Propofol

2rntish · Oct 12, 2004

Reminds me of an old saying. You are just like an ostrich, you can bury your head in the sand but your *** still shows.

Too many miles between us. I will go my way, you go yours. There are happier threads to follow.

You stand on legalaties, I will stand beside pt care. You side with the board, I will work with the Drs who are comforting and caring for pts. You make sure all the i's are dotted, I will try to make sure the meds are available to pass.

I work in the real world where nurses do what they have to do. We no longer have time for back rubs and foot soaks. Nursing has changed, some of us have as well. I don't like computer documentation, I think it is unsafe. What about barcoding...times are a changing. Us, good ol boys, unethical, cowboy, practicing outside the board guidelines, and whatever else I have been called will continue to take care of pts the best we can.

I just saw John Wayne aggressive ICU nurse...I used to work with a passive ICU nurse that was scared to do anything including defib a pt without a DR there. Get a grip.

And read the Dip literature very closely and see if it is your interpretation or what the manuf actually states. Think like a lawyer since you seem to be drooling over my subpeona. Does it say a nurse CANNOT do it in a monitored situation???

rn29306 · Oct 12, 2004

Reminds me of an old saying. You are just like an ostrich, you can bury your head in the sand but your *** still shows.
Too many miles between us. I will go my way, you go yours. There are happier threads to follow.
You stand on legalaties, I will stand beside pt care. You side with the board, I will work with the Drs who are comforting and caring for pts. You make sure all the i's are dotted, I will try to make sure the meds are available to pass.
I work in the real world where nurses do what they have to do. We no longer have time for back rubs and foot soaks. Nursing has changed, some of us have as well. I don't like computer documentation, I think it is unsafe. What about barcoding...times are a changing. Us, good ol boys, unethical, cowboy, practicing outside the board guidelines, and whatever else I have been called will continue to take care of pts the best we can.
I just saw John Wayne aggressive ICU nurse...I used to work with a passive ICU nurse that was scared to do anything including defib a pt without a DR there. Get a grip.
And read the Dip literature very closely and see if it is your interpretation or what the manuf actually states. Think like a lawyer since you seem to be drooling over my subpeona. Does it say a nurse CANNOT do it in a monitored situation???

My head isn't stuck anywhere, I am actually going back to school to better myself while others are taking a shortcut and bypassing what is known to be safe and accepted. You are way off when it comes to crossing i's and t's. Until a year ago, I was doing transports and unit ICU. Sometimes my charting was 4-6 hours behind due to being at the patient's bedside, almost having mds in headlocks to get done what was needed to be done. No one said all bedside RNs did was footbaths and sitz baths.

As far as my "interpretation" of diprivan in the previous posts, all were actually straight from the works on their webpage. Why don't you got to http://www.astrazenaca-us.com/pi/diprivan.pdf and read it for yourself. It is used for "induction and or maintanance of anesthesia" or "when administered IV, as directed (that means anesthesia for you) it can be used to initiate and maintain monitored anesthesia (key word) care sedation during diagnostic procedures". The quotations actually mean this is word for word what the mfg states. Interpretation is left to you, although I think this is pretty clear on what is being said.

You are so right, "it IS amazing what two years additional education will do for you". Ignorance is not knowing the difference and proceding. Stupidity is knowing what is right and wrong and yet proceeding anyway. I prefer to stay away from either. :rotfl:

2rntish · Oct 12, 2004

Last post (I almost spelled pist :chuckle ) for the day. Not all of the state boards of nursing agree with you and your BON. I know of atleast one that leaves it up to the facility and the MD at the bedside.

I also wonder if all the extra training is to push that little syringe. If the MD is directing the procedure...what in the hell or you going to do that requires extra training outside of ACLS, PALS, advanced airway. Last time I checked most MDs studied a little pharmacology. Probably know ASA I, II, III....how much to give....or is that the extra training you are talking about.

Do you have a code team at your hospital? How long does it take them to respond??? Can you not still bag THE OCCASIONAL pt that needs vent support from FENTANYL, DEMEROL, VERSED, DIPRIVAN. Get your head out of the sand and look at ALL DRUGS. Look at the ACTUAL COMPLICATION RATE not what a drug company influenced by money from certain groups who are trying to hang on to a little autonomy and willing to put up big bucks. LOOK AT THE NUMBERS. 10,000 cases and the DOCOMENTED need for resp support is a hell of a lot less than those complications seen in recovery or OR where all the gifted gas passers work.

