Use of Diprovan in your ER

S.T.A.C.E.Y, LPN · Dec 19, 2007

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.

ERRN4EVER · Dec 20, 2007

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. :monkeydance:

berry · Dec 20, 2007

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

WOW what a contradiction first off you can not handle any airway all the time and that cowboy mentality is why an incredible number of ERs have an open lawsuit at any given time (not related to propofol but by decision made by mds and rns who feel they are the on top of everything). The first step that should be made to preserve you and your patients safety is to not induce general anesthesia outside the OR this can become a very slippery slope when using propofol especially in combination with benzos and narcotics.

Moderate sedation/analgesia ("conscious sedation") is defined as: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

When you cross over into deep sedation or general anesthesia and you begin to have respiratory and cardiovascular problems. You don't have what you need at hand to fix problems most (none that I have used) crash carts don't have neosynephrine or ephedrine to deal with hypotension (common problem with propofol). While I in no way want to demean your or any other paramedics airway skills you are in NO way the airway expert. As a srna over the last 2 years I would bet dollars to dimes I have intubated more patients than you have in the last 5-10 years. I am the one at the head of the bed (with back up crna or ologist) when the trauma code runs in not the ER doc. Paramedics maybe intubated on average .5-1 patients a month you may personally do more but many go 1-2 months without intubating a patient while anesthesia providers may intubate 3-5 patients every day in the OR even so you will still not find the lack of respect in regards to being able to handle every airway.

The bottom line is it is you patients life on the line and your license. As of today the manufactures of propofol sell it as a drug for

Induction of general anesthesia in adult patients and pediatric patients > 3 years of age

Maintenance of general anesthesia in adult patients and pediatric patients >2 months of age

Intensive Care Unit(ICU) Sedation for intubated, mechanically ventilated adults.

Medic/Nurse, BSN, RN · Dec 20, 2007

Well, well, well.

Hey there berry -

"Cowboy" NREMT-P/RN here. I'm sure that you did not mean to be "demeaning" - it just slipped out. :eek:

I generally avoid the "my _____ is _____ than your _____" contests because NO ONE WINS!

But, I will CLEAR up some of the conclusions you jumped to --- for your BENEFIT, of course. (You never know, the next paramedic type person you don't "mean to demean" may not be so secure!)

I remain resolute in the fact that I CAN manage ANY airway. Period. You took the leap to conclude that by "manage" that means dropping the ET tube. Sure, an ETT is one way to "manage" an airway (and I generally prefer it). However, I have other options if the patient needs 'em. Managing the airway only means that I maintain a route for ventilation and optimal oxygenation of a patient - reducing/elimination of the aspiration risk is included in the package! Simple. I have a number of methods available for achieving airway management!

As to the #'s game - I declined to play above (but, be careful as to your number estimates - it is clear that you plucked that # from some reference, it may not apply to me - or anyone else I know!). As to the conditions of practice, I will add this:

My patients:

* are never NPO, often have full bellies

* have a wide variety of clinical presentations, many of which necessitate RSI and a few need crash airways. I even have to nasally place an ETT ever so often.

* never present to me in a well lit comfortable room

* have a wide variety of dental/oral issues. Dentures and removable appliances are in place, meth mouth is more common than I would like (tends to eliminate parts of the soft palate, lots of icky tissue)

* frequently have c-spine precautions in place (a bit more restrictive)

* in trauma patients, the derangement of the "normal anatomy" is only limited by your imagination

Anyway, I hope that you get the point. You the "SRNA" and me the "Paramedic/RN" have different practice realities. But the one common reality we have to share is the:

ABILITY TO MANAGE ANY AIRWAY. (Note I did not specify intubation!)

I will agree that AIRWAY MISMANAGEMENT is a primary reason for litigation, but careful about the accusations of "cowboy mentality" that must be why so many "ER's have open lawsuits". How do you know this???

A professional recognizes that other professionals have certain areas of expertise. A certain amount of courtesy is expected. To blanket "paramedics" as you did in your post could be considered offensive to some. However, to your credit you do admit to having backup by a CRNA or MD.

Anyway, FYI - we do agree on the Diprovan issue. I hate the drug. It is generally not useful to my practice. I have better options for RSI induction and post intubation sedation. End of story. But, occasionally we do get a call to transfer a vented patient that has Diprovan running. I generally will have to supplement it (something about those jet engines, the vibration, stimulation brought on by extreme conditions) with additional medications just to keep the patient comfortable. Often, I just turn it off and use a more appropriate medication regimen.

Practice SAFE!

cardiacRN2006, ADN, RN · Dec 21, 2007

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.

Ummm, who said I was practicing dangerously? Who said oversedating patients until apneic was OK?

I swear sometimes people just scan posts and don't actually read them.

I said, and have always said, that RNs shouldn't be allowed to give propofol to non-intubated patients. I also said that you don't NEED to always intubate if a pt becomes apenic D/T propofol.

Please re-read.

Also, bagging a patient for a few minutes IS really not a big deal. Sometimes, pts get accidently extubated while on better things then propofol (things that don't wear off in a few minutes.)

Guess what? We bag them until we re-intubate. In the case of propofol, we bag them until we see how they fly. And most, if not all, of my pts have a belly full of tube feeing.

That's why it's called Basic life support. And in my hospital, we have to get certified every year. I'd hope that every nurse is capable of providing basic emergency care.

DutchgirlRN, ASN, RN · Dec 21, 2007

Our CRNA's use Diprovan in combination with other meds to anesnitize patients for MRI's. Several pt's have had an "awake anesthesia" experience, awake enough to know they were in the scanner and were terrified yet paralyzed, unable to move, unable to talk. Any comments?

