Propofol - page 4

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,... Read More

  1. by   adidas99
    .....
    Last edit by adidas99 on Jan 28, '07
  2. by   TMPaul
    Quote from LibraSun
    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.
    We use it for rapid intubation.
  3. by   TMPaul
    Quote from yoga crna
    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
    It's used in Advanced Trauma Life Support. We were taught how to use it to do RSI. I personally haven't used it and hope I never have to.
  4. by   stevierae
    Quote from robrn
    Librasun, Thanks for your support in the use of
    propofol for sedation. I am a nurse that works at the
    GI lab you described in southern Oregon. With proper
    monitoring (EKG, SAO2, NIBP and ETCO2) Propofol is not
    only safe but also very effective. For instance
    narcotic using patients (we never see them) need large
    amounts of narcotics and benzos just to control the
    patient. If we are into an ERCP for 30 to 40 min
    nothing is more frustrating then having a patient
    twist and turn dislodging the cannula the MD just got
    into the duct.
    Our administration of propofol is small incremental
    doses in which the patient's airway is not compromised
    and total comfort is achieved. I can't say that
    patients don't desaturate but I haven't noticed a
    discernable difference in patients receiving propofol
    as compared to Fentynl and Versed. Here we don't just
    use propofol, as the MD's that do, must be
    credentialed in deep sedation. Some of our MD's are
    not, and don't use propofol so I have a pretty good
    grasp on the use of both.
    If we give our patient instructions prior to the
    procedure with Versed there is a retrograde amnesia.
    With propofol there is no retrograde amnesia, and as a
    bonus the patient is wide-awake about 15 min. after
    the last dose of propofol.
    In conclusion propofol is safe and effective in the GI
    lab setting when used by properly trained RN's, MD's
    and well monitored here in southern Oregon we have
    administered propofol to about 25,000 patients without
    any adverse effects.
    I encourage you to visit http://drnaps.org for more
    Information about training and Nurse Administered
    Propofol Sedation. Thanks again for your support.
    sorry I first placed this as a new thread and it isn't.

    Here's what I don't understand--putting safety issues aside---

    WHY do you want to do an anesthesia provider's job---FOR A NURSE'S PAY????

    WHY????

    I just don't understand why you'd take on the extra headaches and liability--with NO extra compensation. And, believe me, there is HUGE potential liability for you.

    I am an operating room nurse and a legal nurse consultant. I, too, have very strong feelings on the issue of nurse administered propofol, and they are, in part, THAT PROPOFOL SHOULD NOT BE GIVEN, BY A NURSE, TO A NON-INTUBATED PATIENT!!!!!!!! EVER!!!!

    There are nurses perfectly cabable of administering Propofol, yes. They are called CRNAs.

    I LIVE in Oregon. I will be WAITING for the day when I see the Medford facility called on the carpet for unsafe patient care practices, and I will be VOLUNTEERING my services as a behind the scenes consultant--or as an OR nurse expert--OR assisting with expert location--to any attorney who wants to put a stop to this dangerous practice and shut your facility down.

    In fact, maybe I can be the one to make a few calls and speed up the process.

    I am really tired of "gonzo" nurses who don't know what they don't know, and think it makes them look important to do an anesthesia provider's job. If you are not capable of delivering one level higher than deep sedation--that is, general anesthesia; skilled intubation and all--then you should not be delivering deep sedation. I don't even think you should be delivering MODERATE sedation. That's an anesthesia provider's job.

    I get tired, also, of hearing about your capability to "rescue." Yeah, yeah, we're all (operating room nurses)ACLS certified; nothing special about that. But you guys in endo labs seem to think that as long as you can deliver--or THINK you can deliver; based on what you learned in classes-- ACLS, it almost makes it OK to take unnecessary risks.

    Why GET a patient to a point where he needs to be "RESCUED?" The fact that he ends up there in the FIRST place shows that YOU HAD NO BUSINESS DOING WHAT YOU DID THAT GOT HIM THERE!!!!!!!