How do you propose to staff all the cath labs and endo suites??? I don't know about your neck of the woods but we don't have a CRNA or better for every case. We do have an MD... I've got a good idea ...let's not use a wonderful drug like Diprivan that has fewer complications than the good ole John Wayne drugs like Demerol. Keep pushing the old stuff, I'll take the good stuff. Research the nurse practice acts and if you can't find atleast one that allows the facility to decide. Pretty aggresive for our little podunk state. Maybe you can call our BON and give them your facts. Maybe our BON will change their mind "just for you". I am sure they DID NOT read any drug information before they made their decision.

rn29306 · Oct 12, 2004

Last post (I almost spelled pist :chuckle ) for the day. Not all of the state boards of nursing agree with you and your BON. I know of atleast one that leaves it up to the facility and the MD at the bedside.
I also wonder if all the extra training is to push that little syringe. If the MD is directing the procedure...what in the hell or you going to do that requires extra training outside of ACLS, PALS, advanced airway. Last time I checked most MDs studied a little pharmacology. Probably know ASA I, II, III....how much to give....or is that the extra training you are talking about.
Do you have a code team at your hospital? How long does it take them to respond??? Can you not still bag THE OCCASIONAL pt that needs vent support from FENTANYL, DEMEROL, VERSED, DIPRIVAN. Get your head out of the sand and look at ALL DRUGS. Look at the ACTUAL COMPLICATION RATE not what a drug company influenced by money from certain groups who are trying to hang on to a little autonomy and willing to put up big bucks. LOOK AT THE NUMBERS. 10,000 cases and the DOCOMENTED need for resp support is a hell of a lot less than those complications seen in recovery or OR where all the gifted gas passers work.
How do you propose to staff all the cath labs and endo suites??? I don't know about your neck of the woods but we don't have a CRNA or better for every case. We do have an MD... I've got a good idea ...let's not use a wonderful drug like Diprivan that has fewer complications than the good ole John Wayne drugs like Demerol. Keep pushing the old stuff, I'll take the good stuff. Research the nurse practice acts and if you can't find atleast one that allows the facility to decide. Pretty aggresive for our little podunk state. Maybe you can call our BON and give them your facts. Maybe our BON will change their mind "just for you". I am sure they DID NOT read any drug information before they made their decision.

Favorite line from the Matrix series........"Ignorance is bliss."

jwk · Oct 12, 2004

our chief of staff had the board of nursing change their stance on cs several years ago to include lpns. bring it on.
gonzo.

well, i only made it to the middle of this thread before i had to make my first response.

why on earth would lpn's be allowed to give conscious sedation? in the majority of states, they can't even push iv meds legally.

first response - more to follow - this one's to juicy to pass up! :chuckle

jwk · Oct 12, 2004

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.

You can always tell when someone doesn't know what they don't know - it's by the number of "certifications" and licensure abbreviations they put after their name to make it seem impressive.

Did you know that in some states (Florida for example) it is ILLEGAL for RN's to give propofol?

All of you seem to think that because the ER or GI doc is standing there and gave the order that your *** is covered in case something goes wrong. IT'S NOT!!! You are responsible for your own actions.

Quincke · Oct 12, 2004

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!
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.

Just a few comments from a previous ICU nurse who used propofol to sedate INTUBATED pts...

First, the true half life of propofol is NOT 1.8 minutes. The actual half life is 30 minutes to 1 hour in a healthy pt younger than 60 and up to 3 hours in an older pt or one with organ insufficiency. What you are actually think of the is distribution half life (due to redistribution) which is typically 2-4 minutes.

Second, did you actually titrate the drip after the doctors set it up for your ECTs in the midwest or did you just turn it off. Also, what would you have done if you did have an airway problem?

Third, I don't think anyone is selling RNs short. This is just a drug that has a VERY narrow margin of safety. Since I have been in anesthesia school, I have learned so many things about propofol that I did not know before. It if very tricky to give just the right dose of propofol without making the pt apneic (like for a MAC), especially when combined with midazolam or fentanyl. I had ACLS, PALS, etc. when I was working in the ICU, but none of that compares to really being taught how to manage an airway (i.e. anesthesia school).

Just curious, what sort of airway devices are kept in the GI lab? What emergency meds are kept there? How long would it take to get anesthesia or some else able to manage the airway and intubate if needed to get to there?

stevierae · Oct 12, 2004

I work in the real world where nurses do what they have to do. We no longer have time for back rubs and foot soaks.

So, 2rntish, are you one of those RNs who thinks you are somehow "too good" to do these things? Baths, backrubs, washing and combing hair, cutting nails--all part of good nursing care?