TRAMA1RN · Dec 21, 2007

If an Rn in the ER is ACLS certified and cannot protect an airway she/he better get out of my ER. When Diprovan is used for MODERATE sedation you are NOT totally putting them into a complete sedative state, that would not be moderate sedation. Our patients are still able to move and respond, there is always an airway/trauma bag immediately available as well as intubation equipment. Again if you work as an RN in the ER you better be ACLS certified and competant, or get out of the ER, again this goes bag to too many inexperienced RN's working in the ER. Give me a medic in the ER anyday over inexperienced RN. I know my medics can handle an airway most better than MD's.

CritterLover, BSN, RN · Dec 21, 2007

when diprovan is used for moderate sedation you are not totally putting them into a complete sedative state, that would not be moderate sedation.

but see, that is the thing.

diprivan is not indicated for moderate sedation.

its therapeutic class is "general anesthetic." it is indictated for "mac," but that is a deeper level of sedation, administered by an anesthesia provider.

GilaRRT · Dec 21, 2007

http://www.astrazeneca-us.com/pi/diprivan.pdf

The med insert for Diprivan from AstraZeneca.

Diprivan has three accepted uses.

"1) Induction of general anesthesia in adult patients and pediatric patients > 3 years of age

2) Maintenance of general anesthesia in adult patients and pediatric patients >2 months of age

3) Intensive Care Unit(ICU) Sedation for intubated, mechanically ventilated adults."

So, when we sedate patients in the ER for procedures, Diprivan is being used off lable for these procedures.

Again, I must emphasize a prior point. You need to think long and hard if you really think a BLS class constitutes adequate airway management education. I do not remember learning about airway assessment techniques such as the LEMON exam, or about difficult airway options, the use of rescue airways, and how to manage crash and failed airways in my last BLS class.

GilaRRT · Dec 21, 2007

Oops, DutchgirlRN, I did not answer your question above. I would suspect a non depolarizing neuromuscular blocker was given to provide long acting paralysis. If this is the case, it would be possible for some of the short acting sedatives and narcotics (diprivan and fentanyl) to wear off before the paralytic. Or a sub therapeutic dose of of sedation and analgesia was given or maintained. In any event, it may be very difficult to assess adequate sedation and analgesia in a paralyzed patient. Vital signs changes can help. I am not sure if BIS monitors are used or for these types of procedures.

Most of my intubated patients are in rough shape, so I try to be as liberal as possible with sedation and analgesia to prevent this problem.

sfsn · Dec 22, 2007

In our ER Diprovan is considered deep sedation, not moderate. Therefore we as RNs can not administer it. It can only be pushed by a MD. It is preferrable to have 2 MDs present (one to reduce the hip and one to push the Diprovan and manage the airway if needed). I've never seen it given in our ER unless 2 MDs were in the room. But I have heard that ENA is trying to promote policies that allow administration of deep sedation by RNs.

JoeCRNA · Dec 24, 2007

Well, well, well.
Hey there berry -
"Cowboy" NREMT-P/RN here. I'm sure that you did not mean to be "demeaning" - it just slipped out.
I generally avoid the "my _____ is _____ than your _____" contests because NO ONE WINS!
But, I will CLEAR up some of the conclusions you jumped to --- for your BENEFIT, of course. (You never know, the next paramedic type person you don't "mean to demean" may not be so secure!)
I remain resolute in the fact that I CAN manage ANY airway. Period. You took the leap to conclude that by "manage" that means dropping the ET tube. Sure, an ETT is one way to "manage" an airway (and I generally prefer it). However, I have other options if the patient needs 'em. Managing the airway only means that I maintain a route for ventilation and optimal oxygenation of a patient - reducing/elimination of the aspiration risk is included in the package! Simple. I have a number of methods available for achieving airway management!
As to the #'s game - I declined to play above (but, be careful as to your number estimates - it is clear that you plucked that # from some reference, it may not apply to me - or anyone else I know!). As to the conditions of practice, I will add this:
My patients:
* are never NPO, often have full bellies
* have a wide variety of clinical presentations, many of which necessitate RSI and a few need crash airways. I even have to nasally place an ETT ever so often.
* never present to me in a well lit comfortable room
* have a wide variety of dental/oral issues. Dentures and removable appliances are in place, meth mouth is more common than I would like (tends to eliminate parts of the soft palate, lots of icky tissue)
* frequently have c-spine precautions in place (a bit more restrictive)
* in trauma patients, the derangement of the "normal anatomy" is only limited by your imagination
Anyway, I hope that you get the point. You the "SRNA" and me the "Paramedic/RN" have different practice realities. But the one common reality we have to share is the:
ABILITY TO MANAGE ANY AIRWAY. (Note I did not specify intubation!)
I will agree that AIRWAY MISMANAGEMENT is a primary reason for litigation, but careful about the accusations of "cowboy mentality" that must be why so many "ER's have open lawsuits". How do you know this???
A professional recognizes that other professionals have certain areas of expertise. A certain amount of courtesy is expected. To blanket "paramedics" as you did in your post could be considered offensive to some. However, to your credit you do admit to having backup by a CRNA or MD.
Anyway, FYI - we do agree on the Diprovan issue. I hate the drug. It is generally not useful to my practice. I have better options for RSI induction and post intubation sedation. End of story. But, occasionally we do get a call to transfer a vented patient that has Diprovan running. I generally will have to supplement it (something about those jet engines, the vibration, stimulation brought on by extreme conditions) with additional medications just to keep the patient comfortable. Often, I just turn it off and use a more appropriate medication regimen.
Practice SAFE!

Sounds COWBOY to me...