Nurses Pushing Propofol for Conscious Sedation -Your Thoughts?

allnurses Guide · May 18, 2011

Advertising or personal attacks are NOT allowed.
This CRNA with a MSN has done a terrific job representing a provider's perspective. He (I assume) couldn't have done a better job if he were a lawyer for a provider org or drug company.
Perhaps the difficulty in communicating also has to do with the differences in corpus callosum. I will sign off this thread now since I have not received any other responses.

Fair enough I will quit antagonizing, but there are two sides to every story. Maybe next time you can find a provider who will communicate better.

There are many ways that sedation for colonoscopies can and are done. The overall method that has shown to have the best outcomes is propofol sedation with or without small amounts of versed and fentanyl or Demerol. One of the biggest areas of research right now in anesthesia is POCD (postoperative cognitive dysfunction). Propofol has shown to offer fastest return to baseline cognitive function. The reason I say all this is because I would bet most providers don't take the time to explain these things to patients or take the time to build rapport with their patients.

PMFB-RN, RN · May 18, 2011

My hospital has a protocal for using propofol for sedation by regular (non CRNA) ICU, ER and Rapid Response nurses who have gone through a hospital training program.

I use it all the time for cardioversions, reductions of dislocated shoulders, GI procedures done in the ICU etc.

foraneman · May 19, 2011

I did my Masters research looking at sedation practices for GI procedures. I am sorry your outcome was less than satisfactory, but I see this all the time where patients come in wanting all these things that are out of the normal for that particular place and expect excellent outcomes. These patients set themselves up for failure before the procedure even starts.

I have to disagree. It is not up to a patient to know what is or is not 'out of the normal' for a particular clinical setting. It is up to the practitioners to educate the patient, whether health professional or not, as to what their capabilities or particular clinical protocols are. Do you do colonoscopies without propofol? SIMPLE question. Can it be done with only fentanyl? SIMPLE question. Can it be done with ped colonoscope? SIMPLE question.

All deserve simple, courteous and direct answers. Patients asking questions and making requests for care should never be labeled as 'setting themselves up for failure'. I might highlight the fact that this scenario is ANOTHER reason why RN's should NEVER be administering propofol sedation for this or any other procedure. ONLY a trained anesthesia provider, like a CRNA, should do so. ANY CRNA could take this patient request in stride and titrate fentany;/versed/demerol/dilaudid/whatever if the patient did not want propofol. I might point out that the propofol in the CRNAs hands would however be the best patient choice in most cases...with a touch of fentanyl no doubt. I don't say this to 'protect turf' or $$$...I am saying I would NEVER in a million years let an RN sedate myself or a family member with propofol...EVER EVER EVER...that's because I HAVE seen the 1 in 500...or 1000....or whatever u want to claim...that after a 'little' propofol turns blue, vomits bile and has a laryngospasm while the non-anesthesia provider freaks out pushing the big button on the wall.

Since propofol has no analgesic properties you either dose to a near plane of general anesthesia to avoid any pain recall or you add an analgesic. The fact that the OP did not have ANY effect from the 'fentanyl' here is rather concerning. If one adds the inappropriate behavior of the RN to the mix you have to wonder about the possibility of diversion for self administration.

foraneman · May 19, 2011

And I NOW I better add this before I catch hell.....IF an RN has undergone a VERY specialized training program which results in their being PROFICIENT at sedating, paralyzing and intubating patients, with full stomachs and difficult airways, then they likely can safely administer propofol sedation. NO GI nurse has that training except as a fluke from previous experience.

Regarding sedation of ER, ICU and rapid response patients....I would be interested in hearing how many are intubated, or are sedated with the goal of intubating, versus just sedated. Full stomachs sedated with propofol? Since all these patients WOULD be full stomachs....

PMFB-RN, RN · May 19, 2011

Regarding sedation of ER, ICU and rapid response patients....I would be interested in hearing how many are intubated, or are sedated with the goal of intubating, versus just sedated. Full stomachs sedated with propofol? Since all these patients WOULD be full stomachs....

*** None are sedated with a GOAL of intubating. They are not all full stomachs either. I don't know why you would think / say that. We usually keep them NPO prior to cardioversions, EGDs and other planned procedures.

I have to do 30 supervised intubations each year to maintain my competency but I am only part time. Full time people have to do fewer. All of us also do or used to do transport, either ground or flight or both.

Propofol and propofol / fentanyl sedation has been working very well in our faciliety. I don't think anyone would want to go back to versed & fentanyl only.

They do not use propofol in our GI lab unless either the rapid response nurse does it (happens occasionaly at NOC but unusual) or a CRNA (more common during the day). The GI nurses still use versed / fentanyl.