    Ususally "rescue" means that you have to call on someone--i.e., an ER doc, who has to drop what he is doing and come to YOUR "rescue" by intubating the patient for you and dealing with all the unnecessary problems that have been created--i.e., a period of anoxia or hypotension or both.

    You've had no adverse effects to date? Famous last words....many a nurse who gave Propofol in a plastic surgery clinic has used that phrase--and maybe she DIDN'T have any "adverse effects," by sheer luck or the grace of God--until the day she DID, and her facelift patient died...
    Last edit by stevierae on Sep 11, '04
  5. by   yoga crna
    I agree. Just yesterday, I had an asthmatic patient have a bronchospasm with a test dose of propofol. It was scary for all of us, including the patient. She did all right. Propofol is a potent drug, that is an anesthetic. Unless you are a CRNA, you shoudn't administer anesthetices. Read the package insert and realize your liability for giving anesthesia without being educated or certified.

    If any of you cowboys or cowgirls who are administering propofol would like to have an intelligent discussion on the following topics, let me know. This is just a small amount of information that must be in your head before administering propofol.
    1. Oxygen hemoglobin dissociation curve when interpreting SpO2. How does the curve shift with hypotermia, hypercapnia and hypoxia.
    2. What muscle relaxant to you give for rapid intubation?
    3. How do you perform Sellick's Manuever and what do you want to accopmplish?
    4. Discuss the synergistic and additive effects of propofol and narcotics, benzodiazepines and barbiturates.
    5. What is the standard of care for propofol administration when given by an RN (non-anesthetist)? Hint--the same standard as a CRNA.


    The most interesting discussion I have seen on the topic is by anesthesia students who gave propofol as an RN prior to going to anesthesia school. To a person, they said they had no idea of the pharmacology, physiology or had to obtain a quick airway in a difficult situation.

    Let's make a deal, I won't do general nursing if you don't go anesthesia.

    YogaCRNA
  6. by   stevierae
    Quote from yoga crna
    5. What is the standard of care for propofol administration when given by an RN (non-anesthetist)? Hint--the same standard as a CRNA.
    YogaCRNA
    Exactly right. Don't think you can fall back and use the excuse that, when a tragic, irreversible complication--or even DEATH-- occurs, that you can all of a sudden falll back into your "just a nurse" mode and say, ""Well, we weren't TAUGHT that in our classes at (whatever your endo lab is called...)

    Once you take it upon yourselves to do an anestheisa provider's job, YOU ARE HELD TO EXACTLY THE SAME STANDARD OF CARE THAT A CRNA IS HELD TO!!

    And guess what standard THEY are held to? EXACTLY THE SAME AS AN ANESTHESIOLOGIST!!!!

    Trust me on this! Ask your own gastroenterologists!

    If a family practice doc takes it upon himself or herself to do a colonoscopy, regardless of the training they claim they've had (less than 1% of FPs in the U.S. are credentialed to perform colonoscopy) and he or she ruptures the spleen, or causes some other rare but recognized--or NOT recognized-- complication that lands him or her in court, do you think he or she can fall back on the defense that, "Well, I'm just a family practice doc..." ABSOLUTELY NOT!!!!!

    This individual is NOW held to the same standard of care that a gastroenterologist would be held to--and you can bet NO gastroenterologist--or no FP, for that matter--will speak up in his or her defense.

    Do you really think they will stand up in YOUR defense, when you kill one of their patients? Don't believe it for a minute.
  7. by   stevierae
    I know that I have posted this before. What I want to know is--why does the gastroenterology lab in Southern Oregon--that prides itself on doing nurse administered propofol-- not have to follow these rules? Myabe they are in blatant violation of the rules, and just think that they are above them. Maybe they simply make their OWN rules.

    10 to 1 I already know the answer--they are "qualified to rescue" when they have a near miss. It's the "near misses"--can you say "sentinel events?"-- that we never hear about.



