Use of Diprovan in your ER - page 2

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... Read More

  1. by   CRNAGAL
    Quote from cardiacRN2006
    Not necessarily true...You would just have to bag them until the propofol wore off, which would be a few minutes.
    Actually, its more than a matter of just "bagging them for a couple minutes". Now that your patient is apneic, he has also lost his protective airway reflexes and is at risk for aspiration or worse. Especially for a patient in the ER who more than likely is not NPO. For the folks not familiar with aspiration pneumonia, it is deadly. Not everyone is easy to mask ventilate, even in the OR under optimal conditions. An oral airway does not guarantee the ability to mask ventilate adequately. Don't count on the MD to be good at bagging, either. Most people, unless they deal with mask ventilation frequently, RT, paramedics, etc. , do not do an adequate job of ventilating. Not trying to get into a debate here about who should or shouldn't give propofol, just pointing out that losing the airway is a big deal.
  2. by   meandragonbrett
    RN's shouldn't administer propofol to non-intubated patients period.
  3. by   scattycarrot
    Quote from meandragonbrett
    RN's shouldn't administer propofol to non-intubated patients period.
    I agree. Where I worked last the only people allowed to administer Diprovan were anaethetists and only concious sedation was alowed to reduce shoulders and fractures, etc....so we used Midazolam and Morphine typically, sometimes fentanyl and we always used consious sedation charts.If the patient wasn't talking to you, it was considered a GA and no more meds were to be given till that patient was at least mumbling to you and responding to questions. If deeper anaesthesia was needed, eg..Diprovan ,than it was time to call the anaesthetists in. It didn't matter what level of doc you were, you were not allowed to push diprivan. I think people can be too blase about pushing certain meds, and this is one of them. Unless you are have someone to care for the unprotected airway that you have now given the patient, then it shouldn't be used at all. Just my opinion!
  4. by   jayne109
    The only thing we use Diprivan for is an intubated patient. No boluses. I had a nurse that wanted me to Bolus a patient that was waking up and I adamantly refused. I worked too hard for my license.

    We use the RASS scale and the order is to usually titrate to a RASS of 0 to -1. We have a whole big protocol and the chart is reviewed every time we use-which is actually not very often.
  5. by   cardiacRN2006
    Quote from CRNAGAL
    Actually, its more than a matter of just "bagging them for a couple minutes". Now that your patient is apneic, he has also lost his protective airway reflexes and is at risk for aspiration or worse. Especially for a patient in the ER who more than likely is not NPO. For the folks not familiar with aspiration pneumonia, it is deadly. Not everyone is easy to mask ventilate, even in the OR under optimal conditions. An oral airway does not guarantee the ability to mask ventilate adequately. Don't count on the MD to be good at bagging, either. Most people, unless they deal with mask ventilation frequently, RT, paramedics, etc. , do not do an adequate job of ventilating. Not trying to get into a debate here about who should or shouldn't give propofol, just pointing out that losing the airway is a big deal.

    So, your MDs and RNs are not capable of emergency airway management??? How scary! Propofol wears off in like, what, 1.5 minutes?

    Every nurse in the ED and ICU (and OR and PACU) should be able to do this.

    Sure, I'd like all people to be experts in airway management. But you don't have to be an expert to bag someone! I did it all the time as an EMT and that was a 6 month class. And yes, I'm quite familiar with aspiration pneumonia.


    Realistically, people are intubated when they lose their airway over a dose of propofol? When do you extubate, 5 minutes later?
  6. by   scattycarrot
    Quote from cardiacRN2006
    So, your MDs and RNs are not capable of emergency airway management??? How scary! Propofol wears off in like, what, 1.5 minutes?

    Every nurse in the ED and ICU (and OR and PACU) should be able to do this.

    Sure, I'd like all people to be experts in airway management. But you don't have to be an expert to bag someone! I did it all the time as an EMT and that was a 6 month class. And yes, I'm quite familiar with aspiration pneumonia.


    Realistically, people are intubated when they lose their airway over a dose of propofol? When do you extubate, 5 minutes later?
    I think there is a subtle difference between emergency management of airways and the management of an airway which we have lost due to over-sedation. In the first situation, you are responding to the patients clinical condition and you just do the best you can for that patient until the patient regains their airway or you just bag until senior help arrives or in the case of an EMT, you get your butt to a hospital where they may well be intubated. In the second situation, you are delibrately inducing unconciousnss and the patient deserves to have the best treatment possible in case things go wrong (which they do!) and that means having the proper personnel there to react if needed. No-one is going to criticize or sue you for bagging a patient in an emergency situation and they aspirate but I can't see a good excuse for this in a supposdly controlled enviroment. Its about whats best for the patient and in my book, thats having the correct staff there to step in when things go wrong.
  7. by   CraigB-RN
    Quote from meandragonbrett
    RN's shouldn't administer propofol to non-intubated patients period.
    I gave 1mg of Dilaudid to a patient the other night that went apnic on me, (1st dose and swore that he hadn't taken anything else. Had disclocated elbow) had to be bagged and given narcan. Does that mean RN's shouldn't give Dilaudid. Granted i was flying and had all this emergency airway stuff right next to me. I've had patients go apnic using valium (yes I'm showing my age) after shoulder reductions. I've had patients go apnic from allergic reaction to antibiotics.

    It's a training/education issue, and your rignt in someplaces they chouldn't be. I was a DON in a rural facility in KS, and you better believe I didn't let anyone give diprovan other than the CRNA. I didn't allow them to do concious sedation at all.

