Propofol - page 18

I wondered if anyone of you as RN's use propofol? Only the anesthesia people are using it. When anesthesia is used they use propofol. We as Rn's are pushing the Demerol, Versed, Morpheine, Nubain,elc.for conscious sedation.... Read More

  1. 0
    To become paralyzed by the thought of what might occur, is equivalent to doing nothing toward better patient care. I applaud the hospitals that are willing to exercise, and support, the best practice of their nurses. Recently our hospitals insurance carrier was changed. The nurses that administer IV sedation were interviewed for many hours. The insurance carrier was very satisfied with the way IV sedation is done at our facility.
    I agree if you treat “a million” patients with propofol you will most likely have a bad experience. I also believe that if you give “ a million” doses of ____ (fill in the blank) you will have a bad experience. It is thinking like that, that doesn’t allow for advances in health care that can reduce risk and decrease mortality.
    With propofol the procedure is painless and effective. If I can participate in a procedure that may save the life of a patient that is terrified of a painful procedure. You ask is it worth it? Yes, I believe it is.
    Training in the area of sedation is a must, ACLS, ED experience is preferable. However to have an anesthesiologist or crna on every case is not practical, not feasible and fiscally irresponsible.

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  2. 0
    Quote from robrn
    To become paralyzed by the thought of what might occur, is equivalent to doing nothing toward better patient care. I applaud the hospitals that are willing to exercise, and support, the best practice of their nurses. Recently our hospitals insurance carrier was changed. The nurses that administer IV sedation were interviewed for many hours. The insurance carrier was very satisfied with the way IV sedation is done at our facility.
    I agree if you treat “a million” patients with propofol you will most likely have a bad experience. I also believe that if you give “ a million” doses of ____ (fill in the blank) you will have a bad experience. It is thinking like that, that doesn’t allow for advances in health care that can reduce risk and decrease mortality.
    With propofol the procedure is painless and effective. If I can participate in a procedure that may save the life of a patient that is terrified of a painful procedure. You ask is it worth it? Yes, I believe it is.
    Training in the area of sedation is a must, ACLS, ED experience is preferable. However to have an anesthesiologist or crna on every case is not practical, not feasible and fiscally irresponsible.
    I think you missed the major point--I have been involved in the proper education of nurses to do IV sedation for over 10 years, so I hardly think you can say that I am holdng back progress in RN role development. I have no problem with RNs properly administering sedation---but propofol is not a sedative. It is an anesthetic and that creates a different set of issues. The JCAHO standards for sedation state that the person doing the sedation should be able to rescue the patient from one level deeper than the level they are trying to achieve. Patients are on a continuum from sedation to general anesthesia once sedatives have been given. To give propofol to patients as you describe indicates the presence of a level deeper than moderate or even deep sedation. Managing a deep sedation that progresses to a general anesthetic s no longer within the scope of practiceof an RN unless that person is a CRNA. I agree that it is not practical to have an anesthesia provider for every sedation--nor is it necessary. Nurses should seek opportunities to expand their scope of practice, but there have to be limits, otherwise the increased risk of liability may do more harm than good to the profession. WHen we do things we do not totally understand the overall import or potential consequences of we reinforce the position often used by physicians when they are fighting anyexpansion of our professional role---"they don't know what they don't know". We have to set the limits because it is to the economic advantage of the physicians/facilities to have RNs do additional duties---and unfortunately concern for $s can often override the proper development of RN role growth. Just some things to think about.
  3. 0
    Quote from robrn
    With propofol the procedure is painless and effective. If I can participate in a procedure that may save the life of a patient that is terrified of a painful procedure. You ask is it worth it? Yes, I believe it is.
    How about this...Is it worth it for a patient to receive an adequately prepared and clincal savvy provider? Yes, I believe it is.

    Your above statement shows you lack the pharmacologic understanding of a drug you are such a proponent of. Propofol lacks ANY analgesic properties. Hypnosis is not analgesia.