    FYI on Propofol Administration by RNs


    Saying that it has received several reports of adverse events, including
    the death of a cosmetic surgery patient, after RNs improperly
    administered propofol, the American Association for Accreditation of
    Ambulatory Surgery Facilities (AAAASF) is rushing to ensure that only
    those trained to give general anesthesia or rescue from general
    anesthesia administer propofol in its 1,100 or so accredited facilities.
    The AAAASF announced last week that facilities that want to continue to
    use propofol -- even if only for "conscious sedation" -- must either
    upgrade to a Class C facility (where all anesthesia must be administered
    by an anesthesiologist or CRNA) or promise to always use an anesthesia
    professional to administer the drug. Facilities must comply by May 1.

    "We decided that we need to get our standards in line with the
    manufacturer's recommendations," says Jeff Pearcy, executive director of
    the AAAASF. "The easiest way to do that was to require those facilities
    that want to continue to use propofol to become Class C facilities."

    For Class B facilities that would like to continue to use propofol but
    won't use other types of general anesthesia, complying with the new
    standard is simple. These facilities must fill out a form certifying
    that they have a dedicated anesthesiologist or CRNA administering the
    sedative-hypnotic. They also must have neuromuscular blocking agents
    available in the facility. No on-site inspection is necessary. There
    will be no additional charge, says AAAASF.

    Those facilities that are upgrading to a C and plan to use general
    anesthesia (inhalational) in addition to using propofol must comply with
    all Class C criteria, says AAAASF.

    AAAASF President Michael F. McGuire, MD, a board-certified plastic
    surgeon, says the major motivation for making the change was that
    "administration of propofol by a non-anesthesia provider is really not
    appropriate."

    Dr. McGuire adds that the new standard has caused quite a bit of
    confusion and concern, mostly among Class B facilities that don't give
    inhalational anesthesia and misread the standard to mean they couldn't
    administer propofol unless they bought an anesthesia machine and CO2
    monitor. Part of the confusion, he says, lies in the nature of the
    propofol.

    "Is propofol a general anesthetic or a sedation agent? It's both.
    Really, truly, it is both," says Dr. McGuire. "At a certain level and in
    a certain individual, it is a sedation agent. In other individuals or at
    higher does, it becomes a general anesthetic agent. It's so
    unpredictable, which is not a problem if you're an anesthesiologist but
    can be if you're a surgeon trying to do surgery and supervise a nurse
    giving the medication."
  8. by   stevierae
    i just took a look at the southern oregon gastroenterology lab site where they do nurse administered propofol.

    i found it very interesting that the doctors were giving themselves all kinds of pats on the back for supposedly pioneering the technique in 1998, and were mentioned by name, but the 3 nurses involved were mentioned only by those words: "3 nurses."

    gee, they didn't even deserve a mention by name for their part in (allegedly) making history and attracting patients from all over the world.

    why didn't the docs just call them what they really are? "cheap labor." they should also define their job description this way: "expected to carry out the role of an anesthesia provider;
    (whether crna or anesthesiologist)
    be held to the standard of care of an anesthesia provider
    (crna or anesthesiologist)
    and accept all risks and responsibilities normally taken on by an anesthesia provider
    (crna or anesthesiologist)
    but do it at the same salary of any other registered nurse, without complaints."

    here's a blurb off the site. the doctor with his reference to "having gone to heaven and being among the angels" (what---did they have to "rescue" him from a near death experience?!) when he woke up and felt the "loving presence" of the nurse" is enough to make you gag. the metaphor about the nurse as compared to a mother checking her baby's formula on her hand is even more saccharine. who wrote this nonsense?!!!!

