Propofol

rn29306 · May 15, 2005

I think that it is much safer to give the 80yo frail patient small incremental doses of propofol for a procedure, than giving boluses of narcotics and benzos then allowing that patient to go home in a narcotic daze only to fall and break something.

Have you ever given Propofol to frail 80 y/os?? They tank their BP quicker than you can blink and do you think their autoregulation after 80 years of functioning can even attempt to compensate, shunt the correct blood volume to adequately perfuse the renal, probably flow-dependent previously stented coronary arteries, spinal cord, and brain? Survey says no. This is assuming you can treat what you have induced with immediately available neosynephrine and ephedrine...In the time it takes you do obtain these meds from the pyxis, you might as well go write a blank check and put it in the mail for the laywers to divy up for the court settlement. We won't even disucss airway management here either..

Propofol patients can be offered a painless procedure.

Before you attempt to talk anesthesia with anesthesia providers, perhaps you should clarify what are induction agents vs analgesics. Just a thought...

Propofol has no analgesic properties. Giving grandma propofol assuming it provides analgesia and offers "a painless procedure" just taxed her heart under stress and you guys get to watch an MI evolve on the EKG tracing.

Please leave anesthetic administration to anesthesia providers..

stevierae · May 16, 2005

Propofol has no analgesic properties. Giving grandma propofol assuming it provides analgesia and offers "a painless procedure" just taxed her heart under stress and you guys get to watch an MI evolve on the EKG tracing.

And possibly take grandma out in a body bag. So much for "painless procedures" and "patient satisfaction."

I really doubt that the gastroenterologists or RNs giving sedation in endo labs or free standing surgery centers would recognize an MI evolving on the EKG tracing---I doubt they'd even be aware of what wave changes might indicate or even suggest ischemia. And, since grandma is snowed under propofol--which has progressed to deep sedation, to make the procedure "painless--" she can't tell them of her crushing chest pain. Even if she could, they'd probably attribute it to "pressure" and tell her, patronizingly, "Don't worry, dear--we'll be done soon."

So true, the adage, "Some people don't know what they don't know."

mwbeah · Jun 2, 2005

http://www.gastro.org/pubs/pdf/perspectives/05/FebMar.pdf

The Propofol Debate.......a good link

joyful nurse · Jun 2, 2005

As I understand it, most State Boards of Nursing address this issue as far as under what condtions, and what training an

RN must have to push Propofol. Otherwise I agree totally with the earlier writer who said," You don't know what you don't know."

originalred · Nov 22, 2005

Anybody doing any research on this or does the "tribal mentality" still hold true?

We can't do it because we never have??? Still see posts where a lot of patients have survived propofol admin by a damn nurse.

sjrn85 · Nov 26, 2005

If you want to administer propofol, go to anesthesia school. It is is a potent anesthetic that can cause cardiac depression, hypotension, respiratory depression and loss of a protective airway. I give it every day and am always impressed with its unpredictablity and potency. Also, it is listed as an anesthetic and should only be given by professional anesthetists. See the package insert. It would be interesting to see how a jury would respond to an non-anesthetist administering an anesthetic.
Sorry guys, I feel stronly about this issue.
YogaCRNA

I couldn't agree more. I give fentanyl and midazolam, and that's just fine for me. Having ACLS has nothing to do with being capable of giving propofol; you've got to be able to react immediately if the pt. needs an airway. I don't have those skills...heck, intubation isn't even required in ACLS, and doing it once in an ACLS class (if you do get to practice) hardly makes you capable of doing it for real.

I think RNs who give this are foolhardy; just because you've played in traffic for 20y and never gotten hit by a car doesn't mean playing in traffic is safe.

We all have our place in the healthcare system, but there are reasons why licenses also have limitations.

rn29306 · Nov 28, 2005

As I understand it, most State Boards of Nursing address this issue as far as under what condtions, and what training an
RN must have to push Propofol. Otherwise I agree totally with the earlier writer who said," You don't know what you don't know."

The Georgia Board of Nursing just addressed this issue.

No RNs will be pushing Propofol on unintubated patients.

Hospitals are making policy in light of the GBON's take on the propofol issue.

bethin · Nov 28, 2005

Holy Cow!! Have none of you guys taken ACLS? I would LOVE to be able to give Propofol. The patient wakes up in seconds. It has a half life of 1.8 minutes!!! I would rather bag a pt for 1.8 minutes than give an 85 y/o 85 lb lady 125mcg of fent and 5 mg of versed!!!!!! Then have to reverse her!
I understand there is an Endo lab in southern Oregon that trains RNs in GI to administer propofol---would love to go there!!!
When I worked in the Midwest as a recovery room nurse we had a procedure room for ECTs, and the Drs started the propofol and we managed it during and post procedure. I NEVER had a problem with airway (if that is the concern)--only with people waking up TOO FAST!
Don't sell yourself too short, RNs keep people alive all the time. All the nurses in our GI lab have ICU/ER experience and ACLS. We need to expand our expertise, not limit it. As long as we are appropriately trained and supervised by an MD, there is no reason to fear administering a medication that enhances the patients comfort and safety during procedures.

