothly.

    NEVER wave a needle in front of the patient. Especially not a bone marrow needle. All of the tray prep was done before we set foot into the room or ward.

    The designated role of one of the team was to casually block the patient’s view of the HONKING GINORMOUS NEEDLE at all times and distract them with a bit of conversation and hand holding. Usually a student lab tech or nurse did this part, and then they took the samples straight back to the lab.

    The docs never claimed it would not hurt, they explained the local anaesthetic would have a few prickly sensations from the tiny needle, there would be pressure as the other needle went in, and that the aspiration might produce one short stabbing pain with no lingering pain afterwards.

    And they gave a choice of a sedative or no sedative, also explaining that the sedative meant starting an IV plus the bone marrow aspiration, and would leave a groggy feeling that would last for several hours.

    Than ask which is preferable: possibility of one brief, hurtslikehell pain versus certain several hours of recovery from the sedative? The result: Most of the patients decided against the sedative. I remember one teenager who waved at her hovering mom and said, “She’s the one who needs the sedative, let’s get this over with.” Mom was aghast, but the girl got her way.

    Get the patient breathing smoothly, arm and hand muscles relaxed, focused on something besides the procedure, and they seem to feel less pain. One patient accused me of trying to distract her when I asked about a picture of children – what could I do but admit it, and point out that the procedure was over. Others would say, “@#$%! that hurt!” but were not distressed because they knew it was coming and it went away as promised.

    Did this take longer than it would have under sedation? I never timed it. Did we leave the patients feeling worse than they would have under sedation? Absolutely not. Most of them were already eating their breakfast by the time we left the room.

  11. sowellfan says:

    Peter Lipson: What exactly do you mean when you say, “the aspiration always make people very, very uncomfortable.” From my layman’s perspective, it sounds like that’s code for, “It hurts like hell.”, but it’s just trying to avoid the pain words. FWIW, I prefer that the term ‘uncomfortable’ be left to describing how you feel when a creepy guy sits next to you on the bus.

  12. mph says:

    I’ve had two bone marrow biopsies, and the aspirations were the most intense pain I’ve experienced in my life. I was not offered sedation in either case. I’m sure the pain was not caused by anxiety… I was not particularly nervous, and I can tell you specifically that the penetration of the skin was painless, the core biopsy was rather painful, and the aspiration was a blinding, white-hot pain. I also had a CT-guided biopsy of the abdominal lymph nodes, and I found that procedure to be painless (once they gave me a second shot of local).

    If my pain was unusual, then I’m glad to hear that not everyone else goes through the same thing. Wish I were one of them.

    That said, if I needed another one and were offered sedation, I don’t know that I would take it. The pain is brief, and afterwards I can go on about my normal business, and I know from experience that I can withstand it.

  13. Calli Arcale says:

    My two cents is that it would be good to see a proper study done of this. I know folks who would never have a procedure like this done without sedation.

    I was sedated for an upper-GI endoscopy (followed by ramming a tube down over the endoscope to widen a constriction in my esophagus). It made me rather drunk and sleepy afterwards, but otherwise had no real effect on my perception of the experience. I did not enjoy the experience especially. If (or more likely when, given my GERD) I have to have it done again, I will refuse the sedation; it didn’t help at all, and just made me groggy and weird afterwards.

    I know folks who would insist on sedation, though, because they get very anxious. And then there’s the folks who *think* they can make it but can’t. I know nurses who swear by medicating folks because their experience is that those who are wrong about their pain/discomfort/freak-out-factor tolerance will generally be wrong in a BIG way. Is it worth medicating everybody (with the risks that go along) just to avoid freakouts? There are lots of well-anecdotally-informed opinions on that. I’d like to see some large, well-designed studies to really answer the questions.

  14. Harriet Hall says:

    Peter Lipson said “the aspiration always make people very, very uncomfortable.” Not always. I felt no discomfort with the aspiration, only pressure. And I am not the only one.