    "our protocol, on the other hand, involves nurse decision-making, within the confines of the protocol, to administer a tiny, incremental dose when called for by patient adversive movement and only if the breath is robust, as determined by the nurse's constant palpation

    we have had no apnea, not do we expect this ever to happen.

    were it to happen, we think the length of the apnea would be in keeping with our colleagues at the cleveland clinic.

    since the nurse is palpating each breath and otherwise watching the patient like a hawk, and since propofol is white and opaque, one could envision a certain metaphor of a mother checking a baby's formula on her hand or wrist to make sure it is the proper temperature.

    the nurse certainly exudes a loving presence to calm the patient, which is part of our protocol.

    one local physician opened his eyes after his screening colonoscopy recently and told the nurse that he thought he had gone to heaven and was among the angels."
    Last edit by stevierae on Sep 11, '04
  9. by   stevierae
    here's one more official statement, for you gonzo nurses ---especially those at labs like the one in southern oregon--who think that the rules don't apply to them.

    blown up to 500x its normal size, it will look excellent sitting in front of a jury, when you are called one by one to the witness stand to testify as to why you thought you could make your own rules.

    aana-asa joint statement regarding
    propofol administration*
    april 14, 2004

    because sedation is a continuum, it is not always possible to predict how an individual patient will respond. due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonistic medications, agents such as propofol require special attention.

    whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. this restriction is concordant with specific language in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.

    similar concerns apply when other intravenous induction agents are used for sedation, such as thiopental, methohexital or etomidate.

    *this statement is not intended to apply when propofol is given to intubated, ventilated patients in a critical care setting.
  10. by   2rntish
    i just don't understand why you'd take on the extra headaches and liability--with no extra compensation. and, believe me, there is huge potential liability for you.

    i am an operating room nurse and a legal nurse consultant. i, too, have very strong feelings on the issue of nurse administered propofol, and they are, in part, that propofol should not be given, by a nurse, to a non-intubated patient!!!!!!!! ever!!!!

    there are nurses perfectly cabable of administering propofol, yes. they are called crnas.

    i live in oregon. i will be waiting for the day when i see the medford facility called on the carpet for unsafe patient care practices, and i will be volunteering my services as a behind the scenes consultant--or as an or nurse expert--or assisting with expert location--to any attorney who wants to put a stop to this dangerous practice and shut your facility down.

    in fact, maybe i can be the one to make a few calls and speed up the process.

    i am really tired of "gonzo" nurses who don't know what they don't know, and think it makes them look important to do an anesthesia provider's job. if you are not capable of delivering one level higher than deep sedation--that is, general anesthesia; skilled intubation and all--then you should not be delivering deep sedation. i don't even think you should be delivering moderate sedation. that's an anesthesia provider's job.

    i get tired, also, of hearing about your capability to "rescue." yeah, yeah, we're all (operating room nurses)acls certified; nothing special about that. but you guys in endo labs seem to think that as long as you can deliver--or think you can deliver; based on what you learned in classes-- acls, it almost makes it ok to take unnecessary risks.

    why get a patient to a point where he needs to be "rescued?" the fact that he ends up there in the first place shows that you had no business doing what you did that got him there!!!!!!!

    ususally "rescue" means that you have to call on someone--i.e., an er doc, who has to drop what he is doing and come to your "rescue" by intubating the patient for you and dealing with all the unnecessary problems that have been created--i.e., a period of anoxia or hypotension or both.

    you've had no adverse effects to date? famous last words....many a nurse who gave propofol in a plastic surgery clinic has used that phrase--and maybe she didn't have any "adverse effects," by sheer luck or the grace of god--until the day she did, and her facelift patient died...[/quote]

    do you think the gonzo nurses are the ones ordering these meds? what i am sick and tired of are nurse consultants who think they know everything about medicine when you are just a nurse. why not let the crnas take care of propofol issues in court. why are qualified as an expert when you just stated no nurse should have anything to do with it?
    try tackling the drs who order these things be given. and don't start with"the nurse always has the right to tefuse to carry out an order" crap. i understand that.
    our endo lab has no gonzo nurses and no nurse consultants that think they hung the moon. i monitor all conscious sedation cases and have seen fewer rescue case in that dept that radiology that only uses versed, op surgery that will use versed...
    get off your high horse, look at the numbers. is the drug really safe but you have a few idiots out there that don't know how to use it???
    inapsine also caused quite a stir years ago. adjunct to general anesthesia...whoa...maybe crnas should give that.
    i do not like your threat to make a few calls to speed the process along. if you want to respond privately to my e-mail i will be happy to give you our info. welcome the challenge. our chief of staff had the board of nursing change their stance on cs several years ago to include lpns. bring it on.