I work OR, but I would certainly do--and have done-- those things for any patient who was under my care if I worked in any other patient care area. I would consider it part of my JOB. I've even done it in the operating room--that is, bathed patients and brushed their hair and cut their nails before discharging them to PACU or ICU. Sometimes patients come to us who have been severely neglected hygienically in nursing homes, or are homeless, or haven't even had their faces washed while they were in ICU. Why shouldn't I take those extra couple of minutes to clean them up and possibly make them feel a bit better post-op? How do YOU feel when your hair is dirty or tangled, for heaven's sake?

You would probably have time to do it too if you weren't so busy doing someone else's (anesthesia's) job, or "teaching" other people why it's somehow OK to do anethesia's job.

Please expound on what you are saying about LPNs and conscious sedation. I know of no state where this is allowed. LPNs don't have the assessment skills to follow the continuum of anesthesia.

2rntish, you have STILL never answered this one question: Why would you choose to do something for which you are not monetarily compensated? If I am going to do something that requires more risk, training, and responsibility, I want the additional $$$ that comes with the territory. Even charge nurses demand extra compensation, as do nurse educators.

GI docs are not anestheisa providers. Don't get the idea that simply because they are in the room you are covered. Some simply stand there and can't even do CPR. Some surgeons are the same way. It's not their area of expertise, after all---that's what they depend on anesthesia for! Anesthesia providers are the experts in this arena, after all!!

Why do you feel so strongly about this topic, if you don't even work endo? Where the heck DO you work, anyway? I've never heard Diprivan referred to as either "Dream Cream" or "Dip." "Milk of amnesia" yes, by those youngsters who are seeing it used for the first time--most of us who have been around since its inception call it by its recognized names--Diprivan or Propofol--as we would any other drug.

jwk · Oct 13, 2004

No hostility here (I don't think). I have seen situations in ER where we have several RN,CCEMT-P working. A patient comes, difficult intubation, facial trauma...anesthesia is called, can't get the tube in. Critical care paramedic is mentioned. People who have lived and breathed this sort of thing and told they were not "qualified" and if a Dr couldn't do it, what made them think they could. I have been in the same ER with a different DR in charge that would allow help. Things went very well.
I saw an LPN under a DR direct supervision make an incision for a PEG tube. I hit the roof. Stupidest thing I had ever seen, certainly not in her scope of practice. The DR told her exactly where, when, how... she had seen it done hundreds of times. Dr was holding the scope...Guess what, the patient did fine.
No I don't want an LPN cutting on me but if the DR is there, guiding every move, much like they are when the RN pushes Diprivan, it will be OK.

Does the concept of what is legal and is not legal ever enter your mind? Apparently not. That is so far outside any LPN's scope of practice it's ridiculous. So what if the doc is standing there? If she went too deep an cut an artery, you think she'd have leg to stand on? NOPE!

srnaKate · Oct 13, 2004

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.

You just have GOT to be kidding! These, dear readers, are the words of a DANGEROUS FOOL! If by now he is not able to discern the legal implications, never mind the physiologic ramifications of using this drug he is just plain stupid. The saddest part of all is that the literature and evidence is before him and yet, he protests and claims to be in control. What is kmchugh trained for that the ER nurse with 10-20 years experience is not? ANESTHESIA! Can someone that dense actually hold a license?

Oh by the way, Dopamine and propofol are a little different, don't try comparing them!

apaisRN, RN, CRNA · Oct 13, 2004

In what world are patients on dopamine drips on the floor? Certainly not mine. I was taught that dopamine is a powerful drug with a lot of potential for harm. I'd hate to see it used on an unmonitored patient, or one on a floor with 1:6 ratios (which is good these days!).

charles-thor · Oct 13, 2004

Someone's previous post regarding RNs giving propofol in the absence of a secure airway:

" EVERY SCENARIO I HAVE DISCUSSED INVOLVES AN MD BEING AT THE BEDSIDE"

Unless the MD was an anesthesiologist, you are strongly mistaken that this individual will be able to appropriately treat adverse anesthesia related events - difficult airway, ect. GI docs know as much about anesthesia as my mechanic understands about quantum physics.

To administer general anesthetic agents to patients without protected airways requires CRNA, MD, or AA after your name.

Some things to consider:

- Propofol is the most destabilizing intravenous anesthetic.

- Tidal volume reduced more than respiratory rate, thus in the presence of

an adequate rate, minute ventilation may remain inadequate allowing

hypoxemia to ensue.

- Propofol decreases the ventilatory drive in response to hypoxia AND

hypercarbia.

- Don't get caught up in the fallacy that easy titratability always translates

into safety.

- In addition to reading the package insert regarding appropriate

administration, take a second to review the AANAs and ASAs joint

statement regarding propofol dministration

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.