Nurses Pushing Propofol for Conscious Sedation -Your Thoughts?

  1. 0
    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
  2. 67 Comments so far...

  3. 0
    Do a search. There is a very long thread from the past on this subject that will give you all the info you could ever want.
  4. 0
    I will do that.

    Thank you,

    Randy
  5. 0
    Most of the previous posts are from several years back.

    "Times are changing" It would be interesting to see some current comments.

    Thank you,
    Randy
  6. 0
    Quote from SedationConsulting
    Most of the previous posts are from several years back.

    "Times are changing" It would be interesting to see some current comments.

    Thank you,
    Randy
    There are numerous studies on nurse administered propofol sedation/NAPS. My group actually did our Masters research project/literature review comparing different sedation strategies in the GI clinic with and without the use of propofol.

    The last I knew there were about 22 states that allowed RNs(not CNRAs) to administer propofol for moderate sedation. The research is overwhelming in the consensus that NAPS is safe under the right conditions/dosages.

    Is there something particular you are wanting to know?
  7. 0
    I asked a similar question in my post "lower endoscopy usual practice". I discussed conscious sedation practices for colonoscopy and I was surprized at the opinions that I got; I was mainly interested in unsedated exams but got a lotof info on propofol. The Chief GI doc said that patients overwhelmingly preferred propofol to the benzo/narcotic combination, but they didn't do many cases with propofol because it required a CRNA to push it and that added an unreasonable amout of money to the bill. He also said that it was often difficult to keep things on schedule because they were constantly waiting of the CRNA to show up to administer the drug. What surprized me was his opinion that a patient deeply sedated (ie with propofol) is more likely to get perforated that a lightly sedated or unsedated patient. Nurses are not permitted to push propofol in our hospital; a while back one of the CRNA's was telling me that the new drug fospropofol may be approved to be administered by non-CRNA's...which makes little sense to me since fospropofol is metabolized into propofol.
  8. 0
    Quote from laurentrilli
    I asked a similar question in my post "lower endoscopy usual practice". I discussed conscious sedation practices for colonoscopy and I was surprized at the opinions that I got; I was mainly interested in unsedated exams but got a lotof info on propofol. The Chief GI doc said that patients overwhelmingly preferred propofol to the benzo/narcotic combination, but they didn't do many cases with propofol because it required a CRNA to push it and that added an unreasonable amout of money to the bill. He also said that it was often difficult to keep things on schedule because they were constantly waiting of the CRNA to show up to administer the drug. What surprized me was his opinion that a patient deeply sedated (ie with propofol) is more likely to get perforated that a lightly sedated or unsedated patient. Nurses are not permitted to push propofol in our hospital; a while back one of the CRNA's was telling me that the new drug fospropofol may be approved to be administered by non-CRNA's...which makes little sense to me since fospropofol is metabolized into propofol.
    Fospropofol still has the same labeling that propofol has ie. not to be used for sedation by non anesthesia providers.
    I have heard the same thing about higher potential for bowel perforation from another GI physician, but just because you give propofol doesn't mean it has to be deep sedation. You can titrate propofol to give any level of sedation you want. Most anesthesia providers are very comfortable with deep sedation, so we often choose deep sedation over moderate sedation. Deep sedation is often easier to deal with/obtain than moderate sedation.
  9. 0
    Quote from wtbcrna
    There are numerous studies on nurse administered propofol sedation/NAPS. My group actually did our Masters research project/literature review comparing different sedation strategies in the GI clinic with and without the use of propofol.

    The last I knew there were about 22 states that allowed RNs(not CNRAs) to administer propofol for moderate sedation. The research is overwhelming in the consensus that NAPS is safe under the right conditions/dosages.

    Is there something particular you are wanting to know?
    I would be very interested in seeing the results of your research project/literature review comparing different sedation strategies in GI clinics. My business partner is an anesthesiologist with a background in research, He started using propofol in a research setting at a major university hospital for computer controlled infusions back in 1991. He feels that in the proper hands it is a wonderfully effective drug and should be more widely used by GI Dr.s, as I am sure you are aware as a CRNA, we even get requests from dentists who want to examine its use in prolonged dental procedures that would require moderate sedation.

