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| |  Procedural Sedation in the ICU
How many of you are in a place where you (or some anesthesia provider) has to go to the ICU to perform procedural sedation. Here, RNs can't push Propofol, Ketamine etc, so often times the doc will push it with the nurse observing the patient and the doc ALSO performing the procedure. This doesn't seem like a remarkably good idea to me...
How is it done where you are?
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Feb 10, 2005, 01:31 PM
Originally Posted by bryanboling5 How many of you are in a place where you (or some anesthesia provider) has to go to the ICU to perform procedural sedation. Here, RNs can't push Propofol, Ketamine etc, so often times the doc will push it with the nurse observing the patient and the doc ALSO performing the procedure. This doesn't seem like a remarkably good idea to me...
How is it done where you are?
Funny - I just posted our policy on another thread...
The hospital policy here is that no one but anesthesia providers (MDA, CRNA, or AA) may give Propofol, Ketamine, Amidate, Pentothal, or Brevital with the exception of propofol infusions for patients on vents in the ICU. Non-anesthesiologist physicians are not exempted from this policy, and it is strictly adhered to throughout the hospital.
Any intubation, cardioversion, GI or Radiology case that requires any of the above drugs for sedation must be attended by anesthesia.
| | No. 2 |
Feb 10, 2005, 03:37 PM
When pt's are vented of course we push just about anything thats only if mech ventilated. If not mech ventilated we may push versed, ativan, any pain meds and have low dose propofol drip.
| | No. 3 |
Feb 10, 2005, 10:09 PM
At our ICU the nurse can moderately sedate with versed/fentanyl, usually for endoscopy. The ASA and AANA have a position statement on propofol use and it makes sense--there is no reversal agent for propofol (time?) and you have to be prepared to intubate if you get carried away. Of course if you're already intubated... Here is the link: http://www.asahq.org/news/propofolstatement.htm
I have on three occasions in the last 4 months given very deep sedation versed/fentanyl/vec for bedside trach and peg jobs. I think this will only fly in a military hospital though.
| | No. 4 |
Feb 11, 2005, 07:08 AM
Originally Posted by BigDave I have on three occasions in the last 4 months given very deep sedation versed/fentanyl/vec for bedside trach and peg jobs. I think this will only fly in a military hospital though.
I'd call that a general anesthetic.
| | No. 5 |
Feb 11, 2005, 02:59 PM
When I worked in the ICU I also gave versed/fentanyl for a PEG placement, and etomidate for cardioversion. Although I physically pushed the drug, it was also required that anesthesia was at the bedside.
| | No. 6 |
Feb 11, 2005, 05:48 PM
In my area the competent critical care RN can administer MD ordered sedation (usually Versed and Diprivan) for procedures. Generally this would take place in special procedures, but the critical patients may need these procedures emergently, and to stay in ICU.Sometimes the docs will ask anesthesia to attend and frequently they CANNOT due to their own workload, etc.
Airway and vital signs are closely monitored continuously of course. I've never been asked to give a paralytic unless we were establishing an airway in the process.
I know a lot of anesthesia providers don't like the idea of critical care nurses giving Diprivan on unintubated patients but to me it seems a turf battle instigated by CRNA's. I read a lot of this on the BB. Until CRNA's staff the ICU I don't see this changing.
| | No. 7 |
Feb 11, 2005, 06:16 PM
I have no problems with RNs giving propofol as long as they know how to manage an airway. Unfortunately, I don't think this is the norm. When I was working in the ICU, I thought I was moderate good at managing an airway... but it wasn't until anesthsia school that I realized I was wrong.
As the post on the joint statement from the ASA and AANA demonstrates, both anesthesia associations strongly believe that propofol should only be given by skilled anesthesia providers, so your comment on CRNAs perpetuating a turf battle is absurd.
| | No. 8 |
Feb 11, 2005, 07:08 PM
Updated
Feb 11, 2005 at 07:11 PM by rn29306
RNs and general anesthetics..
99.7% of all CRNAs and SRNAs have at one time been critical care RNs in the units. Please trust those of us who have been on both sides of the fence that emergency management of unexpected complications is far better handled in the OR than in the units. We have an entire department at our immediate disposal, not to mention a pharmacy of drugs either already drawn up and on our tabletop or are two feet away in some sort of Omnicell or Pyxis. Anesthesia imparts on most all patients a condition upon induction that would qualify as all hell breaking loose in the units, which is not a pretty sight (I know from first hand experience). If a person does not have immediately, and I mean no more than 2 feet away, ephedrine, neosynephrine (and the knowledge / understanding of when to use each one), 4 different type of blades, 3 different types of tubes, bugies, and alternative airway methods AT MINIMUM then don't give anesthetic drugs.
I did alot as an RN (both in hospitals and esp pre-hospital) and would not change it for the world. With that said, RNs don't know a whole lot about airway management, unless you have some kind of EMS or flight training. Not trying to flame, but most of us know this is true.
MDs who ask that GA drugs to be given by an RN to an unintubated pt are asking a RN to do something that is against the drug mfg statements, is convenient on the physician's behalf, is outside most state-derived nurse practice laws, and is against what the two largest and most influential anesthesia organizations in this country have agreed upon. There is nothing to back you up but a plea of desperation...You are hanging yourself, and more importantly, your patient out to dry with no backup.
| | No. 9 |
Feb 11, 2005, 08:42 PM
Originally Posted by rn29306 99.7% of all CRNAs and SRNAs have at one time been critical care RNs in the units. Please trust those of us who have been on both sides of the fence that emergency management of unexpected complications is far better handled in the OR than in the units. We have an entire department at our immediate disposal, not to mention a pharmacy of drugs either already drawn up and on our tabletop or are two feet away in some sort of Omnicell or Pyxis. Anesthesia imparts on most all patients a condition upon induction that would qualify as all hell breaking loose in the units, which is not a pretty sight (I know from first hand experience). If a person does not have immediately, and I mean no more than 2 feet away, ephedrine, neosynephrine (and the knowledge / understanding of when to use each one), 4 different type of blades, 3 different types of tubes, bugies, and alternative airway methods AT MINIMUM then don't give anesthetic drugs.
I did alot as an RN (both in hospitals and esp pre-hospital) and would not change it for the world. With that said, RNs don't know a whole lot about airway management, unless you have some kind of EMS or flight training. Not trying to flame, but most of us know this is true.
MDs who ask that GA drugs to be given by an RN to an unintubated pt are asking a RN to do something that is against the drug mfg statements, is convenient on the physician's behalf, is outside most state-derived nurse practice laws, and is against what the two largest and most influential anesthesia organizations in this country have agreed upon. There is nothing to back you up but a plea of desperation...You are hanging yourself, and more importantly, your patient out to dry with no backup.
That was very well said!
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