Is Indiana RN allowed to give Ketamine for procedural sedation ?? - page 3

This question is directed to all Indiana RN's. Does anyone know if RN's in IN are allowed to administer Ketamine IV/IM for procedural sedation? What is your hospital policy?... Read More

  1. by   rn29306
    Quote from EDinNC
    nurses don't manage airways?? What??!! Where do you practice? We are taught ABC's above all else.... what is A?? This includes the management of that airway. Depending on where you work, RN's can intubate. (Even Paramedics can manage an airway) There are reversal agents for meds we push, as well.

    You may be taught ABCs, but nurses are not taught airway management. Unfortunately, there is simply nothing further from the truth.


    Speaking of reversals....
    What's the reversal for Ketamine?
    What's the reversal for Amidate?
    What's the reversal for Propofol?
    Traditional CS medicines (fent, benzos) have reversals and thus the relative safety margin..

    This is not a personal attack on you in general. It takes experience to see that sometimes you don't know what you don't know. Anesthesia school teaches you many things, including the fact that as a staff RN I knew jack little about airway management. I have intubated both in-house and in the field (or rather in-car) on several instances as a staff RN. I thought I was on top of my game. WRONG. The set up we have immediately available as the table-top set up in the OR is outstanding. I'm talking about medicines already drawn up, sitting there. Not across the department, not in a pyxis. Inches from your hand is what I'm speaking of. I have a hard time believing that you have this set up for every CS case that you do when you give general anesthetics. And I've worked ER, I know how its done.

    While there are some EMS companies that do allow a select few paramedics to perform RSI, check the studies done. Actually there were worse associated patient outcomes with performing RSI in the field rather than traditional EMS medications for intubation. Unrelenting hypoxia is a rather downer on your day, esp moreso for your patient. It all comes to the setup, preparation, and anticipation of a difficult airway, which neither EDs or EMS companies can perform to the extent that an OR does everyday.

    I see where you are coming from. Intubation is relatively easy after about the first 30. That is what most anesthesia people will tell you. It's really not that hard of a task to learn. What is hard to manage is the difficult airway and how to flow from one scenario to another in the Difficult Airway pathway. Do you honestly do an airway assessment (or know how to) before you give a general anesthetic for CS to a patient? I have never seen this done outside the OR in all my years of doing ER and ICU before anesthesia school. One of the most difficult aspects of airway management (which they DO NOT teach in nursing school - that is a joke) believe it or not, is effective mask ventilation. Notice the word effective here. I have been to so many codes to intubate where an RT is shoving .9 - 1.2 liters down someone with every ventilation (word used very lightly) with such pressure that there is no way in hell that it is going into the lungs. What happens next? I attempt to intubate and next thing there is about 700 mls of usually coffee ground emesis in the oropharynx that despite going in with suction and a blade, aspiration occurs and you might as well get a body bag then. One thing you John Wayne nurses will have happen, because it happens to us on a semi-regular basis, is the can ventilate - cannot intubate scenario and your MD had better be able to do this effectively without inflating the gastric until either: 1. anesthesia shows up, or 2. the general anesthetic you just gave (which has no reversal BTW), wears off. Lord help you if you get into a cannot-ventilate, cannot-intubate. Even FOI cannot help, esp if you used ketamine as the agent.

    There is a reason drugs are listed as general anesthetics. Staff RNs are not CRNAs or anesthesiologists, nor are you trained in advanced airway management. Simple truth, not a prejudiced statement against nursing.
    But what you are doing is pushing these drugs without training. Who do you think the ED calls for difficult airways, if the MD is smart about things? That's right, anesthesia. CRNAs usually show up, and again, there is a reason for that also.

    One of my classmates worked in California and was actually on the CS team which did adminster general anesthetics in the ED. His view on airway management before CRNA and after CRNA are drastically different. He thought he could manage an airway before school also. Experience teaches you things - sometimes you just don't like the answer.
    Last edit by rn29306 on Sep 6, '05
  2. by   rn29306
    Quote from hrtprncss
    Flumazenil and Narcan....Nuff said
    If you bothered to read the postings, you would see that some RNs here are talking about giving GA drugs for CS, something that romazicon or narcan will not touch...Nuff said.