    To those calling for studies, that was my point: the practice of sedation is not evidence-based. We are doing it (or not) based on personal experience, custom, and speculation.

    Even if a study showed an overall benefit, it is still possible that selected patients like me would not benefit. All I’m asking is that instead of automatically sedating everyone we at least consider the option of no sedation and offer the patient a choice.

  15. pec says:

    It’s what our culture has evolved into — constant comfort must be maintained at any cost. As a whole, we do not promote toughness or resilience. Kids can’t go out and play because they might get a scraped knee. So we are a society of fat anesthetized, sedated wimps.

    Of course some medical procedures would be horribly painful without drugs. But we do not need a general anesthetic or sedative for something that might hurt a little.

    If you learn to tolerate a little pain you will feel much better in general, and you won’t constantly run to the doctor for more pills.

    I agree with Harriet’s post.

  16. weing says:

    I can still vividly remember a root canal I had done without any anesthesia whatsoever. I would never repeat that experience and never have since.

  17. Emily says:

    I had two endoscopies-one with and one w/out sedation. Sedation was fine for me, but the one w/out sedation wasn’t too bad either. It was pretty uncomfortable, but compared to something like childbirth was nothing. It was also really short. Had it been much longer, I think sedation would have been a good thing. Since I had to schedule the procedure around the holidays, though, I was really glad to keep my day drug free and spend it with family.

    The doctor told me that he would have done it himself without sedation, but the nurses told me that they hadn’t ever seen anyone do it. I don’t think I would have even been given the option if I hadn’t asked about it. IMO, it worked well for my circumstance and I like the idea of patients being informed about the choice.

  18. pec says:

    weing,

    I really don’t think anyone is advocating root canals without anesthesia.

  19. Here are some more studies:

    “We found that 3/4 of hematologic patients who underwent BMA reported procedural pain; one third of these patients indicated severe pain. Pre-existing pain, anxiety about the diagnostic outcome of BMA or needle-insertion, and low employment status were independent risk factors.”

    http://www.ncbi.nlm.nih.gov/pubmed/19243321?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    “In conclusion, notwithstanding local anesthesia, the great majority of adult hematological patients experience transient pain during BMA that is of at least moderate intensity in over a third. Pretreatment with tramadol lowers pain intensity significantly and is well tolerated.”

    http://www.ncbi.nlm.nih.gov/pubmed/12967736?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

    “Nitrous oxide is an effective analgesic when performing bone-marrow biopsies. Ten percent of patients feel a moderate to severe pain instead of one third. Despite some mild side effects, there is a very good appreciation by patients.”

    http://www.ncbi.nlm.nih.gov/pubmed/18992971?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    “Midazolam in conjunction with local anaesthesia provides rapid and reversible sedation as well as effective pain relief during bone marrow biopsy, and is superior to Entonox; however, care must be taken to monitor respiratory function.” (Entonox is nitrous oxide)

    http://www.ncbi.nlm.nih.gov/pubmed/18755727?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    There are others, but these hit the main themes. Reviews also conclude that there is currently a paucity of controlled trials and therefore more research is necessary, but it is happening.

    But I agree with Harriet – SBM/EBM means we ask the questions and do the studies, not simply do something because it is custom and seems to make sense. But at present there is reasonable evidence to conclude that BMB is painful for the majority of patients, and there are various treatment options that are effective. What we need is more direct comparison to develop an EBM standard of care.

  20. Harry says:

    Having been on both sides of the knife, though not for a bmb, I’ll take the fentanyl in the office and chicken soup when I get home.

  21. Scott says:

    Had a bit of an interesting experience with IV sedation myself. When I was getting my wisdom teeth out, I got that done at a dental school (cheap, which was nice for a penniless grad student) with IV sedation.

    I *woke up in the middle.* Was conscious enough to feel what was going on, but not conscious enough to communicate that fact. VERY bad experience.