Yes, I love propofol. I've has so many colonoscopies and endoscopies that I've become immune to the standard drugs. I had an endoscopy where I was wide awake, although I had been medicated. The next one I had I had to drive 60 miles to Indy to a bigger hospital. They administered propofol (by a nurse). When I woke up I was fully awake. I didn't have the hangover effect.

The hospital I went to had trained the RN's on the medication. They know what may happen. They knew the risks, side effects, etc. I was comfortable with it. But if you're not comfortable giving it, don't give it.

OhERRN1984 · Nov 28, 2005

I live in Ohio, fairly big city, not huge, but not samll.

In my "area" almost all of the hospitals allow for an RN to push small dose propofol for "conscious sedation", or to run as a drip. I have used it in Cardiac Cath lab, and ER, unfortunately many times, hardly ever with a pt with a protected airway, and it SUCKS. You spend more time dialing it down, then pt becomes responsive only to have the Dr say turn it up. Oh, gee, OK, I just thought the fact I`ve been bagging this pt with a 50/20 BP would MAYBE be an indication this crap isn`t what we need to use..................................AND thats with the Dr standing there, THEY DON`T CARE, we are the dufus killing the pt, and if any of you golden eyed I can do anything, I`m a nurse types feel warm and fuzzy with this med, you go. What I will say is in court it was U running the med, yeah go ahead and document that I told the Dr yada yada yada, U still are the dufus killing the pt. And U will be the sacrificial lamb in court also.

I guess the key word to all of this is "CONSCIOUS", which isn`t exactly what the Drs have in mind when they order it. I won`t waste anyones time with a definition of what "conscious" sedation is, and I`m not really sure how it applies in your state, but in Ohio it follows with JCAHO guidelines, actually I was shocked, as before contacting the Ohio BORED of Nursing I was under the impression they had a set of rules, yes/no what a nurse could do, and if you did the wrong thing they could pull your license. The shocked part was when I inquired about a RN`s role using Propofol. I was told that any use of a drug OK`d by the hospital I was working for was under the guidelines of safe nursing practices, and failure to maintain these guidelines could/would invite suspension, loss of license. Of course I immediately followed with, well OK, what are the safe practice guidelines for the use of Propofol, and quickly found myself in a circle with no end. The State of Ohio doesn`t have a set of rules, but I was "urged" to check the JCAHO guidelines by them.

http://www.jcaho.org/

Check these out people. Do a simple search, check cons sedation, then add the word propofol, under the conscious sedation propofol the only hit you will get is for "pain mgmt" of all silly things, propofol has NO analgesic properties first off, secondly the word propofol cannot be found, at least by me in the text.

Next READ the pkg insert, says for use by a licensed anesthesiologist.

THIRD and the funniest thing you can do. Call your independent insurance carrier, if you don`t have 1 thats your problem. Anyhow call their 800#, please do this from a payphone.......... Tell them you want information as you are an RN, using propofol............. If yours is like mine, they don`t start giving info, they start asking questions..........who is this? what is your policy ID #? yada yada yada, they want to end coverage, but need to know who`s coverage they are ending...............It will be yours if they find you are an RN, not CRNA using this drug, push, drip, intubated or not.

Remember this always...........................You are you`re only friend, only U care about your license, the Dr`s have their own worries, the hospital, probably non-profit is only worried about profit, go figure. The long and the short of it is if you don`t cover your behind no one else will.

The problem is this, hospitals do what Drs want to have done, so they write policies for the nurses to follow, thus U get to do a yearly 2 minute yada yada test on conscious sedation, and SHAZAM you be an anesthesiologist.................Only real problem is a written policy does not make you so, nor does it change any policies written by the larger entities, such as JCAHO, nor does it decrease your liability as a practioner following any other BAD written/verbal order. Go check your state nursing BORED of nursing, yeah that part is real clear, you be responsible for your actions, even if the Dr writes the order, and the hospital writes the policy.