    I hope this dawned on you. What is even scarier is the fact it did.....
    Last edit by rn29306 on Sep 6, '05
  3. by   rn29306
    Quote from nursemomruns
    There isn't anything in the INPA that says what drugs a nurse can or can't give. What it does say is that you have to have the experience and education to do what you do.
    That is the problem with general anesthetics. You are not anesthesia-trained, nor are you anesthesia-educated so why are you giving anesthesia and apnea-inducing drugs? Forget institution-based teaching and competancy training, most are a joke in the first place. There is not a shortcut to knowing how to provide this care. You want to provide anesthesia drugs to patients, go back to school for CRNA, MD anesthesiologist, or be a flight RN.
  4. by   hrtprncss
    Quote from rn29306
    That is the problem with general anesthetics. You are not anesthesia-trained, nor are you anesthesia-educated so why are you giving anesthesia and apnea-inducing drugs? Forget institution-based teaching and competancy training, most are a joke in the first place. There is not a shortcut to knowing how to provide this care. You want to provide anesthesia drugs to patients, go back to school for CRNA, MD anesthesiologist, or be a flight RN.

    Then if everything is sub par in your eyes, bag the patient, administer your own anesthetics, intubate and push ur own ventilator to sicu. God forbid I push something on the vent button and accidentaly increased the fio2 to 100 percent.
  5. by   MassED
    Quote from rn29306
    You may be taught ABCs, but nurses are not taught airway management. Unfortunately, there is simply nothing further from the truth.


    Speaking of reversals....
    What's the reversal for Ketamine?
    What's the reversal for Amidate?
    What's the reversal for Propofol?
    Traditional CS medicines (fent, benzos) have reversals and thus the relative safety margin..

    This is not a personal attack on you in general. It takes experience to see that sometimes you don't know what you don't know. Anesthesia school teaches you many things, including the fact that as a staff RN I knew jack little about airway management. I have intubated both in-house and in the field (or rather in-car) on several instances as a staff RN. I thought I was on top of my game. WRONG. The set up we have immediately available as the table-top set up in the OR is outstanding. I'm talking about medicines already drawn up, sitting there. Not across the department, not in a pyxis. Inches from your hand is what I'm speaking of. I have a hard time believing that you have this set up for every CS case that you do when you give general anesthetics. And I've worked ER, I know how its done.

    While there are some EMS companies that do allow a select few paramedics to perform RSI, check the studies done. Actually there were worse associated patient outcomes with performing RSI in the field rather than traditional EMS medications for intubation. Unrelenting hypoxia is a rather downer on your day, esp moreso for your patient. It all comes to the setup, preparation, and anticipation of a difficult airway, which neither EDs or EMS companies can perform to the extent that an OR does everyday.

    I see where you are coming from. Intubation is relatively easy after about the first 30. That is what most anesthesia people will tell you. It's really not that hard of a task to learn. What is hard to manage is the difficult airway and how to flow from one scenario to another in the Difficult Airway pathway. Do you honestly do an airway assessment (or know how to) before you give a general anesthetic for CS to a patient? I have never seen this done outside the OR in all my years of doing ER and ICU before anesthesia school. One of the most difficult aspects of airway management (which they DO NOT teach in nursing school - that is a joke) believe it or not, is effective mask ventilation. Notice the word effective here. I have been to so many codes to intubate where an RT is shoving .9 - 1.2 liters down someone with every ventilation (word used very lightly) with such pressure that there is no way in hell that it is going into the lungs. What happens next? I attempt to intubate and next thing there is about 700 mls of usually coffee ground emesis in the oropharynx that despite going in with suction and a blade, aspiration occurs and you might as well get a body bag then. One thing you John Wayne nurses will have happen, because it happens to us on a semi-regular basis, is the can ventilate - cannot intubate scenario and your MD had better be able to do this effectively without inflating the gastric until either: 1. anesthesia shows up, or 2. the general anesthetic you just gave (which has no reversal BTW), wears off. Lord help you if you get into a cannot-ventilate, cannot-intubate. Even FOI cannot help, esp if you used ketamine as the agent.