    gonzo.
  11. by   2rntish
    I am all for pt safety. There are things that happen in every hospital in the country ( even those with Gonzo nurse consultants) that put the pt at risk. Nurses must decide with seconds to think about it, should I or shouldn't I. Sometimes we choose correctly sometimes we don't.
    Personally I am undecided about diprivan, dream cream, milk of amnesia...What I do know is that are pts in Endo love it. I try to have an open mind about these things. The physician (who last time I checked has more training than nurse consultants and CRNAs) seem to think it is OK.

    Last year we administered ~3000 doses of propofol and ~4000 of versed. Primarily in endo, some in cath lab, rad, er...

    Would anyone like to guess what the complication rate was????
  12. by   stevierae
    Quote from 2rntish
    i just don't understand why you'd take on the extra headaches and liability--with no extra compensation. and, believe me, there is huge potential liability for you.

    i am an operating room nurse and a legal nurse consultant. i, too, have very strong feelings on the issue of nurse administered propofol, and they are, in part, that propofol should not be given, by a nurse, to a non-intubated patient!!!!!!!! ever!!!!

    there are nurses perfectly cabable of administering propofol, yes. they are called crnas.

    i live in oregon. i will be waiting for the day when i see the medford facility called on the carpet for unsafe patient care practices, and i will be volunteering my services as a behind the scenes consultant--or as an or nurse expert--or assisting with expert location--to any attorney who wants to put a stop to this dangerous practice and shut your facility down.

    in fact, maybe i can be the one to make a few calls and speed up the process.

    i am really tired of "gonzo" nurses who don't know what they don't know, and think it makes them look important to do an anesthesia provider's job. if you are not capable of delivering one level higher than deep sedation--that is, general anesthesia; skilled intubation and all--then you should not be delivering deep sedation. i don't even think you should be delivering moderate sedation. that's an anesthesia provider's job.

    i get tired, also, of hearing about your capability to "rescue." yeah, yeah, we're all (operating room nurses)acls certified; nothing special about that. but you guys in endo labs seem to think that as long as you can deliver--or think you can deliver; based on what you learned in classes-- acls, it almost makes it ok to take unnecessary risks.

    why get a patient to a point where he needs to be "rescued?" the fact that he ends up there in the first place shows that you had no business doing what you did that got him there!!!!!!!

    ususally "rescue" means that you have to call on someone--i.e., an er doc, who has to drop what he is doing and come to your "rescue" by intubating the patient for you and dealing with all the unnecessary problems that have been created--i.e., a period of anoxia or hypotension or both.

    you've had no adverse effects to date? famous last words....many a nurse who gave propofol in a plastic surgery clinic has used that phrase--and maybe she didn't have any "adverse effects," by sheer luck or the grace of god--until the day she did, and her facelift patient died...
    do you think the gonzo nurses are the ones ordering these meds? what i am sick and tired of are nurse consultants who think they know everything about medicine when you are just a nurse. why not let the crnas take care of propofol issues in court. why are qualified as an expert when you just stated no nurse should have anything to do with it?
    try tackling the drs who order these things be given. and don't start with"the nurse always has the right to tefuse to carry out an order" crap. i understand that.
    our endo lab has no gonzo nurses and no nurse consultants that think they hung the moon. i monitor all conscious sedation cases and have seen fewer rescue case in that dept that radiology that only uses versed, op surgery that will use versed...
    get off your high horse, look at the numbers. is the drug really safe but you have a few idiots out there that don't know how to use it???
    inapsine also caused quite a stir years ago. adjunct to general anesthesia...whoa...maybe crnas should give that.
    i do not like your threat to make a few calls to speed the process along. if you want to respond privately to my e-mail i will be happy to give you our info. welcome the challenge. our chief of staff had the board of nursing change their stance on cs several years ago to include lpns. bring it on.

