Propofol

And some nurses want to give propofol just so they can prove what "nursing studs" they are, regardless the risk they are taking with their patients. This is a stupid argument. If this poster had half as much knowledge as he has bravado (and that bravado is at the expense of patient safety), he'd never give anesthetic medications.

The truth is that I am paid a salary, and I work for the hospital. We have no anesthesiologists. We do anywhere from 10 to 30 endoscopies a week, and the sedation for them is administered either by myself or the other CRNA at the hospital. I get paid the same amount whether anesthesia does the "conscious" sedation or not. At our hospital, anesthesia providers exclusively administer the propofol, as well as fentanyl, ketamine, and a number of other anesthetic agents. Not because we get paid more, not because we can bill more for the service, but because we put patient safety first.

I was frankly shocked at some of you who said "I can give propofol safely, because I am ACLS certified." Guess what? I give propofol daily, several times a day, and my justification isn't that I'm safe because I know ACLS. In fact, if I need ACLS after administering propofol, then I made a big mistake.

Are you all aware that propofol can cause a dangerous drop in blood pressure? If you are, what medications do you have available that can treat that side effect? Because there are patients for whom a drop in BP can be lethal in a matter of minutes. Or that it can induce apnea? What will you do when you cause a patient to be apnic, and you can't ventilate them? Yes, that happens, and you better be ready to intubate them. The catch is that if you cannot ventilate someone with a bag/mask, they will probably be a difficult intubation. And I don't care how many dummies you have intubated at ACLS class, intubating a living human being is a completely different experience.

What are you going to do when you give someone 100 mcg of fentanyl, and induce chest rigidity? Look it up, it happens. The chest becomes so rigid that no amount of force on a bag will put air into the patient's lungs. When it happens, about your only option is to paralyze the patient and intubate them. When you give fentanyl, do you have a paralytic handy?

I really am not trying to belittle anyone. I simply want to get across that these drugs, for all the talk of short half lives and rapid emergence, have the ability to bite you, and bite you hard when you least expect it. And if you aren't prepared for this eventuality, the patient is likely going to die, notwithstanding your expertise in ACLS. CRNA's and anesthesiologists face these effects every day, and we are prepared for them. How many of you have atropine, ephedrine, neosynepherine, and succinylcholine readily available (i.e. drawn up and on the cart) when you administer these drugs? I do, every time. It isn't cheaper, but it's safer for the patient. If you have these drugs, do you know the appropriate dose for your patient?

The point is that when an anesthesia provider says that only people trained in anesthesia should administer anesthetic medications, it isn't out of a desire to enrich ourselves. It's out of a desire to see that patients are cared for safely. And if the endoscopist wants to proceed, having an RN, who is very good but not trained in anesthesia, administer deep sedation, who is really trying to make as much money as possible?

Kevin McHugh, CRNA

Very good post kmchugh. You may have saved another life, or more, today. (patient and nurse)

We use propofol in our unit on a lot of our ventilated traumas that we feel will be extubated early in the morning, because propofol wears off very quickly. We have a titration protocol, and generally we start the drip at 5-10 mcg/kg/min and titrate up from there to keep patient usually around a 3-4 on the Modified Ramsey scale. If we feel like we are using this drug for sedation on a long term basis, we obtain a lipid panel and monitor that on a regular basis.

I don't feel like this is a drug that should be used on patients that aren't already ventilated, and I have a personal experience to go along with that.... LifeTeam brought us a trauma with a head injury who was very combative en route, so they gave some ativan.... it didn't work, so they started a propofol drip.... when we were moving him to the table, they reported that he had no problems maintaining his own airway, even tho his GCS was probably around a 5-6, so they didn't intubate...... I asked, how much propofol they had him on.... they reported 50mcg/kg/min and a total of 6 mg of ativan.... I just wondered if anyone heard my jaw drop to the floor..... at any rate, I looked at the patient and noticed he had no chest rise..... he wasn't so much breathing..... so, we intubated him quickly. Once the propofol wore off, he had his own spontaneous breaths.... they could have killed him.

However, I think that it can be used responsibly. Naturally, you wouldn't start this drug on a patient that is already hypotensive, or a patient without an artificial airway already established.