    I'll also agree with people that most concious sedation protocols probably don't take into account last meals with enough importance.
  8. by   CRNAGAL
    No, I wouldn't intubate my patient for 5 minutes if they went apneic from propofol, my patients are NPO and it is part of my job of which I am fully trained, qualified and licensed to perform. Also, having to bag your patient who is undergoing conscious sedation is not only poor form but a general anesthetic. You are practicing dangerously, and beyond your scope, if you think that giving sedation to the point of apnea and bagging someone for a few minutes is no big deal. End of discussion.
    Last edit by CRNAGAL on Dec 18, '07
  9. by   GilaRRT
    There is a significant delta between emergency airway management and elective procedures. Scattycarrot hit the nail on the head. When we RSI a person with these meds, we are doing so because an emergency or potential emergency exists. We have an airway issue and are essentially forced to secure it with RSI. Also remember, in some cases we may not RSI if a difficult airway is predicted.

    In many cases, sedation with these agents will be more elective. An emergency does not exist. Even in the case of compromised circulation to an extremity, I would still want a properly educated provider pushing the meds. This is not a life or death situation, where emergency airway management is.

    In addition, somebody can easily become hypoxic and hypercarbic in 90 seconds. I understand many will say that people can go several minutes before they desaturate. However, these numbers are taken from preoxygenated healthy patients. When you consider the obesity problem and the many number of co-morbid conditions that many people in the USA have, I would not bet on several minutes to desaturation quotes.

    So, they become hypoxic and even when the agent wears off, their mental status is depressed and they do not have adequate resp drive or airway reflexes. Then, they are one of the people who cannot be mask ventilated and we are back to a non anesthesia provider essentially dealing with a failed airway.

    I am not against non anesthesia providers providing sedation; however, where do we draw the line? How much education is required? I have seen people provide this service with nothing more than ACLS credentials and ER experience under their belt. You are crazy if you think bagging Fred the head or dropping a couple of ET tubes and perhaps an LMA on Fred in an ACLS class constitutes adequate education in airway management. IMHO
  10. by   Medic/Nurse
    Hey there GilaRN - you have an excellent response in the above post.

    When folks come to the ED and need sedation - you can bet they will have had Mt Dew and Doritos just PTA (so the NPO thing is moot),

    You can also bet that they may not be giving comprehensive medication/medical/surgical histories - so there is an added risk.

    Oh, and many have co-morbid conditions - so those odds against you too.

    Now, where does this leave you? If for some reason that you get step off the "can't intubate/can't ventilate" abyss --- you will be in the deep dark dooy IF it goes poorly and you were the one to administer the medication and an airway is mismanaged.

    My rules for administering any drug that can cause significant RESPIRATORY DEPRESSION:

    1. Assemble all stuff. Drugs, reversal agents, crash cart, monitor, airway supplies.
    2. Assess patients airway. Stick out your tongue and then I visualize for Class assignment.
    3. Have a minimum of 3 options for the untoward event. BVM/oral-nasal airway, ETT, LMA, King airway, surgical cric!
    4. Pt must have 2 IV's at a minimum (one of these has to be just the crystalloid of the day). Pt is plugged up and wired for monitoring.
    5. THhis one is my ONLY patient until they "Wake-up"

    I think all these steps may save me from a bad decision (and the patient from the same). I do the same things, the same way, every time!

    Sure, we can banter the short metabolisms of the drugs - but, I prepare for the worst. BVM may be fine, but risky in some cases.


    I can manage ANY airway. No question. This has zero to do with my nursing background. My paramedic background makes this possible.

    Hey there CardiacRN - I bet you are blessed to be working in a facility that allows nurses a shot at intubations. Lucky girl. Any problems, how many attempts/placements do the RN's get each quarter. What about competency - do you guys get to go to the OR for a day to "catch up" if you haven't gotten "tubes' in your units??

    Anyway.I still hate Diprovan. But, I do love a good discussion.

    Practice SAFE!
  11. by   TRAMA1RN
    For PA nurses
    In response to your question about the RN administering Diprivan for moderate sedation, the Registered Nurse Rules and Regulations Section 21.413 (d) states "As used in this subsection, "conscious sedation" is defined as a minimally depressed level of consciousness in which the patient retains the ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal commands. The registered nurse who is not a certified registered nurse anesthetist may administer intravenous conscious sedation medications, under Section 21.14, during minor therapeutic and diagnostic procedures ..." Section 21.17 states "The administration of anesthesia is a proper function of a registered nurse and is a function regulated by this section, this function may not be performed unless: (1) The registered nurse has successfully completed the education program of a school for nurse anesthetists ... (2) The registered nurse is certified as a Registered Nurse Anesthetist ..." Section 21.18 (a) states: "A registered nurse shall: (1) Undertake a specific practice only if the registered nurse has the necessary knowledge, preparation, experience and competency to properly execute the practice." This information can be found on the Board of Nursing website at www.dos.state.pa.us/nurse.

    This was recieved from my BON, still a little confusing, but this should help clear the matter up at least for PA nurses.
  12. by   S.T.A.C.E.Y
    One ER I was at only had one doc working at a time. The RNs could push push propofol only if the doc was there too, but it was required that an RT was present for all concious sedations. A couple of the docs there were so bad at dosing, that quite often the RT would have to do their thing since the pts respiratory drive had been knocked out. At the hospital I'm at now, some docs still use propofol for concious sedation, but they always have another doc present to manage the airway just in case--but i've never seen it needed. I've only really seen propofol used for RSI and concious sedation, never to maintain sedation. RNs can only push with doctor's presence.
  13. by   ERRN4EVER
    Our state BON has also recently stated that the use of Diprovan by nurses other that CRNA is prohibited.

    But it is still used in our ER. It is however never given by a nurse, it is administered by a one of the Paramedics. Reason being since they work directly for the Doctor group, and are considered Paramedic Extenders and work for and under the Doctor's License.

    Personally, I love the drug and wish the BON would reverse there decision, but dont see it happening.

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