  22. Kimbo Jones says:

    I had the opposite experience. I went into have all 4 of my wisdom teeth removed several years ago and BEGGED them to sedate me. 1) I had a really terrible dentist and as a result I had developed a significant anxiety towards dental procedures. 2) This was my first major medical procedure as I had never had any dental/medical problems prior to this other than preventative molar fillings — I had not even so much as a hospital admission.

    My dentist refused to send me to the endodontist who did sedation (there are 2 major clinics in the area), instead sending me to the endodontist that uses nitrous oxide gas.

    The gas made me more anxious as I felt drunk and completely vulnerable IN ADDITION to my extreme level of anxiety. As a result, I had a panic attack during the procedure. I couldn’t breathe, I felt like the dentist was tearing my jaw off, and I’m sure they must have heard my screaming in the lobby…next door.

    Later I ended up in the hospital because I was allergic to the pain medication I was given.

    Luckily, I have a new dentist and endodontist and when I required a root canal for a broken tooth last year things went much more smoothly, although the site of the needle produced quite a strong aversion response and I was unable to open my jaw as my endodontist swung around with it in his hand (it was right in my face and I wasn’t expecting it). After that minor freak out and some discussion about the procedure and my anxiety, I was good to go.

    A little discussion went a long way. So does listening to the patient. I knew what I could tolerate and I was ignored. It made a routine procedure extremely traumatic. And because both options weren’t available at that clinic, I was unable to change their minds at the last moment. Also, as I was a relatively naive teenager at the time (and my parents had to drive me a few hours to another city), I didn’t know any better than to just leave and demand an appointment at the other clinic.

    Worst. Procedure. Ever.

  23. Kimbo Jones says:

    “Later I ended up in the hospital because I was allergic to the pain medication I was given.”

    I should specify that I was on strong medications because I was so bruised and swollen due to the trauma of the procedure. As I was unable to sit still while panicking, the dentists were quite forceful. If the procedure had gone more smoothly, I question whether I would have had to take so much pain medication and whether I would have ended up in the hospital at all. Athough I don’t know for sure whether that was preventable.

  24. yeahsurewhatever says:

    “Has it become a knee-jerk reflex to sedate everyone as a general principle? Why?”

    Possible answers:

    1. Very few patients ever object to being sedated, and many ask for it by name.

    2. Sedating the patient guarantees that they won’t panic for a random reason, which is a benefit that’s *probably* greater than the low risk of adverse reaction to the anesthetic.

    3. Let us suppose that most surgeons tend to be more comfortable operating on unconscious patients. So in a sense, sedating the patient also sedates the doctor.

    4. Many people would rather not assume the psychological burden of being cognizant of being operated upon. They would rather know about it as hearsay, and just reap the benefits.

    I don’t think this is a case of blatant paternalism… any more. I think the habit goes back to previous decades when it was, and since then everyone has just learned to expect it. Particularly the patients. It has become part of “the sick role”, and general anesthetic absolves the patient of any possible form of responsibility, until it wears off.

  25. James Fox says:

    To those who opined that Dr Hall was making her point with anecdote, I didn’t see where Harriet was making the assertion that IV sedation WAS being over used. She used her own experiences to raise questions and suggest an overuse. It seems to me that this is typically where studies and research starts. A perfectible valid beginning for a perfectly valid discussion but perhaps not for a polemic.

  26. Eric Jackson says:

    REINSCHEID

    The criticism that there are procedures and practices in conventional medicine that are not explicitely supported by direct scientific evidence is not without merit. It does however seem to vary between what area of medicine is being discussed, for example a great deal of the practices in physical therapy are not directly supported (or so I have been informed in various lectures at my university), but fields such as cancer treatment have a very strong grounding in peer reviewed controlled trials.