    According to this article http://www.eurekalert.org/pub_releas...-gsr120209.php
    over 600,000 cases by GI docs have been done safely.

    The main points being proper training and patient selection are crucial to safe practice.
    Proper training is pretty vague. The patient selection, pharmacology, pharmacokinetics, synergistic effects, plasma sensitive half times etc... all of that can be taught in a didactic setting.
    What is the best way to provide advanced airway management training short of see one, do one, teach one which is the training I received in the military?
  10. 0
    Quote from SedationConsulting
    I would be very interested in seeing the results of your research project/literature review comparing different sedation strategies in GI clinics. My business partner is an anesthesiologist with a background in research, He started using propofol in a research setting at a major university hospital for computer controlled infusions back in 1991. He feels that in the proper hands it is a wonderfully effective drug and should be more widely used by GI Dr.s, as I am sure you are aware as a CRNA, we even get requests from dentists who want to examine its use in prolonged dental procedures that would require moderate sedation.

    According to this article http://www.eurekalert.org/pub_releas...-gsr120209.php
    over 600,000 cases by GI docs have been done safely.

    The main points being proper training and patient selection are crucial to safe practice.
    Proper training is pretty vague. The patient selection, pharmacology, pharmacokinetics, synergistic effects, plasma sensitive half times etc... all of that can be taught in a didactic setting.
    What is the best way to provide advanced airway management training short of see one, do one, teach one which is the training I received in the military?
    lol...I am military trained CRNA. Here is my reference list. Take a look at the meta-analysis by Qadeer and then there is another article by Walker et al. where an anesthesiologist set up sedation training for nurses and they did a 4yr prospective study on over 9K patients.

