Nurses Pushing Propofol for Conscious Sedation -Your Thoughts? - page 2

by *traumaRN* 21,234 Views | 67 Comments

I would be interested in getting feedback from GI nurses that are involved in propofol sedation in settings with and without anesthesia. Your thoughts and experiences please. Thank you, Randy... Read More


  1. 0
    I'm gathering from these comments that more research needs to be done. The article from 'eureka' has some odd study designs, so I question it. I think it's also interesting that less than half the states allow non-anesthesiology trained nurses to administer propofol...there should be a unanimous decision if you ask me.

    I just read an issue brief from Preventing Colorectal Cancer.Org http://www.preventingcolorectalcance...rief_Final.pdf

    and am convinced that propofol is the best option for sedation during CRC screenings, but the administration by trained personnel is crucial. It's insane that gastroenterologists can go to a weekend course in Vegas and come home certified in anesthesia. A rigorous training program or sticking to certified CRNA's/Anesthesiologists seems like the only responsible choice.
  2. 0
    Quote from AnneFromMD
    I'm gathering from these comments that more research needs to be done. The article from 'eureka' has some odd study designs, so I question it. I think it's also interesting that less than half the states allow non-anesthesiology trained nurses to administer propofol...there should be a unanimous decision if you ask me.

    I just read an issue brief from Preventing Colorectal Cancer.Org http://www.preventingcolorectalcance...rief_Final.pdf

    and am convinced that propofol is the best option for sedation during CRC screenings, but the administration by trained personnel is crucial. It's insane that gastroenterologists can go to a weekend course in Vegas and come home certified in anesthesia. A rigorous training program or sticking to certified CRNA's/Anesthesiologists seems like the only responsible choice.
    Anne,

    I agree with the majority of your post. More research does need to be done. Propofol does facilitate the procedure and should be more widely used in CRC screenings. We are talking about a practice that should only be attempted by highly trained practitioners.

    I think it is erroneous to draw the conclusion that if a state nursing board does or does not allow a practice, it is an indicator of what should be happening. As part of my job as an anesthesia consultant, providing training and CE for physicians, nurses, dentist etc... and assisting with the development of sedation programs for facilities, I communicate with state dental, medical and nursing boards across the country on a daily basis. Their job is to protect the public - that's it, and that is all they want to do. It is up to the practitioners to reach a consensus as to what the policy should be, not the state boards, you will never get a unanimous decision from 50 states on anything, nor should you.

    I'm not familiar with any "weekend Vegas courses" that certify gastroenterologists in anesthesia, but the main thing would be for them to have sufficient training and skill in airway management, better yet it makes more sense for the nurse to have the airway management skills.
    The propofol package insert clearly states:

    WARNINGS
    For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trained
    in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Patients should be continuously
    monitored, and facilities for maintenance of a patent airway, artificial ventilation, and oxygen enrichment and circulatory resuscitation must be immediately
    available.
    For sedation of intubated, mechanically ventilated adult patients in the Intensive Care Unit (ICU), DIPRIVAN Injectable Emulsion should be administered
    only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management.

    If the Dr. is doing the procedure, it is up to the nurse to monitor the patient (see underlined above)
    Now one would probably point out the first part of that statement that says " should be administered only by persons trained in the admin of GA" but upon closer look that is for general anesthesia and mac sedation. For a colonoscopy we are talking about conscious sedation (remember the continuum) Not to mention the fact that if you look up how many anesthesia providers there are in this country and divide that by the number of procedures done using propofol each year, you will have a better understanding of the problem.

    We need more nurses who are competent enough to administer this drug safely, that is done through training and continuing education.

    That's my soapbox opinion.