    Sedation appears to be one of those, having been in practice for so long that it has not been subjected to a great deal of direct science to evaluate its necessity. In my understanding, IV sedation usually involves a single or combination of several agents:

    Benzodiazepine tranquilizers, specifically Versed (midazolam)
    Opiate analgesics such as Fentanyl
    And occasionally other agents such as ketamine

    Benzodiazepines are heavily favored due to a combination of sedative properties, anxiolysis and antiretrograde amnesia. This profile addresses what are probably the main patient concerns with invasive procedures of any sort, the outright fear and anxiety provoked by it. The physical pain is addressed with local anesthetic agents such as lidocaine. The theory behind this being that with a combination of intravenous benzodiazepines and local anesthetic the patient will experience minimal to no physical pain, and will have the unpleasantness of the experience blunted by impaired memory and anxiolytic action by the benzodiazepine.

    The suggestions of reassurance, personal attention, or a video demonstrating the painlessness of a procedure by Harriet Hall are rather excellent, and certainly worth investigating. What I really think needs to be done to clarify the issue is a definition of what constitutes a ‘minor procedure’ in this context, and a consideration of what factors contribute requiring the use of IV Sedation. This has provoked a rather interesting discussion.

    But in summary I think we need the following if we’re going to look at this we need the following:

    +What constitutes a ‘minor procedure’ where IV sedation is in use as a general practice?
    +What factors contribute to a patient requiring IV sedation (or other sedative interventions)?
    +Likewise, what factors contribute to a patient not requiring IV sedation?

  27. Jaysus. I want IV sedation just READING about this procedure!

    I am willing to believe that I may be more squeamish than others. ;)

  28. yeahsurewhatever says:

    “It does however seem to vary between what area of medicine is being discussed, for example a great deal of the practices in physical therapy are not directly supported (or so I have been informed in various lectures at my university), but fields such as cancer treatment have a very strong grounding in peer reviewed controlled trials.”

    You don’t need to go to medical school to be a physical therapist. It’s “allied health care”, not medicine.

  29. weing says:

    Even minor procedures need definition. Mine is any procedure done on someone else. If done on me it’s definitely a major procedure.

  30. khan says:

    I demand sedation (at least the local kind). When the dentist had to go after the cracked molar (#31) it took four shots of whatever they user; he didn’t argue with me, he kept it up until I said it was OK.

    I can definitely understand wanting to avoid the ‘freak out’ factor halfway through.

    Can also see problems with controlled studies re pain.

  31. ImperfectlyInformed says:

    When I think of mainstream medicine which isn’t evidence-based (whether that’s because it’s simply a poor procedure or not the best procedure), I don’t think of things like anesthesia and sedation. Doesn’t seem like there’s many adverse effects and it’s quick. Although it costs something, people seem to want it. Admittedly, unlike tommyhj I don’t like to feel anything at the dentist, so maybe I’m biased.

  32. wertys says:

    A interesting wrinkle to the use of IV sedation for scary but minor procedures is that benzodiazepenes such as midazolam and diazepam may be able to reduce the nocebo hyperalgesia response, according to Benedetti and others. This effect, ie reduction of nocebo hyperalgesia does contribute meaningfully to reduction of overall pain, and probably explains why anxious or fearful patients do better with some BZD on board. It also helps account for the success of what I might term “controlling the cognitive framework” of the procedure. this includes explaining the procedure, preventing distressing or scary images being given, and setting or managing expectations prior to the procedure.

  33. wertys says:

    reference for nocebo hyperalgesia..

    http://www.jneurosci.org/cgi/reprint/26/46/12014

    I do some potentially painful procedures on peoples’ backs as part of my interventional pain management practice, and at the public hospital, the philosophy is that doing said procedures should take advantage of expectations, context etc so procedures tend to be done with full perioperative formalities including IV sedation upon request. At my private practice across the road I work on the opposite assumption, ie that the procedures should be as de-medicalized as possible. The patients walk into the theatre, and I don’t use any sedation, having carefully set out exactly what will happen beforehand. For very anxious latients I prescibe a single dose of either alprazolam or lorazepam to be taken at home before arriving for the needle. I use a ‘no-touch’ protocol for the injections instead of full sterile draping and gowning.