    This is unbelievable.
  4. 0
    Quote from robrn
    To become paralyzed by the thought of what might occur, is equivalent to doing nothing toward better patient care. I applaud the hospitals that are willing to exercise, and support, the best practice of their nurses. Recently our hospitals insurance carrier was changed. The nurses that administer IV sedation were interviewed for many hours. The insurance carrier was very satisfied with the way IV sedation is done at our facility.
    I agree if you treat “a million” patients with propofol you will most likely have a bad experience. I also believe that if you give “ a million” doses of ____ (fill in the blank) you will have a bad experience. It is thinking like that, that doesn’t allow for advances in health care that can reduce risk and decrease mortality.
    With propofol the procedure is painless and effective. If I can participate in a procedure that may save the life of a patient that is terrified of a painful procedure. You ask is it worth it? Yes, I believe it is.
    Training in the area of sedation is a must, ACLS, ED experience is preferable. However to have an anesthesiologist or crna on every case is not practical, not feasible and fiscally irresponsible.
    Clueless on so many different levels.

    You want to use propofol, in an ED, for a procedure that may "save the life of a patient that is terrified of a painful procedure". Right. There is NO procedure in the ER to "save the life of a patient" where propofol is indicated. NONE. And as already stated, there are no analgesic properties to propofol. If you're giving enough that they're not responsive, IT'S A GENERAL ANESTHETIC!!!.

    "ACLS preferable"? What a joke.

    "Fiscally irresponsible"? Again, what a joke. We do what's best for the patient, period.

    It also amazes me that any liability insurance carrier would happily go along with RN's giving sedation with propofol. Talk about fiscally irresponsible. That package insert warning on propofol is all that ANY attorney needs to get a settlement with lots of zeroes in the number.
  5. 0
    We do in PACU at times. Also I float to the pain center. They use it all the time for spinal blocks. Propophol is dose based, and wears off quickly. I believe you can only use it here, if the pt is intubated or anesthesia is present.
  6. 0
    I need help with Propofol. I am a pharmacist in on a medical surgical floor.
    We are using Propofol DRIPs for sedation in vent patients. Does anyone have any information on propofols use with vent patient and medical sugical floors? We have ACLS nurses, monitoring, code carts and MDs versed on it use what else is needed? or is it contratindicated total on a "Med-Surg" unit.

    Thanks, VInce
    Last edit by NRSKarenRN on Jun 17, '06
  7. 0
    There is a difference in sedation vs aneshtesia. As ICU nurses we use propofol drips for ICU sedation on VENTILATED patients. There are various sedation scales used across the nation to ensure that the patient is not oversedated (RASS, MAAS, RAMSEY, to name a few). And now the BIS moniters are becoming more prevalent, which is a very objective way to view sedation (acutally looks at brain waves). Dripping propofol in is much different than pushing it. Pushing it is against my nurse practice act. That is considered anesthesia and nurses are not allowed to administer anesthesia (at least in my state). Also, even if you're just on a drip that is too high and the patient is too deep, this is considered anesthesia as well. Don't forget the goals of icu sedation on the vent. It is not to snow the patient, but to have them be tranquil but arousable. Now in GI lab i would hope only the doc is pushing anesthesia.
  8. 0
    i was just checking out the "dr. naps" site, which appears to have recently been updated.

    this (below) is directly off the site. it's ("naps) just so wrong, on so many levels. i hope some anesthesia providers comment on this--i mean, the principles (at least some of them) may be correct, but they should be entrusted to anesthesia providers--not "ulenas" (the facility's oh-so-clever term for their rns.)