The previous poster made lots of good points about sedation, and those pointers he made don't only apply to propofol or fentanyl, but you can cause apnea and hypotension with dilaudid, morphine, versed, ativan (not as much).... so all of these drugs should be administered with caution.

I am very rarely called upon to do conscious sedation during a procedure, as most of our patients will either go to the OR or Special procedures assist with the procedure if it's in the room. So, maybe my comments are out of line... I just wanted you to realize that there are areas where the use of propofol is perfectly acceptable and preferred.

Another thing to point out in regards to propofol that a lot of physicians don't realize is that it IS an anesthetic, not an analgesic..... so, it does nothing for pain. If you use it in the way we are using it, you may also need to supplement with pain meds, based on indicators such as respirations, heart rate, etc....

I honestly don't think that the nurses that are pushing propofol ( as well as other sedation meds) are listening to the arguments made by yoga, athomas, mchugh, etc.

There's a lot to consider when using these drugs, not just to keep an eye on chest expansion, sats, vitals,etc. You need to #1 know what to be looking for in adverse reactions #2 how these should be treated and #3 have the knowledge, experience to treat the problem correctly the first time.

The most important issue is liability. Not only to the patient's safety, but also legally. If you've got an endo doc screaming at you to push propofol and you do it against your nurse practice act, hospital's policy, etc, I guarantee you he won't stand up in court and take the blame ( even if this mattered - you are still liable for your actions). Be prepared to pay heavily for your mistakes if something happens and you and the doc can't handle it.

The best way to empower nurses ( if this is what some of you are after), is to educate them (this means anesthesia school for the use of anesthetics). It's great to expand your horizons and make yourself valuable, but keep patient safety first and operate under your practice act.

Remember, nobody is looking out for you, but you!

BJ

Another pat on the back to kmchugh. Well said.
I mentioned earlier that under no circumstances do we nurses in our Endo Unit, give propofol. We have anaesthetists administer it, and have all necessary equipment in the room for the possibility of adverse reactions (ie; intubation equipment, paralytic agents and a whole variety of other drugs to deal with BP drops etc).

This is fine. You are talking about a patient who is already intubated and ventilated. Chances are, anesthesia personnel started the propofol infusion. In any event, I don't really have any problem with the use of propofol as a sedating agent on a tubed and ventilated patient, but that's not the point of this discussion.

The point is that nurses not trained in anesthesia should not be using propofol for "conscious sedation" on patients who are not intubated and for whom we are counting on spontaneous respirations. Propofol is an anesthetic agent, and can be very useful in places like the endo room, or the ER. By the same token, when an anesthesia provider uses it, they are prepared for the eventualities that can come with the use of the drug (fentanyl as well), nurses are not. And we haven't even discussed all the possible issues! For example, no one has yet mentioned the fact that there are patients who will become apenic and lose airway reflexes with an "appropriate" dose of propofol. Just think of how disasterous this could be for a patient with reflux, something you all probably see in endo daily. The patient stops breathing, and the nurse tries to ventilate with a bag/valve/mask. But, the nurse has a little trouble, and uses a bit more pressure to ventilate, and forces air into the stomach of a patient who has reflux, and whose airway protective reflexes have been blunted by the same nurse, using propofol. See where this is going? Aspiration, and the potential for a minimum three week stay in the ICU on a ventilator, because someone wanted to use propofol, without proper education.

If you let a GI or ER doc browbeat you into using a drug that that has consequences that you are not prepared for, whose fault is that? Who will bear the brunt of the disciplinary action for that? You will.

Kevin McHugh, CRNA

If anyone is still on this thread....We use it every day in our Endo rooms.
RN pushes, Doc is in room (in dept somewhere) We avg 40-50 cases a day. I can recall 2 that required intervention (resp support) or reversal. Was it the Versed, Demerol????
If it is used in other facilities with no reactions, why not use it?? We use to have a policy that pts on Dopamine gtts (titrated or not) in ICU. Now, every other pt on med/surg has a dop gtt.
We may need to broaden our horizons.

And kmchugh, what are you trained for that the ER nurse with10-20 years experience is not??? I am not selling your education short butI think you may be selling others education/experience short.

So, just how are you reversing propofol these days? And do you really think an experienced ER nurse is on the same level with a CRNA? Please tell me you are just joking, or either trying to stir up drama, because if not, then you are scaring me!!!

Kinda slow today. Don't be scareed.

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