    There is a reason drugs are listed as general anesthetics. Staff RNs are not CRNAs or anesthesiologists, nor are you trained in advanced airway management. Simple truth, not a prejudiced statement against nursing.
    But what you are doing is pushing these drugs without training. Who do you think the ED calls for difficult airways, if the MD is smart about things? That's right, anesthesia. CRNAs usually show up, and again, there is a reason for that also.

    One of my classmates worked in California and was actually on the CS team which did adminster general anesthetics in the ED. His view on airway management before CRNA and after CRNA are drastically different. He thought he could manage an airway before school also. Experience teaches you things - sometimes you just don't like the answer.
    I can appreciate your answer, obviously you're in school. Our Anesthesiologists are the ones to push Ketamine, per our policy. We have our RSI kit at the bedside. RN's at OUR facility do not intubate. The information you provide is interesting. I would be interested to have some ED specific CEU's on airway management, in the case of a difficult airway. Should that happen, the MD is responsible, and like you said, God help him. Like I said, I can appreciate your answer, but it doesn't require an implication of superiority on your part because you have a specific skill. But if you're skilled and effective at what you do, wonderful. Also, our hospital doesn't employ CRNA's.
  6. by   William_SRNA
    Paramedics are taught advanced airway management as a standard and perform alot more intubations than an RN. I wouldn't have a problem with a paramedic perfroming RSI.



    Quote from EDinNC
    nurses don't manage airways?? What??!! Where do you practice? We are taught ABC's above all else.... what is A?? This includes the management of that airway. Depending on where you work, RN's can intubate. (Even Paramedics can manage an airway) There are reversal agents for meds we push, as well.
  7. by   William_SRNA
    I am not sure what you are referring to can you quote my post you are referring to?


    Thanks


    Quote from mak2
    Hoop jumper, I am not sure I follow you, any time you do CS you should be prepared to intubate. What is it you are talking about. Do you work on a unit without monitoring available?
  8. by   chip193
    Quote from EDinNC
    (Even Paramedics can manage an airway)
    Paramedics can do far more with an airway than most RNs - save CRNAs,some APRNs, and some transport/flight RNs. Please, the Paramedic's bread and butter is airway - and ACLS.

    Chip
  9. by   nursemomruns
    Quote from rn29306
    That is the problem with general anesthetics. You are not anesthesia-trained, nor are you anesthesia-educated so why are you giving anesthesia and apnea-inducing drugs? Forget institution-based teaching and competancy training, most are a joke in the first place. There is not a shortcut to knowing how to provide this care. You want to provide anesthesia drugs to patients, go back to school for CRNA, MD anesthesiologist, or be a flight RN.
    I think you are assuming alot about the educational background, experience, and abilities of others in this discussion.

    Wasn't this question originally about using Ketamine for CS, not general anesthesia?
  10. by   rn29306
    Quote from nursemomruns
    Wasn't this question originally about using Ketamine for CS, not general anesthesia?
    Ketamine is still an anesthetic drug. I guess if you insist on using a GA drug in your ED, ketamine is one of the safest to be giving.
  11. by   jwk
    Quote from chip193
    Paramedics can do far more with an airway than most RNs - save CRNAs,some APRNs, and some transport/flight RNs. Please, the Paramedic's bread and butter is airway - and ACLS.

    Chip
    You really don't want to go there.

    I've been doing anesthesia 25 years (after being a paramedic before that). I have seen exactly 1 surgical airway in that time. Most cricoid sticks are done by paramedics in the field because they don't do enough intubations to retain their competency at the skill. "Paramedic's bread and butter is airway" - I don't think so. Nor is it the ER or ICU nurse or even the ER doc. Some may be better at it than others, but none will compare to anyone from your anesthesia staff. Yes, paramedics do intubate more than RN's, and on many patients, they do fine. Does that make them the experts? Nope.
  12. by   jwk
    Quote from rn29306
    You may be taught ABCs, but nurses are not taught airway management. Unfortunately, there is simply nothing further from the truth.