    Even allowing for the substantial selection bias inherent in comparing the 2 pt populations, I believe that the group without sedation certainly do no worse, and are treated more in accord with the over-arching philosophy of patient-centred self-management that is espoused by pain specialists. I believe that their experience of being able to avoid sedation, even if they are concerned about it, helps to demonstrate that they have some untapped resources in their own brains that can be mobilized to support their efforts to live better despite having chronic pain.

  34. Calli Arcale says:

    It might be worth defining some terms. AFAIK, “sedation” refers to drugs that make a person sleepy and/or relaxed and/or not really caring about what’s going on. I’m thinking mostly of conscious sedation, where the patient is still more or less awake, but the person can be drugged into actually sleeping. That’s part of general anesthesia, but not all of it.

    Local anesthesia is not sedation at all, although sedation can be used *with* local anesthesia.

    I had my second child born by c-section (was aiming for VBAC, but baby was breech) under a spinal block. I was not sedated at all, and was therefore completely alert and conscious for the entire process. It was nice.

    My grandfather meanwhile had quite extensive surgery on his knee while completely alert. He was not sedated at all, but had a spinal block. This was in part because he has a deathly fear of dying on the operating table, and therefore dreads losing consciousness during the process. Also, he tends to react badly to general anesthesia; he’s a veteran and has had some ugly flashbacks. (Waking up convinced that the nurses were German soldiers, for instance.)

  35. DevoutCatalyst says:

    Anyone up for cardiac bypass surgery without general anesthesia?

    http://www.youtube.com/watch?v=zPBdSNMnXSc

  36. Newcoaster says:

    Oddly, I’ve never done, had or even seen a bone marrow biopsy.
    However, it certainly fits in a class with things where there should be some options available for the patient. You could add endoscopies to your short list. However, I agree with some other comments that you haven’t really proved your case with anecdotes and one small obscure study that actually says the opposite of what you are claiming. I think you’ve dropped the ball on this on Skepdoc.

    Overall, I am a big fan of procedural sedation (and it is PROCEDURAL sedation, not the oxymoronic “conscious sedation” )
    As a part-time ER doc I do a lot of painful procedures, and its better for the patient to have no pain and memory of the unpleasantness, and waaaay better for me to have an extremely cooperative patient who won’t make an unexpected move, or scream in my ear at critical point. If you want me to set your broken leg without propofol/fentanyl…we can negotiate…but I’m going to win that discussion most of the time.

    I always use it for painful procedures in young ones. Ketamine is your friend with Kids.

  37. Harriet Hall says:

    Newcoaster,

    You accuse me of not providing evidence, and that was my point – that there is no compelling evidence. You say you are a “fan” of sedation but you offer no evidence either. I’m glad that you agree with me that patients should have options, which was my other main point.

    With my bone marrow procedure and my breast biopsy (actually two breast biopsies), I had no pain and no memory of unpleasantness, I was extremely cooperative, did not make any unexpected moves, and I did not scream or flinch or even say “ouch” at any point. So sedation is clearly not required for everyone to achieve the outcomes you say you seek.

    I did not even attempt to address pain relief for children, and I am not questioning using medication for pain relief. When I had my babies I asked for everything they could safely give me. I was in pain and wanted relief. In the case of minor procedures, if I am not in pain I prefer to avoid medication and the attendant side effects, even if the risks are minimal. My experience predicted that I would not have pain with those procedures except for the injection of local anesthetic, and my predictions were correct – for me.

  38. HCN says:

    Pain can be subjective, and it can be affected by the person’s genetic response to pain. The same goes for a person’s response to pain medication.

    I hate narcotic pain medication, it literally makes me sick. I really mean “literally” and I really mean “sick.” I am one of the significant percentage of the population who cannot tolerate narcotics, they make me vomit. I was prescribed some when I broke my ankle, and it really does work to have to hobble in crutches with a temporary wrap (no cast until most of the swelling goes down) to upchuck in a toilet.