    gonzo.[/quote]

    ummmm....i am an operating room nurse... with over 25 years of experience. i do travel assignments in operating rooms all over the west coast, in major teaching hospitals and trauma centers, and i scrub and circulate all specialties. i have a fair grasp of the way things are done elsewhere. you?

    what you are doing is not conscious sedation--it is moderate or deep sedation--something only an anesthesia provider should be doing. i would only testify to nursing soc--that is, to what a reasonable and prudent nurse is allowed to do--and that does not include moderate or deep sedation.

    and, oh, trust me--any crna or anesthesiologist would be more than willing to testify that what you are doing does not constitute safe patient care--that only an anesthesia provider should be administering propofol.

    and, i know more than one gastroenterologist expert who does not feel that propofol is even the appropriate sedation of choice for colonoscopy. most people go with fentanyl and versed, and truly conscious sedation. they want their patient to be alert enough to let them know if--and where--and the nature of--any pain or discomfort, so that they can intervene accordingly. in other words, they want the patient to be an active participant in the procedure.

    this is what i feel perfectly comfortable testifying to in court--the fact that you are overstepping your bounds. you are stepping outside the parameters of what is permitted of a registered nurse. if you are from the southern oregon facility, read the oregon nurse practice act!!! if you are from somewhere else, read your own state's nurse practice act!

    does the joint statement put out by the american association of nurse anesthetists and the american society of anesthesiologists denouncing your practice mean nothing to you? what about the one put out by aaaafs? how do you think a jury would react to both those statements, blown up about 500x?

    argue about semantics and terminology to call it whatever you want, but the bottom line is, no rn should be administering propofol to a non-intubated patient. ever.

    in fact, i won't even give conscious sedation---not even "just fentanyl and versed." they don't pay me enough to do an anesthesia provider's job, and, truthfully, i think every patient deserves an anesthesia provider gving his anesthesia. i know my limits--i am only an operating room nurse. i know what i don't know.

    you have lpns giving conscious sedation? lpns are not even allowed to carry out patient assessment!! how can they give conscious sedation, if they cannot continually assess the patient?

    you still have not told me why you choose to do an anesthesia provider's job for a nurse's salary. is it the "prestige" you enjoy, that makes it all worthwhile?

    oh, and inapsine? most reasonable and prudent practitioners across the country have all but abandoned its use. zofran and even decadron are being utilized to combat post-op nausea--and in some places compazine is making a comeback. there are those diehards who insist on using iv phenergan, but more and more reasonable and prudent nurses are reluctant to give that particular drug iv, due to the effect of its ph on peripheral veins, and just saying "no" to giving it via peripheral iv. i absolutely will not give phenergan through anything but a picc, ej, or ij--regardless of who says it's "ok" or who orders it.

    there are many of us out there that don't do things simply because a doctor or a nurse supervisor tells us to. we think for ourselves, and we function, always, in our primary role--that of patient advocate.
    Last edit by stevierae on Sep 13, '04
  13. by   Medic946RN
    In the Endoscopy center I now work in RN's cannot push propofol or fentanyl. However when I work in the ED. I do it all the time. We give it for pt's placed on vents and use it for conscious sedation. I've given fentanyl to assist with placing chest tubes. These drugs are just that drugs, all have risks and benefits and side effects. If you are familiar and comfortable in giving the drug there's no problem. I love our CRNA's that work with us. But I didn't need another two years to learn conscious sedation. Having said that, I wouldn't step into an OR and do the same thing because I don't have experience using the drugs over a long period of time, greater than 4 hours or so that I might have to hold a vented pt in the ED while they scramble to make room for them in unit.

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