    Thank you,
    Randy

  3. 0
    You asked for opinions, I'm a med student (oldest in my class)..propofol is an induction anesthetic and should only be administered by anesthesiologists..nurses SHOULD NOT administer this drug. Personally, I would not be comfortable with a nurse (CRNA) doing my aneshtesia; I specify an MDA for safety. When I was a nurse, I thought that CRNA's did a great job; now that I have had a LOT more exposure I want an MDA doing my anesthesia, sedation etc..................
  4. 3
    Quote from laurentrilli
    You asked for opinions, I'm a med student (oldest in my class)..propofol is an induction anesthetic and should only be administered by anesthesiologists..nurses SHOULD NOT administer this drug. Personally, I would not be comfortable with a nurse (CRNA) doing my aneshtesia; I specify an MDA for safety. When I was a nurse, I thought that CRNA's did a great job; now that I have had a LOT more exposure I want an MDA doing my anesthesia, sedation etc..................
    Well I am glad that med school has totally brainwashed you.

    1. Propofol is a sedative, general anesthetic agent, & antiemetic.
    2. Since you know so much about propofol and are sure that only MDAs should administer it, can you tell me how many different formulations there are for propofol in the US? Which formulation(s) is safe for neonates, and which formulation(s) probably increases the severity of ARDS when used long term on ARDS patients?
    3. Instead of listening to the ASA and SDN propoganda why don't you actually quote some research that states that MDAs are safer than CRNAs.
    4. Have you ever been/completed CRNA school? That way you actually have some first hand knowledge of what you are talking about. I have trained med students during their anesthesia rotations on many occassions, and shared classes with med students. I also trained right beside MDA residents.
    5. Try reading some studies before making outrageous comments that have no merit. Feel free to dig up any that I missed. http://www.aana.com/Resources.aspx?id=666&terms=silber
    6. You obviously have no idea who delivers the vast majority of anesthesia in the US. I will give you clue it isn't MDAs. There isn't enough MDAs in the US to even come close to being able to delivering the amount of anesthesia needed in this country. A significant miniority of anesthesiologists don't even deliver anesthesia. They specialize in interventional pain management (a lot of time because it is very lucrative practice), become critical care specialists, specialize in regional anesthesia (and rarely set foot inside the OR) etc.
    7. Since we are stating opinions here: I would prefer a CRNA to do my anesthesia, and I will tell you why. CRNAs are trained to be systematic in their approach, to think outside the box when necessary, we give the majority of anesthesia, and we have been around longer as an organized profession. On the other hand anesthesiologists at most places rarely actually give anesthesia, they "supervise", MDAs in general are very sloppy, learn through trial and error what works best, and tend to be a lot more cavalier than most CRNAs.

    For everyone else's viewing pleasure see below:

    Pine Study in the AANA Journal
    [Pine, M, Holt, KD, Lou, YB. "Surgical Mortality and Type of Anesthesia Provider."
    AANA Journal. 2003;71:109-116.]






    In the April 2003 AANA Journal, Dr. Michael Pine, a board-certified cardiologist widely recognized for his expertise in analyzing clinical data to evaluate healthcare outcomes, and a team of researchers published the results of a groundbreaking study titled "Surgical Mortality and Type of Anesthesia Provider." The study analyzed the effect of different types of anesthesia providers—specifically Certified Registered Nurse Anesthetists (CRNAs) and physician anesthesiologists—on the death rates of Medicare patients undergoing surgery

    The results revealed that patients are just as safe receiving their anesthesia care from CRNAs or anesthesiologists working individually, or from CRNAs and anesthesiologists working together.

    A. Rationale for Undertaking Study
    According to the researchers, the study was undertaken:

    To attempt to answer lingering questions about surgical patients' safety related to types of anesthesia providers, even though estimates of anesthesia-related deaths today are as low as 1 in 200,000 to 300,000 cases. [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.]


    To provide state governors with valid scientific data to help them decide whether their respective states should opt out of the federal physician supervision requirement for nurse anesthetists. [Federal Register. Vol. 66, No. 219, pp. 56762-56769.] Without such data, governors must rely on older studies (see analyses of Bechtoldt and Forrest studies, pp. 6-9 in this booklet) or seriously flawed studies (see analysis of Silber/Pennsylvania study, pp. 21-28 in this booklet).
    B. Background
    The researchers studied 404,194 Medicare cases that took place from 1995-1997 in 22 states. Only cases with clear documentation of type of anesthesia provider were studied, and adjustments were made for differences in case mix, clinical risk factors, hospital characteristics, and geographic location. The types of surgical procedures included carotid endarterectomies, cholecystectomies, herniorrhaphies, mastectomies, hysterectomies, laminectomies, prostatectomies, and knee replacements.

