Use of Diprovan in your ER

Medic/Nurse, BSN, RN · Dec 17, 2007

Check with your state BON for advice.

Many BON's have elected that non-CRNA's CANNOT bolus push this drug. This is generally considered an induction agent. However, most all states allow for infusion via drip for sedation.

This alone may account for the difference.

I would not push this med until I CONFIRM with my BON that it is within my scope of practice.

Personally, I do not like the drug for many uses.

It is oil based. Needs a very large vein. Is (IMHO) unpredictable. Can cause profound hypotension (it does however reportedly maintain CPP in neuro cases - so it may be useful there). Generally, does not work well in my patient populations. I RSI frequently and it is a wicked bad option (I have other better ones). I do sedate for post intubation/vent management (the big indication for gtt's in the ICU) and I hate the drug for that too - again, other better more reliable options.

Good Luck.

Practice SAFE!

ladylabor · Dec 17, 2007

check with your board of nursing's nurse practice act, recently nurses in Oklahoma have been prohibited from using this medication.

RunnerRN, BSN, RN · Dec 17, 2007

My hospital does not allow us to bolus it in my ED. We are allowed to hang as a gtt to "keep someone down" until we can go to the ICU. There are some RNs in my dept who will "accidentally" bolus someone by opening the propofol up for a moment before initiating the gtt - I won't, I feel that is pretty irresponsible; if you're going to bolus someone, at least know the dose you're giving. I personally hate that drug....we don't use it very often, so no one in my dept is very familiar with it, and it can be so difficult to titrate.

We have one trauma surgeon who will always order "Propofol gtt, titrate to effect." What effect? Sedation? Hypotension? CPP maintained? I will start it only if we are going to be holding a vented pt in the ED for a while (more than 2 hours). Otherwise, I'm much happier and more comfortable keeping a closer eye on the pt and dosing q 1 hr w Versed/Vecuronium or whatever sedation/paralytic combo we're using.

That's all mostly my opinion, but I really feel that unless you use something like that all the time you're asking for trouble!

CritterLover, BSN, RN · Dec 17, 2007

i love it for sedation on vented patients.

i was an icu nurse (trauma) before i was an er nurse, and we used it frequently on our vented patients -- esp those with closed head injuries, since it tends to lower icps.

i know some ers use it for conscious sedation -- a big no-no where i work (against the nurse practice act -- considered practicing anesthesia). even if it were legal in my state for rns to push it for conscious sedation, i wouldn't be comfortable with it.

as many times as i've given it, and as comfortable as i am with it, it is difficult to predict how someone will react, airway-wise. i've given "just a touch" and knocked out a patient's respiratory drive. not a big deal, since he was on a vent. however, that trait makes it tenuous, at best, for a non-anesthesia provider to use it in a non-intubated patient.

the bad things about using diprivan in a vented pt is 1) the lipid base causes some issues (infection control, triglyceride levels) and 2) hypotension. there are also reports that it causes recipients to have "dreams of a sexual nature about their caregivers" :eek: (one of our pulmonologists quit ordering it for this reason).

the good things are that it is very short-acting, so you can keep your pt sedated and just turn it off when the doc comes by to assess; and the hypoentsion generally responds to a pause in the drip and a little fluid.

there are several threads (many of them quite heated) in either the er forum or the crna forum about the use of diprivan by rns in non-intubated patients that may help you out. many rns are big fans of using the drug for conscious sedation. they seem to think that just because they've never had a problem with it, that they never will have a problem with it. if you ask me, they are counting on the intubation skills of whomever ordered it to bail them out if things go bad.

to me, the bottom line is that the diprivan manufacturer does not support its use in conscious sedation. this means that even if your bon doesn't prohibit rns from using it in non-ventilated patients, you would probably still lose any lawsuit that resulted from a mishap.

i'm glad that my state doesn't let us use it if the patient isn't intubated. it gives me an "easy out," so to speak, when the doc wants to use it. (they can still use it, but they have to push it themselves. same with ketamine, but that is another heated debate around here.)

GilaRRT · Dec 17, 2007

This is a similar debate when considering the use of etomidate for procedures. I tend to agree that bolus doses of induction agents such as diprivan and etomidate should be given by an anesthesia provider. Perhaps this is a cop out; however, I have seen and used these same agents in RSI's. Creating apnea and an airway disaster in a patient who is having his hip put back into place do not seem like a whole lot of fun to me. We walk a thin line between sedation and induction. I am quite sure that people will take issue with my stance; however, we have highly educated nurses with mad airway skills and OR time under their belt that know how to safely administer these medications all day long.

core0 · Dec 17, 2007

Can anyone share with me how their hospitals handle the use of Diprovan in their ER's. Where I am currently working, the ER RN"s is not allowed to use Diprovan. This past year I wroked in two other ER's and RN's were allowed to use diprovan under ER MD supervision for moderate sedation procedures. Of course I am ACLS, PALS, and CEN with TNCC certs. Also if anyone knows where I can find published works supporting this position it would be greatly appreciated.

As most of the comments below state you should check your nurse practice act. There is a lot of research in endoscopy which shows that with the proper protocol nurse administered propofol is safe. Here is a good article. Refer to the latest research section. Especially the Rex articles.

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=519627

David Carpenter, PA-C

gentle_ben_RN, ASN · Dec 17, 2007

When I worked in the PACU, I saw propofol used frequently, but it was always administered by anesthesiologists or CRNA's. It was used a lot to sedate patients for closed hip manipulatons.

In the ER, I've seen it used some. I had a patient last week that we were going to cardiovert. We had tried demerol and versed but he had a high tolerance for it, and we were not getting adequate sedation. The cardiologist ordered to push propofol. I drew it up for him, but I handed it to him to administer it.

I am a big fan of using propofol as a gtt for vent sedation. When the MD orders "titrate to effect" to me that says do what works;)

mmutk, BSN, RN, EMT-I · Dec 17, 2007

We can hang diprovan, but NO IV pushes. Hospital policy, although I remember when we used to be able to...

cardiacRN2006, ADN, RN · Dec 17, 2007

. if you ask me, they are counting on the intubation skills of whomever ordered it to bail them out if things go bad.

not necessarily true...you would just have to bag them until the propofol wore off, which would be a few minutes.

in my state, we cannot bolus propofol and we cannot administer it to non-intubated pts.

GilaRRT · Dec 17, 2007

Not necessarily true...You would just have to bag them until the propofol wore off, which would be a few minutes.
In my state, we cannot bolus propofol and we cannot administer it to non-intubated pts.

My concern would be related to the airway management abilites of the nurse who is giving these medications. Allot of nurses have very little knowledge when it comes to managing an airway. How often do you see proper BVM technique with proper airway positioning and proper use of cricoid pressure? In addition, there are a number of people who simply cannot be mask ventilated. So, now a non anesthesia provider is essentially dealing with a failed airway.

cardiacRN2006, ADN, RN · Dec 17, 2007

How often do you see proper BVM technique with proper airway positioning and proper use of cricoid pressure? .

I see it done correctly all the time, and would hope that ED nurses above all else would be the most competent in doing so.