    Speaking of reversals....
    What's the reversal for Ketamine?
    What's the reversal for Amidate?
    What's the reversal for Propofol?
    Traditional CS medicines (fent, benzos) have reversals and thus the relative safety margin..

    This is not a personal attack on you in general. It takes experience to see that sometimes you don't know what you don't know. Anesthesia school teaches you many things, including the fact that as a staff RN I knew jack little about airway management. I have intubated both in-house and in the field (or rather in-car) on several instances as a staff RN. I thought I was on top of my game. WRONG. The set up we have immediately available as the table-top set up in the OR is outstanding. I'm talking about medicines already drawn up, sitting there. Not across the department, not in a pyxis. Inches from your hand is what I'm speaking of. I have a hard time believing that you have this set up for every CS case that you do when you give general anesthetics. And I've worked ER, I know how its done.

    While there are some EMS companies that do allow a select few paramedics to perform RSI, check the studies done. Actually there were worse associated patient outcomes with performing RSI in the field rather than traditional EMS medications for intubation. Unrelenting hypoxia is a rather downer on your day, esp moreso for your patient. It all comes to the setup, preparation, and anticipation of a difficult airway, which neither EDs or EMS companies can perform to the extent that an OR does everyday.

    I see where you are coming from. Intubation is relatively easy after about the first 30. That is what most anesthesia people will tell you. It's really not that hard of a task to learn. What is hard to manage is the difficult airway and how to flow from one scenario to another in the Difficult Airway pathway. Do you honestly do an airway assessment (or know how to) before you give a general anesthetic for CS to a patient? I have never seen this done outside the OR in all my years of doing ER and ICU before anesthesia school. One of the most difficult aspects of airway management (which they DO NOT teach in nursing school - that is a joke) believe it or not, is effective mask ventilation. Notice the word effective here. I have been to so many codes to intubate where an RT is shoving .9 - 1.2 liters down someone with every ventilation (word used very lightly) with such pressure that there is no way in hell that it is going into the lungs. What happens next? I attempt to intubate and next thing there is about 700 mls of usually coffee ground emesis in the oropharynx that despite going in with suction and a blade, aspiration occurs and you might as well get a body bag then. One thing you John Wayne nurses will have happen, because it happens to us on a semi-regular basis, is the can ventilate - cannot intubate scenario and your MD had better be able to do this effectively without inflating the gastric until either: 1. anesthesia shows up, or 2. the general anesthetic you just gave (which has no reversal BTW), wears off. Lord help you if you get into a cannot-ventilate, cannot-intubate. Even FOI cannot help, esp if you used ketamine as the agent.

    There is a reason drugs are listed as general anesthetics. Staff RNs are not CRNAs or anesthesiologists, nor are you trained in advanced airway management. Simple truth, not a prejudiced statement against nursing.
    But what you are doing is pushing these drugs without training. Who do you think the ED calls for difficult airways, if the MD is smart about things? That's right, anesthesia. CRNAs usually show up, and again, there is a reason for that also.

    One of my classmates worked in California and was actually on the CS team which did adminster general anesthetics in the ED. His view on airway management before CRNA and after CRNA are drastically different. He thought he could manage an airway before school also. Experience teaches you things - sometimes you just don't like the answer.
    Absolutely 100% correct. This argument is almost identical to the one about endoscopy nurses giving propofol. It shouldn't happen.
  13. by   chip193
    Quote from jwk
    You really don't want to go there.

    I've been doing anesthesia 25 years (after being a paramedic before that). I have seen exactly 1 surgical airway in that time. Most cricoid sticks are done by paramedics in the field because they don't do enough intubations to retain their competency at the skill. "Paramedic's bread and butter is airway" - I don't think so. Nor is it the ER or ICU nurse or even the ER doc. Some may be better at it than others, but none will compare to anyone from your anesthesia staff. Yes, paramedics do intubate more than RN's, and on many patients, they do fine. Does that make them the experts? Nope.
    I did go there and I will stand by the statement. My whole statement.

    And I never said that Paramedics were better than anesthesia at airways.

    Kindly keep the whole quote or at least the context correct.

    Chip

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