    Groundbreaking Results. The Pine study yielded the following important findings:

    Mortality rates were similar for CRNAs and anesthesiologists working individually.


    There was no statistically significant difference in the mortality rate for CRNAs and anesthesiologists working together versus CRNAs or anesthesiologists working individually.


    There was no statistically significant difference in the mortality rate for hospitals without anesthesiologists versus hospitals where anesthesiologists provided or directed anesthesia care.
    C. Conclusions
    Pine et al. concluded the following:

    That while their findings differed from those of Silber et al. (see analysis of Silber/Pennsylvania study, pp. 21-28 in this booklet), they were consistent with earlier research and with current data which estimate that anesthesia-related deaths today are as low as 1 in 200,000 to 300,000 cases. [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.]


    That based on the surgical procedures included in the study, inpatient surgical mortality is not affected by whether the anesthesia provider is a CRNA or an anesthesiologist.
    Pine Versus Silber. The Silber/Pennsylvania study (see analysis on pp. 21-28 in this booklet), which was published nearly three years before the Pine study, contained glaring methodological deficiencies that Pine et al. endeavored to avoid. Specifically, approximately two- thirds of the cases which Silber et al. classified as not involving an anesthesiologist in the patient care either A) actually did have an anesthesiologist involved in some, but not all, of a patient's procedures, or B) had no bill for the anesthesia care (making it impossible to confirm whether an anesthesiologist was or was not involved).

    Further, cases in which anesthesiologists worked alone were not distinguished from those in which CRNAs and anesthesiologists worked together. Finally, only cases in one state—Pennsylvania—were included in the Silber study.

    This failure by Silber et al. to more accurately quantify the cases in which anesthesiologists were involved led the researchers to conclude that there was an increase of 2.5 deaths per 1,000 patients when an anesthesiologist was not involved in the case. This inflated ratio was alarmingly out of sync with the Institute of Medicine's (IOM's) published report that anesthesia mortality rates today are approximately 1 death per 200,000 to 300,000 anesthetics administered, a ratio also routinely cited by the American Society of Anesthesiologists (ASA). [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.] Had Silber et al. identified a more accurate (i.e., larger) number of cases as involving anesthesiologists, the ratio obviously would have been much different.

    Pine et al. sought to avoid the limitations that marred the Silber study by taking the following steps:

    Studying cases from 22 states, instead of just a single state.


    Using only cases that clearly identified the type(s) of anesthesia provider involved in the patient care.


    Distinguishing between care provided by CRNAs and anesthesiologists working together and care provided by anesthesiologists or CRNAs working individually.
    The results of the efforts by Pine et al. to attribute anesthesia care to the correct providers) was twofold: 1) The researchers attained data that is more consistent with current overall anesthesia-related mortality rates cited by the IOM, the ASA, and the American Association of Nurse Anesthetists, and 2) they found no statistically significant difference in mortality rates when anesthesia is given by a CRNA working individually, an anesthesiologist working individually, or CRNAs and anesthesiologists working together.

    Pine Rebuttal to ASA Comments on Pine Study. In May 2003, the "ASA Preliminary Comment on Pine Study" was released. In a gross misinterpretation of the Pine study results, the ASA claimed that Pine et al. found 38 deaths per 10,000 cases in hospitals where anesthesiologists administered or directed all anesthetics, and 45 deaths per 10,000 cases when an anesthesiologist was not involved. From this, ASA suggested that "the Pine study data support what most recent studies have found—that anesthesiologists improve anesthesia outcomes." [ASA Preliminary Comment on Pine Study. Lobbying day handout. May 2003.]