    Fortunately I am one of those persons who does not need much pain medication. I have given birth to three children and have never had much meds. I pushed for 90 minutes on Child #1 with one dose Stadol, labored with nausea with Child #2 with some Demerol and had nothing with Child #2 (I barely made to the hospital! — and really, I only felt something akin to menstrual cramps and some pressure).

    I have actually been called “brave” by a doctor for undergoing a procedure without pain medication… but in truth I never felt a thing.

    The reason is that my nerves have a higher threshold before responding than most people. This is really not a good thing. I have been injured, cut and bruised without a clue as to what caused the injury. Earlier this week I got out of the shower and noticed a large bruise one my leg and wondered how that happened.

    This does not mean I am totally immune to pain, just that it takes more to cause pain in me. When I am in pain, I am also the most horrible person to be around! After multiple decades, my husband knows to leave me alone when I complain of a headache! Fortunately they only happen once in every two or three years.

    I have also been told I am an anesthesiologist’s nightmare.

  39. TsuDhoNimh says:

    sowellfan – I did a lot of arterial stabbing, collecting blood for O2 analysis. I always warned the patients that there was a possibility it would hurt like @#$!! for a second to two, but they had to hold still. Cussing was allowed, wiggling wasn’t.

    One reason for not bringing up the “P” word is that in some people it increases anxiety. But, sliding around the subject may increase anxiety in others. You don’t know which is which and you don’t know the patient’s pain tolerance.

    The absolute worst case would be seeing a parent, hovering anxiously and lying to the child that whatever was coming (often just a venous blood draw) wasn’t going to hurt at all. That sets the child up to think it’s going to be excruciatingly painful. My way of dealing with that situation was to take the parent aside and tell them that lying isn’t working and it makes our job harder, then chat with the child about degrees of pain … had they ever accidentally stuck a pin in their finger, fallen off a bike, busted an arm or whatever. Then place what was going to happen into their personal frame of reference, explain why we needed to do whatever it was.

    **************
    Calli – And then there’s the folks who *think* they can make it but can’t. I know nurses who swear by medicating folks because their experience is that those who are wrong about their pain/discomfort/freak-out-factor tolerance will generally be wrong in a BIG way.

    Depends on the procedure – if they are wrong on a bone marrow aspiration, it’s over in seconds anyway. If it’s one of the tube-down-the-throat things it could be disastrous.

    **************
    Newcoaster –
    You get the broken leg after the first responders have done their bit, and not all of them are allowed to use pain relief drugs. Try removing a ski boot from a broken leg without pain meds, traction splinting, and the ever-popular snowboarder’s busted wrist.

  40. ravettb says:

    My problem with general anesthesia, particularly inhalation anesthesia (which the above doesn’t really cover, I realize), is brain damage. There are now several papers out (e.g., Zou, X., Sadovova, N., Patterson, T. A., Divine, R. L., Hotchkiss, C. E., Ali, S. F. et al. (2008). The effects of l-carnitine on the combination of, inhalation anesthetic-induced developmental, neuronal apoptosis in the rat frontal cortex. Neuroscience, 151(4), 1053-1065.) which seem to show fairly clearly that isoflurane, for example, produces neural apoptosis. This scares me. I’d like to see even fairly major operations given the choice of local anesthesia, especially for older people, who are more prone to such damage.

  41. hatch_xanadu says:

    Forgive me if this has been discussed in the comments and I’ve missed it, but is local anaesthesia the norm for bone marrow aspirations? In my experience it was not; it seemed to me that only *topical* anaesthesia was commonly used at the needle site, but not the more penetrating local anaesthesia. (Please correct me if this is inaccurate; this was about ten years ago.) This certainly could make a big difference in pain levels.

    I understand this is not HH’s main point, but I’m curious.