    (and what in the he** is the "western tongue scale?" or the ""bad dancing scale?" are these universally accepted terms, or just made up for their own purposes?)

    i particularly love the comment in # 33 regarding "satisfying the nurse's whims."

    and # 22--"range: 5- 350 mg to get started"--aren't those some pretty damned broad parameters for a non-anesthesia provider to be entrusted with?


    successful elements of nurse administered propofol sedation

    1. the patient is fasting, or perhaps allowed clear liquids up to three or four hours prior to a procedure. the exceptions are that if a person is unreliable, then it is easier to tell them to be npo after midnight; patients must avoid red and purple liquids before colonoscopy, which is part of the standard prep sheet protocol; patients may need special instructions per their gastroenterologist if they have gastric outlet obstruction or achalasia in regards food the day before, and in the length of fasting.

    2. the patient’s completed history and physical and parq discussion will be in the chart prior to the final words that the patient and the doctor have before proceeding.

    3. on the day of the procedure the nursing assessment will be present in the chart prior to the initiation of the procedure and sedation.

    4. the patient will have a reliable designated driver.

    5. if the patient is supposed to be off anticoagulation, there should be documentation of this on the day of the procedure.

    6. the patient had been advised about diprivan sedation and the differences, advantages, that it is relatively new, and of our local experience. anyone who requests light sedation so that he or she may watch will be granted at least an attempt at this. quite rarely people have requested other forms of sedation that they are familiar with, such as a surgery center of southern oregon patient who requested lamaze breathing and low-dose fentanyl.

    7. extra time is allowed for titration if there is cardiovascular disease or pulmonary disease.

    8. the initial dose is 10-50 mg, depending upon the patient profile, by which we mean the age, size, anxiety level, psychotropic drug use, alcohol use, and the presence or absence of vital organ diseases of any type.

    9. the physician, sedation nurse, and endoscopic technician are all assembled prior to the initiation of sedation and any final decision making in this regard.

    10. the pulse oximeter and blood pressure monitor will be working correctly and the oximeter will be audible.

    11. there will be a running iv in proper working condition and ideally a proximal forearm vein is used; if not, the anticubital will be used.

    12. lidocaine for the prevention of pain during injection is added to the diprivan unless there is a known allergy to lidocaine.

    13. the nurse is cautious to avoid the rare circumstance in which a superficial aberrant artery is inadvertently cannulated. there have been no serious sequelae of this in the literature with either form of propofol, but this is a circumstance to be avoided with any intravenous medicine.

    14. the patient will be ascertained not to be allergic to propofol, soy, eggs, or at least certain components of eggs, or metabisulfite if the generic is being used.

    15. the propofol syringe is labeled with the date and time of expiration (six hours after being drawn), and the month is given in letters rather than numbers to avoid confusion with the european system of dates. usually the amounts of propofol are drawn in 50, 100, or 200mg amounts to allow flexibility and to reduce to a minimum the amount of the drug that is wasted at the end of the procedure.

    16. a strict aseptic approach is taken.

    17. special care is taken with people who have sleep apnea.

    18. propofol for the individual patient is discarded at the end of the procedure and no syringe is carried over to another patient.

    19. the patient is sedated at the proper rate until the eyes close, usually within 45 to 120 seconds, then tiny doses of sedation are given according to the physiologic challenges, the physician's gloved finger on the tongue (the so-called "western tongue scale), and subsequently the posterior oropharnyx to see if coughing is elicited or aversive body language otherwise; the digital rectal exam; and subsequently physiologic testing with the scope itself, particularly the upper esophageal sphincter for egd and ercp and certain classic zones of stretching during colonoscopy, the sigmoid and the transverse colon.

    20. upon retrieval of the scope, particularly colonoscopic retrieval which is longer than endoscopic retrieval, more medication may or may not be needed, according to the patient's response. the physician and nurse are in constant dialogue about how much more time is needed. if the patient has discomfort during the phase just prior to the removal of the scope, e.g. targeting a sigmoid polyp in a spastic sigmoid, the nurse and physician will choose how much medication is needed for discomfort, well knowing that the physiologic stimulus of the scope will probably be taken away from the patient in a very short period of time. here incremental doses of 5 mg are frequently sufficient (rather than 10 mg).

    21. the upper and lower endoscopy nurse assistants (ulenas) are to be trained by other pre-existing ulenas with ample experience and/or by physicians familiar with this technique.