    References
    American Association of Nurse Anesthetists & American Society of Anesthesiologists (Producer). (2004). AANA & ASA Joint Statement on Nurse Administered Propofol Sedation [Video file]. Retrieved from http://www.aana.com/news.aspx?ucNavM...a+asa+propofol
    American Association of Nurse Anesthetists (1996). Considerations for Policy Guidelines for Registered Nurses Engaged in the Administration of Sedation and Analgesia . Retrieved March 28, 2008, from http://www.aana.com/resources.aspx?u...enuID=6&id=706
    Mackenzie, N., & Grant, I. (1987). Propofol for Intravenous Sedation. Anesthesia, 42(), 3-6.
    Stoelting, R. K., & Hillier, S. C. (2006). Pharmacology & Physiology in Anesthetic Practice (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
    Aisenberg J, Cohen LB, Piorkowski JD, Jr. (2007). Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications. American Journal of Gastroenterology, . 102(4), 707-713.
    Akin A, Guler G, Esmaoglu A, Bedirli N, A B. (2005) A comparison of fentanyl-propofol with a ketamine-propofol combination for sedation during endometrial biopsy. Journal of Clinical Anesthesia. (17), 187–190.
    Bentley JB, Borel JD, Nenaad RE et al. (1982). Age and fentanyl pharmacokinetics. Anesthesia & Analgesia. 61: 968-971.
    Brunton LB, Lazo JS, Parker KL. (2006). Goodman & Gilman’s The Pharmacological Basis of Therapeutics (11th edition). New York: McGraw-Hill.
    Cohen LB, Dubovsky AN, Aisenberg J, Miller KM. (2003). Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist. Gastrointestinal Endoscopy, 58(5), 725-732.
    Cohen LB, Hightower CD, Wood DA, Miller KM, Aisenberg J. (2004). Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endoscopy, 59(7), 795-803.
    Fanti L, Agostoni M, Arcidiacono PG, et al. (2007). Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomized controlled trial. Digestive and Liver Disease, 39(1), 81-86.
    Fanti L, Agostoni M, Casati A, et al. (2004). Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP. Gastrointestinal Endoscopy, 60(3), 361-366.
    Gasparovic S, Rustemovic N, Opacic M, et al. (2006). Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: a three year prospective study. World Journal of Gastroenterology, 12(2), 327-330.
    Harrington L. (2006). Nurse-administered propofol sedation: a review of current evidence. Gastroenterology Nursing, 29(5), 371-383; quiz 384-375.
    Heuss LT, Inauen W. (2004). The dawning of a new sedative: propofol in gastrointestinal endoscopy. Digestion, 69(1), 20-26.
    Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. (2003). Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases. Gastrointestinal Endoscopy., 57(6), 664-671.
    Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. (2003). Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients-a prospective, controlled study. American Journal of Gastroenterology, 98(8), 1751-1757.
    Langley, M.S. & Heel, R.C. ((1998). Propofol. A Review of its pharmacodynamic and pharmacokinetic properties and use as an intravenous anesthetic. Drugs., 35, 334-372.
    Leffler TM. (2004). Propofol for sedation in the endoscopy setting: nursing considerations for patient care. Gastroenterology Nursing, 27(4), 176-180; quiz 180-171.
    Levitzky BE & Vargo JJ. (2008) Fospropofol disodium injection for the sedation of patients undergoing colonoscopy. Therapeutics and Clinical Risk Management, 4(4), 733-738.
    Lubarsky DA, Candiotti K, Harris E. (2007). Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. Journal of Clinical Anesthesia, 19(5), 397-404.
    Meining A, Semmler V, Kassem AM, et al. (2007). The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam. Endoscopy, 39(4), 345-349.
    Moos DD. (2006). Propofol. Gastroenterology Nursing, 29(2), 176-178.
    Qadeer MA, Vargo JJ, Khandwala F, Lopez R, Zuccaro G. (2005). Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis. Clinical Gastroenterology & Hepatology, 3(11), 1049-1056.
    Rex DK. (2006). Review article: moderate sedation for endoscopy: sedation regimens for non-anesthesiologists. Alimentary Pharmacology & Therapeutics, 24(2), 163-171.
    Rex DK, Heuss LT, Walker JA, Qi R. (2005). Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology, 129(5):1384-1391.
    Riphaus A, Wehrmann T. (2007). Sedation, surveillance and preparation. Endoscopy, 39(1), 2-6.
    Rudner R, Przemyslaw J, Plotr K, et al. (2003). Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy. Gastrointestinal Endoscopy, vol. 57. No. 6, 657-663.
    Saenz-Lopez S, Rodriguez Munoz S, Rodriguez-Alcalde D, et al. (2006). Endoscopist controlled administration of propofol: an effective and safe method of sedation in endoscopic procedures. Rev Esp Enferm Dig, 98(1), 25-35.
    Sieg A. (2007). Propofol sedation in outpatient colonoscopy by trained practice nurses supervised by the gastroenterologist: a prospective evaluation of over 3000 cases. Z Gastroenterology, 45(8), 697-701.
    Ulmer BJ, Hansen JJ, Overley CA, et al. (2003). Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists. Clinical Gastroenterology & Hepatology, 1(6), 425-432.
    Vargo JJ, Holub JL, Faigel DO, Lieberman DA, Eisen GM. (2006). Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy. Alimentary Pharmacology & Therapeutics, 24(6), 955-963.
    Vargo JJ, Zuccaro G, Jr., Dumot JA, et al. (2002). Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology, 123(1), 8-16.
    Walker JA, McIntyre RD, Schleinitz PF, et al. (2003). Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center. American Journal of Gastroenterology, 98(8), 1744-1750.
    Waring JP, Baron TH, Hirota WK, et al. (2003). Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointestinal Endoscopy, 58(3), 317-322.
  11. 0
    Thats Awesome! Thanks,

    I love the paragraph from the Douglas K Rex article which poses the same questions I was trying to ask.
    "The major remaining issue is how training of nurses
    and endoscopists should be accomplished."

    FUTURE TRENDS AND ISSUES
    The evidence base for nurse/endoscopist-administered propofol
    is now sufficiently strong to support its expansion in appropriately
    selected patients. Patients with higher ASA risk class, difficult
    airways, or at increased risk of aspiration have often been
    excluded from clinical reports of nurse/endoscopist-administered
    propofol. The major remaining issue is how training of nurses
    and endoscopists should be accomplished. Although guidelines
    for developing and training programs in propofol have appeared,
    additional and more specific recommendations from
    the gastrointestinal specialist societies regarding training in

    propofol would help extend the safe use of the drug. The model
    of targeting propofol to moderate sedation
    seems particularly

    attractive to achieving widespread use.


    Last edit by *traumaRN* on Feb 5, '10


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