    That same month, Dr. Pine wrote "Response to 'ASA Preliminary Comment.'" He stated that for the ASA to suggest that his study's data supports "the conclusion 'that anesthesiologists improve anesthesia outcomes'" is evidence of "either a woeful ignorance of the basics of data analysis or a cynical contempt for the intelligence of the intended audience." Defending his study, Dr. Pine wrote that his data actually found 34 deaths per 10,000 cases when CRNAs administered anesthesia while working together with anesthesiologists, and 45 deaths per 10,000 cases when anesthesiologists worked without a CRNA. He pointed out that this difference of 11 deaths per 10,000 cases was "even more impressive than the 7 deaths per 10,000 cases" difference cited by the ASA (see paragraph above), and that based on this data, "the AANA could claim that anesthesiologists should not be permitted to administer anesthesia unless a CRNA is present to prevent the excess mortality associated with physicians attempting to engage in the practice of nursing. However, unlike the ASA, the AANA has enough respect for its audience to avoid making such unwarranted claims."

    Dr. Pine reiterated his study's findings that after risk adjustment there is no statistically significant difference between CRNAs working individually, anesthesiologists working individually, or CRNAs and anesthesiologists working together. He added that his study's data support the conclusion that even when there are two anesthesia providers working together, substituting an anesthesiologist for a CRNA does nothing to lower the mortality rate. [Pine, M. Response to "ASA Preliminary Comment."www.aana.com. May 2003.]
    PMFB-RN, NRSKarenRN, and CNL2B like this.
  5. 0
    "Gastroenterologists State Their Case

    The societies’ position supports the administration of propofol—a fast-acting, non-analgesic sedative—by non-anesthesiologists based on the outcomes of 29 studies and more than 460,000 cases, most of which involved nurse-administered propofol sedation. An updated article on the safety experience with endoscopist-directed propofol was published in October and now includes more than 600,000 cases (Gastroenterology 2009;137:1229-1237); the position statement was published in all four societies’ journals in December 2009 (Am J Gastroenterol 2009;104:2886-2892; Gastroenterology 2009;137:2161-2167; Gastrointest Endosc 2009;70:1053-1059; Hepatology 2009;50:1683-1689)."

    http://www.anesthesiologynews.com/in...ticle_id=14584

    There is some outdated/inaccurate information about CRNAs in the article, but otherwise the article gives a decent update of the controversy of propofol being used in the GI suite.
  6. 0
    Here is Dr. Rex, the director of endoscopy at Indiana University, discussing propofol administration by non-anesthesia providers.


    ERROR: If you can see this, then YouTube is down or you don't have Flash installed. View this video at YouTube
  7. 0
    Here is a link to a new study just released - As of March 1, 2010 done at Washington University in St. Louis MO.

    http://www.modernmedicine.com/modern...tegoryId=40127
  8. 0
    thanks for taking the time to reply to the authority on the subject - "Med student." Interestingly, just today, I was assigned to provide morning breaks and then lunches in a mixed CRNA/MDA staffed busy OR. After going room to room all day and also having done this a few times prior to today, what I find very interesting is how sloppy some MDAs are in pt care & organization. Few examples... pt eyes taped vertically with very thin tape so more than 50% of the eye is exposed, saw that a few times today in MDA rooms I relieved. Example again, numerous syringes uncapped/uncovered with meds scattered all about. Syringes left along side the pts arm where the IV is (i.e., neosynephrine, versed) and not one syringe was labeled with a date, concentration or dosage. Shame, Shame. how lazy can we get. CRNAs seem much more conscientous in this regard. I observed MDAs regularly give intubating dose of propofol without Lido and watch the pt grimace in pain. Again, the Lido is already drawn up for them, labeled and sitting right next to the propofol they slammed in. it is just lazy, anectdotal anesthesia practice. Either we care about pt safety 100% or not. This type of practice makes anesthesia all around look bad.
  9. 0
    Quote from freespirit2011
    Very interesting....non-anesthesiologists administering propofol? Totally unsafe.. And this includes unsupervised nurses (CRNA also)..
    Care to back up your statements with any research/proof? You can't so stop trolling.
  10. 0
    We use it frequently in our ED to reduce dislocations etc. We just have a nurse that's accredited in Advance Life Support and Doc on hand.


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