    22. the ulenas within the protocol decide the timing and amount of dosing, yet within the confines of the protocol, rather than the doctor ordering a dose. the ulena decides, again in close coordination with the physician, who is only three feet away from the nurse, according to the profile of the patient, how much it took to get started (range: 5 to 350 mg), how much time has elapsed since the last dose, how much time is left in the procedure, and in general what is going on with the patient, scope-wise. all of this is correlated with the nociciptive body language of the patient ("bad dancing scale" grades 1-4).

    23. suction equipment should be close at hand.

    24. oxygen is always used. usually this is provided by nasal prongs, although the prongs may be translocated to the mouth on certain occasions.

    25. a working telephone is always available in the room.

    26. ephedrine is readily available in the room and a triple check is made that the epinephrine is not given by mistake.

    27. atropine is readily available in the room.

    28. a crash cart is present in the room.

    29. as little time as possible is spent with the patient in the supine position and all three team members, the physician, sedation nurse, an endoscopic technician, should be in agreement that it is safe to move the patient to this position for scope advantage. as soon as the cecum is reached with this maneuver, the patient is turned back into the safer left lateral decubitus position. [this is good practice with traditional sedation as well, and is not distinct to propofol sedation.]

    30. the ulena will be acls certified and possess excellent upper airway management skills equivalent to an excellent recovery room nurse.

    31. the patient is to bring his or her inhalers, if any, and use them in timing prior to the procedure so that the lungs are in tip-top pharmacologic shape.

    32. patients are allowed to sip juice as soon as they can decide which juice they want, frequently within two minutes of termination of the procedure, as long as they are not experiencing pain from gas distention from colonoscopy or nausea.

    33. some patients can leave within as little at ten minutes. to leave this early, they have to have a perfect aldrete score and satisfy a nurse's whims otherwise.

    34. there are occasional people who have nausea or gas distention after an endoscopic procedure, more commonly after colonoscopy than upper endoscopy. if the symptoms are excessive, injection for nausea or for pain is given by a standing order by the nurse, who then subsequently reports if to the doctor. to receive such a medication, a person is usually quite awake and alert. lesser degrees of discomfort from gas distention (since propofol wears off so quickly) can be treated with tincture of time, nursing attention, and simethecone (more or less as a placebo). fortunately, significant gas distention with discomfort is seen in only about 3% of people and we may be able to reduce this to less than 1% with a more dedicated effort at suctioning air upon retrieval and at the termination of the exam. perhaps particularly susceptible are the people with a lot of diverticulosis and spasm of the left colon.

    35. the ulena will complete the diprivan competency evaluation, fulfill the competency criteria, and fulfill the checklist for continued diprivan competency.

    36. overall, the goal is to choose the proper and safe level of sedation for each patient in regards what is being done for the patient with the strong commitment to painless exams, 100% amnesia, and yet using the least amount of medication. we have found that even if people groan or talk, even making a complete sentence that is grammatically correct, they will not remember what they said, the endoscopic experience at all, and there will be a greater sense of the painless rendering by the team administering sedation. the range of sedation goes from anxiolysis in the preprocedural arena, to levels consistent with light traditional sedation, to deeper levels, but always with the goal in mind of being "two minutes away from sipping juice." in our experience, some of our anesthesiology colleagues have given too much medicine and too fast, although in general they have done a fair to good job and have been very supportive. thus, we will emphasize great attentiveness to the patient's needs and practice careful decision making with every small incremental dose that is given.
    Last edit by stevierae on Nov 29, '06
  9. 0
    This is a joke right? ULENA? A NURSE ASSISTANT giving propofol?
  10. 0
    Quote from Siren
    In Colorado only a anesthesiologist can administer Propofol and I am glad. I do conscious sedation everyday but I do not want to give Propofol. We use versed and sublimase.
    Actually there are nurses in Colorado right now giving Propofol and have been for over a year.

    David Carpenter, PA-C


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