Solution?????? We have to stop acting like sheep, baaaah baaahh baaaaaaaaaaaah. I`m not advocating union, as I don`t think they are worth the time. We the body of nurses need to stop trying to be all things, and settle on a role where we do our job, and the others do theirs. Ask why doesn`t the Anesthesiologist, or at least a CRNA doesn`t preform this function, easy answer, payment.... Insurance does not cover these costs for Anesthesiology or CRNA`s to be paid for procedures NOT done in OR, if they are over 20 minutes duration, and especially in a cath labs situation the EPs want to use the cath lab, why, they get the $$$$$$ there, much less is paid them if they do them in OR. Likely a propofol drip on an EP pt in the cath lab is 2 to 12 hours, no pay, OK nursie heres your chance to be an Anesthesiologist. Similarily a drunken comabative but severly injured fool in the ER, or the cute lil ole combative lady in ICU with a blower running, none of these uses are going to fall into a 20 minute time period, and probably wouldn`t be covered as needed even for 20 minutes.

True case: Poor nurse in EP lab running propofol drip on a very instable pt, b/p was down, intermittent bagging to keep airway open, poor nursie called away from EP lab to assist in helping pts in hold as NO rooms ready, told to go there by lab director, EP Dr fully aware you have left the building, and U had a running dialog with the EP Dr, and were charting the problems with pt, as wel as asking Dr to stop propofol and use Versed and MS (the standard mix by all but 2 Drs in this lab, who used propofol), also documented. Other RN in EP lab "busy" helping EP Dr at console.

35 minutes later you are returning to EP lab, finding unstable pt without spontaneous resp, b/p non exsistant, still being worked on by EP Dr, and his hospital employed companion nurse. Gee we had a lot of arifact, and ectopy a while ago, check her vitals to see how she`s doing............... Ok you gussed it, somehow this is one of those people who still are alive, but shouldn`t be, no air for ???? we`ll never know, Ep lab just made a goof, OOOOpsss. Court was pretty much a slam dunk in that, the RN running the propofol was found negligent. The Dr and the other nurse were not found negligent, go figure. The lab director who had pulled the nurse not found negligent, actually he wasn`t even called for a statement, go figure. The hospital was the paycheck, they took a big hit, however none of the admin who thought that using propofol was a good idea, never called for a statement. They just look at it as a cost of doing business, no thought to clean up the act, change the policy, or even look at the problem. Forget kiling pt`s, and ruining nurses.

This was in a cath lab where I worked, until 11 days before this happened, I left over this stupid drug, worked with admin, Dr`s, staff, Risk Mgmt for 2 months prior to leaving, 23 meetings in all. This IS the premier hospital in our area. Nobody ever saw the problem here, just a negligent nurse, gee they were better off without her. She has since quit nursing altogether, is VERY poor now, and because she was found guilty lives with a ton of guilt.

Propofol does cause great sedation, only problem is it usually isn`t while the pt is in the conscious state, and at least in Ohio thats is where an RN can use this drug. As a deep sedation, through anesthesia the drug is NOT allowed use by RN`s in Ohio, only Anesthesiologists, and CRNA`s are able to use it this way. Even intubated a nurse using this drug will see instability in b/p, cardiac output. This drug is not easy to STOP, sure it has a brief half life, and Drs will say 5 to 7 minutes and you will be getting back to baseline. lots can happen in 5 to 7 minutes.

I hope you are not really sheep, but nurses have to stop doing everything someone else tells us to do, because a lot of times they are not in anyones real interest, especially when other drugs can do a better more stable job. Propofol should never be used for "conscious sedation". Anything but, and nurses are NOT licensed to do, so if you are, well, God bless you, and I hope your luck holds.

sign me: after 20 years of this kinda junk, no longer practicing pt care. :uhoh3:

jwk · Nov 28, 2005

Yes, I love propofol. I've has so many colonoscopies and endoscopies that I've become immune to the standard drugs. I had an endoscopy where I was wide awake, although I had been medicated. The next one I had I had to drive 60 miles to Indy to a bigger hospital. They administered propofol (by a nurse). When I woke up I was fully awake. I didn't have the hangover effect.
The hospital I went to had trained the RN's on the medication. They know what may happen. They knew the risks, side effects, etc. I was comfortable with it. But if you're not comfortable giving it, don't give it.

You don't become "immune" to the standard drugs just by having used them a few times.

Sure, propofol is a great drug, in the PROPER hands - anesthesia's.

robrn · Dec 1, 2005

Anybody doing any research on this or does the "tribal mentality" still hold true?
We can't do it because we never have??? Still see posts where a lot of patients have survived propofol admin by a damn nurse.

If you are interested in a very good prospective study of nurses giving propofol for sedation. Check out Gastroenterology November 2005, volume 129 Number 5.

I would also like to suggest contacting Dr. John A. Walker director of NAPS (Nurse Administered Propofol Sedation) for suggestions and approaches to overcoming adversaries to a better, and safer, way of administering sedation. The evidence is in and the answer is NAPS.

originalred · Dec 2, 2005

Robrn, Thanks for having a open mind on the issue. The "tribal mentality" may start to weaken soon as more people become aware of the issue.