I should add that now, after 4 years of using propofol for sedation there is talk of expanding it's use to the GI lab by BI nurses but has not happend yet. Also we have a CRNA a phone call way with a resonse time from their call room of (usally) much less than 5 min.

allnurses Guide · May 19, 2011

Foranmen I agree it is not outrageous or unusual for patients to request x,y,z for procedures, but if that clinic is only used to doing it x way that is when you know there is going to be a problem. Where an anesthesia provider could use just about any of these medications alone or in combination and have positive outcomes normal RNs and endoscopists aren't going to have that training to do that and the outcome is more than likely going to be less than satisfactory. It should have been a red flag right away for any health professional no matter what their speciality when a clinic goes out of their way to try push doing a procedure only one way. That is the time to either agree, come to some middle ground or just walk away. I personally don't want to be the guinea pig while they try to figure out how to dose a medication based on what is in their nursing drug manual.

The problem with NAPs is that all the studies done with 300k+ patients has shown NAPs to be safe and effective. As a professional organization (the AANA or ASA) has not found any research/evidence that shows NAPs to be unsafe. This to me is me is very biased since our whole argument as a profession is that CRNAs are just as safe and effective as anesthesiologists is based EBP.

I realize as a CRNA that is not popular statement to make, but if we are going to try to deny other professional organizations from using propofol then we need to come up with some kind of research that proves our point other than just our belief that is unsafe for RNs to administer propofol sedation.

allnurses Guide · May 19, 2011

I HAVE seen the 1 in 500...or 1000....or whatever u want to claim...that after a 'little' propofol turns blue, vomits bile and has a laryngospasm while the non-anesthesia provider freaks out pushing the big button on the wall.
Since propofol has no analgesic properties you either dose to a near plane of general anesthesia to avoid any pain recall or you add an analgesic. The fact that the OP did not have ANY effect from the 'fentanyl' here is rather concerning. If one adds the inappropriate behavior of the RN to the mix you have to wonder about the possibility of diversion for self administration.

Yes, I am sure patients have had bad outcomes with NAPs (not from these carefully controlled studies that are out there, but I am sure it happens), but because of its unique properties propofol has been shown to have less adverse reactions in NAPs than using traditional combinations (Versed, Fentanyl and/or Demerol).

I think this is one side to the story only, but in my opinion the clinic did not do their job in properly communicating with the patient. 75mcg of Fentanyl is nothing to a lot of patients especially when you don't know what other medications they are on, if they are a fast metabolizer, red headed etc, and especially when it is used as the sole medication. Then you add on top of that the patient is already extremely anxious dealing with a clinic that has seemingly done little to nothing to ease the patient's anxiety I don't see that 75mcg is an unreasonable dose. I would actually consider 75mcg a little on the low side depending on how fast the procedure went. I would never think to suggest that someone is diverting the drug especially from a clinic that probably doesn't use fentanyl much in the first place if they went to so much trouble trying to convince the patient to use propofol sedation instead.

health professinal · May 19, 2011

“it is also interesting to note that many countries do not routinely do sedation/analgesia at all for colonoscopies, because it isn't considered that painful. a lot of what we perceive is based on cultural perception”.

foraneman, what do you think of that (wtbcrna’s) response related to the experience of pain reported?:”... the pain could make you tighten up, causing the colon to contract and exacerbate the pain. since i have ibs, it’s possible that my colon was already in spasm [thus contributing to the pain]”.

as you put it, “since propofol has no analgesic properties you either dose to a near plane of general anesthesia to avoid any pain recall or you add an analgesic”, this was a concern i expressed but the doc essentially denied this to be true.

ps. before he “agreed” to my request for fentanyl and to my refusal of propofol, he insisted dismissively, “you’ll just have to trust me”.

allnurses Guide · May 20, 2011

The way of perceiving, expressing, and controlling pain is one of these learned behaviors that, when manifested, is culture-specific (2). Moreover, cross-cultural data gathered by anthropologists during their fieldwork--the anthropological term for research--show that, while few universals exist between and among discrete societies, from the small, undeveloped, primitive ones to the large, developed, industrialized ones, pain is one of these universals. Thus, while the stimulation of pain fibers to tell the brain that something is wrong is the same among all human beings, the perceptions and control of pain vary from society to society.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1276504/

Cultural pain perception is well known and studied phenomenon.

health professinal · May 20, 2011

i directed this question to foraneman. i am already aware of the issue of "cultural pain perception". i have a high pain threshold. i am interested in foraneman's and others' opinions specifically re the possibility that ibs spasms might cause pain during a colonoscopy.

allnurses Guide · May 20, 2011

i directed this question to foraneman. i am already aware of the issue of "cultural pain perception". i have a high pain threshold. i am interested in foraneman's and others' opinions specifically re the possibility that ibs spasms might cause pain during a colonoscopy.

public forum so your stuck with me.......especially when you use one of my posts and make a comment on it.

allnurses Guide · May 20, 2011

http://www.nature.com/ajg/journal/v104/n12/abs/ajg2009429a.html

Decreased pain with colonoscopies with warm water intake especially for patients with IBS.