Cosmetic Surgery Death after RN (not CRNA) Administered Propofol

[stevierae]

As usual, it took a patient death to effect change to a dangerous practice. This is why I, an operating room nurse, am so adament about getting the practice of RNs giving conscious sedation stopped, and the reason for my thread about OR nurses--and endoscopy nurses-- giving conscious sedation. This dangerous practice simply needs to stop. As evidenced by an ongoing thread in the gastroenterology nursing section, apparently--at least in some facilities-- endo RNs administer propofol as part of "conscious sedation."

FYI on Propofol Administration by RNs

Saying that it has received several reports of adverse events, including

the death of a cosmetic surgery patient, after RNs improperly

administered propofol, the American Association for Accreditation of

Ambulatory Surgery Facilities (AAAASF) is rushing to ensure that only

those trained to give general anesthesia or rescue from general

anesthesia administer propofol in its 1,100 or so accredited facilities.

The AAAASF announced last week that facilities that want to continue to

use propofol -- even if only for "conscious sedation" -- must either

upgrade to a Class C facility (where all anesthesia must be administered

by an anesthesiologist or CRNA) or promise to always use an anesthesia

professional to administer the drug. Facilities must comply by May 1.

"We decided that we need to get our standards in line with the

manufacturer's recommendations," says Jeff Pearcy, executive director of

the AAAASF. "The easiest way to do that was to require those facilities

that want to continue to use propofol to become Class C facilities."

For Class B facilities that would like to continue to use propofol but

won't use other types of general anesthesia, complying with the new

standard is simple. These facilities must fill out a form certifying

that they have a dedicated anesthesiologist or CRNA administering the

sedative-hypnotic. They also must have neuromuscular blocking agents

available in the facility. No on-site inspection is necessary. There

will be no additional charge, says AAAASF.

Those facilities that are upgrading to a C and plan to use general

anesthesia (inhalational) in addition to using propofol must comply with

all Class C criteria, says AAAASF.

AAAASF President Michael F. McGuire, MD, a board-certified plastic

surgeon, says the major motivation for making the change was that

"administration of propofol by a non-anesthesia provider is really not

appropriate."

Dr. McGuire adds that the new standard has caused quite a bit of

confusion and concern, mostly among Class B facilities that don't give

inhalational anesthesia and misread the standard to mean they couldn't

administer propofol unless they bought an anesthesia machine and CO2

monitor. Part of the confusion, he says, lies in the nature of the

propofol.

"Is propofol a general anesthetic or a sedation agent? It's both.

Really, truly, it is both," says Dr. McGuire. "At a certain level and in

a certain individual, it is a sedation agent. In other individuals or at

higher does, it becomes a general anesthetic agent. It's so

unpredictable, which is not a problem if you're an anesthesiologist but

can be if you're a surgeon trying to do surgery and supervise a nurse

giving the medication."

[jwk]

agreed. but, when dealing with potent benzo's and hypnotics one must understand that each pt will react differently and the provider must be prepared to manage the airway appropriately and administer a reversal agent if appropriate. (not that one sets out to make the pt apneic, but at times it does happen) there are many documented cases of people dying in dental offices from what was supposed to be conscious sedation and turned into full blown anesthesia, if you will.

Conscious sedation that progresses to general anesthesia is almost always due to either impatience, incompetence, stupidity, or some combination thereof. It just shouldn't be happening. Use of flumazenil or narcan in our hospital (except in the OR) means an incident report gets filed and reviewed.

It's a very rare thing that a patient becomes apneic from midazolam in appropriate doses. When it does happen, it's often because the operating physician is impatient and demands more drugs, when the first dose hasn't even had time to circulate and have an effect. 1mg becomes 2 which becomes 3, 4, and 5, and then you wonder why your 90 year old patient for an EGD isn't breathing. If this kind of thing happens in your facility with any kind of frequency at all, you need to closely re-examine your procedures and the ordering physicians (or nurses that blindly follow those orders) need to be re-trained.

[smileyRn96]

This is an old thread, but interesting....we do not call it conscious sedation anymore, we call Moderate sedation....I used moderate sedation a lot in the ED for dislocated shoulders, hips, ankle, and to reduce hernias as well...We used Etomidate mostly in the ED, the patients are on monitor, ambu-bag at bedside, code cart within reach, on o2, suctions ready, iv access with saline bag hanging and ready to bolus if needed, and 1:1 nurse ratio until fully awake post procedure...I never had any real issues to speak of except maybe one time that we gave like 3 ambu breaths to a patient when their sat dropped to 88% and then they began to wake up...We did it all the time, but it was never done without adequate preperation and it was taken very seriously.

Now in my Icu, people love versed and fentanyl. Also, that is all I see endo use and they always look a little nervous.

Propofol to an unitubated pt in MRI????? To me that sounds crazy.

-Smiley

[GmanRN]

I posted a thread that lightly touches on the topic of RNs providing procedural conscious sedation. It hasnt been approved by the mods as of now, but it has the word "HALO" in the title. :)