  42. Harriet Hall says:

    I’ve never even heard of topical anesthesia for bone marrow aspiration. The standard is skin infiltration with a local anesthetic like lidocaine followed by infiltration of deeper subcutaneous tissues. There is no way to anesthetize the bone itself.

  43. drvicchcdds says:

    –Great article! Thanks for the website too.
    –Hope your biopsy results were unremarkable.
    –I am a dentist who has done a fair amount (several hundred cases) of IV sedation, and several hundred more cases without any sedation other than “verbal sedation” and management. I agree: medicine and dentistry are often based on anecdotal rather than research evidence (“It works in my hands … “) and we often have very little in the way of credible clinical research. That’s not to say it is wrong, because the results of research just do not always seem to provide a gold standard, they often seem far from being unbiased, they often seem too nuanced and too distant for overriding value, and they are are not some kind of Dictatorship of Good Results. Gerd Gigerenzer suggests a good simple decision tree for clinical decisions is at least as rational as anything else for clinical decisions.
    –IV sedation is often used, IMHO, because it is safe and sane IF adequate safeguards and training are used, and because surgeons often consider the “worst case scenario” when deciding on a treatment plan. A patient who “freaks out” halfway through an irreversible surgery can make your (and their) day pretty miserable, and there is no way of predicting who will freak out.
    When i am going in for a biopsy or surgery where IV sedation is an option, I always ask the physician, “what would YOU feel more comfortable with?” Some surgeons may enjoy chatting with their patients, but if they don’t, or would rather their patient be more predictably sedated, then they should be the ones to make the call.
    –Keep up the good work. It’s really nice to have this forum and your experience (as long as you stay current).

  44. bluehiker says:

    Personally, I have totally irrational anxiety concerning needles and other sharp metal things. I have to poke myself a couple of times a day to measure blood sugar and sometimes I break out in a sweat and cannot do it without some delay. I’ve have the same problem with my yearly flu shots, twice yearly blood tests. I’ve had various needles go into various place in my spine. I have the same reaction to the sharp pointy thing when getting my teeth cleaned. Some of times there was pain involved, but once its going, I can deal with the pain. For me, its not the pain. In some ways, the pain is ALMOST a relief.

    I’ve also been sedated before some spinal shots. I didn’t feel that it helped. But given the option, I take it – so it must help somewhat…

  45. Catherine says:

    You darn bet ya it’s over-used and without informed consent! Patients are not told that “something to relax you” will rob them of any memory of what happens from that point on.

    Many people have post traumatic stress following the administration of amnesiacs, in particular, Versed.

    This “medication” was given to me, for a D&C, about 25 years ago. I began having nightmares, flashbacks to childhood abuse and panic attacks, none of which I had beforehand. These persisted for nearly six months. I still have PTSD. I will never trust another doctor, particularly an anesthesiologist, as long as I live.

    Patients should have a choice. If they want amnesia, fine, but they should know ahead of time! And, they should know that, even if they think they are fine with it, there can be long term repercussions.

    Doctors should offer local or spinal anesthesia. I had three and a half hours of surgery, in 2005 (partial hysterectomy and vaginal rectocele repair), with nothing but an epidural. No pain during surgery. No nausea, no illeus, no fasting after surgery. And no anxiety during the surgery. (I was a basket case in pre-op, not due to fear of the surgery but for fear I would be knocked out against my will.)

    It was very difficult to get any contact with an anesthesiologist before I went to the hospital. Only when I informed the surgeon that there would be no surgery unless I could choose my anesthesiologist did I get called. When I could not get a satisfactory answer from the “group” doctor, I went through my primary care doctor to find someone who would listen, to whom I could talk in advance, and who would try to do as I asked.

    In my opinion, these drugs are for the convenience of the doctors. I also believe they derive psychological benefit from believing they spared the patient fear or pain, though neither may be true. Most seem shocked when told what kind of long term damage it can do. Either few patients complain (how can you complain when you don’t know what happened to you?), doctors are not listening, or worst, they know all about it and choose to lie.

    How can this abuse be stopped?

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