Can I bolus this patient? A legal / practice question about sedatives and narcotics - page 7

by simvee 20,442 Views | 77 Comments

Hi, I'm a new RN in a trauma ICU. We use a LOT of pain drips and sedative drips. Typical patient has Versed and fentanyl on pumps with orders to titrate as needed to maintain sedation (MAAS score of 2-3). Sometimes they use... Read More


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    Can I just say OMG, OMG, OMG. Propofol has never been legal here to push even prior to MJ. Not even during rapid sequence intubation. MD only! This whole conversation has me wondering about where I work. Thank You. I am now going to look more carefully and really take s look at our policies. We use Baxter pumps. They're not the best for calculating total volume ,but the work. We have to scan bar codes on all our meds. How do you do that if you're bolusing from the bag? How about trying some seroquel or other antipsycotic ? Haldol anyone? Our docs haven't started entering their own orders yet, but we do have already printed order sets. Thanks again for the food for thought.
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    I'm wondering if some of the people with the absolutely shocked and horrified responses have ever worked in an ICU???? If so, on what planet was it located? Sarcasm aside, I agree that there is an issue here, but it is an issue of informatics, physician accountability and nurses willing to accept deficiencies in both of the above. The computer people need to make sure there's an easy way for the doctor to order "bolus from infusing bag" which then gives an appropriate dose range and frequency and thus allows the nurse to legally give and document all boluses. The pharmacy people need to not give the doctors grief when they see such orders because they aren't the ones watching the patient bucking the vent, de-satting, dangerously spiking their blood pressure, etc. Nurses need to refuse to accept a situation where everybody knows it happens and that it's not legal, but they're perfectly happy letting the RN risk her license rather than take two seconds to write an order. The real root of this problem is that the people who develop these systems aren't the ones who actually take care of these patients.

    Regarding propofol, the great thing about propofol is its quick onset and short duration. Those of us that work with adult neurosurgery patients on Q1H neuro exams who d/t their brain injury are completely non-directable and who have strict BP parameters lest they bleed more into their brain and/or have ICPs spiking into the 40s and above when they’re awake (at which point there is a risk for brain herniation) know that it is necessary to keep them well sedated in the times in between neuro exams, but they can't have long acting narcotics/benzos because this may cloud their neuro exam. You have to turn the propofol off for ten minutes, get your neuro as soon as they are awake which you will know because you will hear the vent alarming like crazy and the monitor red alarming because their vitals are going nuts, and then rapid bolus them back to happy-land. Wait 50 minutes, repeat.

    On non-neuro patients who are truly only getting 1 daily wakeup, there really is no excuse for the frequent bolusing. Turn up their basal rate if it's not working. Get an order for more narcotics. It’s not rocket science – there really is no excuse for that. But on vented neuro patients that must be awoken every hour and quickly re-sedated before you kill them, bolusing of propofol is unavoidable. There is no law or guideline stating that propofol cannot be used this way by trained nurses with a physician order on a vented patient in a critical care unit. If the sedation is being used for a procedure, then it is considered a form of anesthesia. Read the insert to a bottle of propofol and you will see that they do state an anesthesiologist must administer propofol when used only for sedation during a surgical procedure and that this physician must be dedicated to the role of anesthesia and not be the one performing the procedure. But they make exception for sedation of vented patients in ICU, in which case trained RNs may administer propofol (with physician order of course). They do not make any statement prohibiting nurses from administering a bolus of propofol if ordered. Again this only applies to trained nurses, in the ICU, when the patient is intubated, and it’s not being used solely for a procedure.
    Regardless, you do need to get an order, even though most of us were trained that it is perfectly OK to do it without an order and without charting (which is the way I was trained by multiple different preceptors) and it seems like a ridiculous thing to call a doc to order for you in the middle of the night. Once the docs start getting enough of such calls, though, I guarantee they’ll coincidentally start remembering to order that PRN bolus at the same time they order the gtt.
    To summarize, on certain patient populations blousing may be necessary. People with no real life experience caring for these patients, whether these people are nurses or not, really don’t have a clue what they’re talking about. The real issue here is nurses not standing up for themselves to insist on a system which allows them to legally practice according to the needs of real life patients in the real world.


    CCL RN, esie, mmutk, and 3 others like this.
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    IDONOTGIVEOUT- Right on!!! I agree with you 100%. Why not write the order for a PRN bolus? Really! Most of the MD's know the ICU nurses do this...... Just right the damn order. It saves alot of patients from harm. There isn't time to obtain an "order" for a bolus, you need to act according to that situation right then and there.

    I do also believe someone who has never taken care of one of these patients has no idea. Sit there and watch the patient cough out the tube because you can't get a Dr on the phone fast enough for an order to prevent this from happening......
    mmutk likes this.
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    I believe Propofol may be a state by state issue. In Arizona, you can lose your nursing license if you bolus propofol.
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    @dh07RN---Is this law only for pts in a non-ICU setting? I am an neuro ICU nurse in IL and we use propofol gtts on our intubated pts. We do bolus them and adjust the rate prn per RASS protocol.

    Just curious.....I'm going to look into the Illinois Nurse Practice Act now. thanks!
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    Quote from ChicagoICUNurse
    @dh07RN---Is this law only for pts in a non-ICU setting? I am an neuro ICU nurse in IL and we use propofol gtts on our intubated pts. We do bolus them and adjust the rate prn per RASS protocol.

    Just curious.....I'm going to look into the Illinois Nurse Practice Act now. thanks!
    I beleive the restriction is bolusing propofol is mandated for patients to be on a vent and the bolus administered through a pump only and only in a critical care setting. The "bolus" restricted for use by non trained personel is the IV push "bolus" if not in the ICU setting. Most states allow nurses "specially certified" in certain situations to give IV boluses (IV push) only if patient 1:1 monitored with MD IN THE ROOM......like in endoscopy in doses consistant with "conscious sedation" and anesthesia "stand by". Hospitals are notorious for saying something is illegal when it is forbidden by their facility.

    So still check your states guidelines and regulations.......
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    I agree with the WHAT PLANET ARE YOU FROM if you do not give an occasional bolus or quick temp titration for your drips when your patient needs it. As long as you have a titration orders it's not a big deal.

    If someone was taking care of my mom I would hope if she needs a quick fent dose prior to a bath or something she could get it.
    CCL RN likes this.
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    Quote from mmutk
    I agree with the WHAT PLANET ARE YOU FROM if you do not give an occasional bolus or quick temp titration for your drips when your patient needs it. As long as you have a titration orders it's not a big deal.

    If someone was taking care of my mom I would hope if she needs a quick fent dose prior to a bath or something she could get it.
    I agree, Of course we have all given that brief wiff of med to ease through a tough spot...... but at some point a descrepancy will occur then how do you account for the lost narcotic. Titration orders are not bolus orders......I know what is done but just the same. The practice here from the OP's statement gave me an impression of excessive use and negligent documentaion which for me accumulated in narcotic descrepancy.
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    Quote from Esme12
    Ok it sounded harsh...............but I really mean this from the bottom and top of my heart........this practice is not good......please call you BON and ask that rhetorical question...........thanks

    Well....NO. It was NOT harsh. Your post (#27) was proper and basically meant to open the OP's eyes.

    There are clearly some serious and very dangerous issues in that ICU/hospital. The manager of that unit needs to get fired for sitting on their ass and not spot checking his/her unit. Seems like there is not a chart audit/PI program in place.

    I would have blown a gasket if my coworkers told me not to chart the narcotic boluses! WTH/W*T*F* are these idiots thinking???

    I've worked too damn hard to get my license and I have promised myself that when I die, I will be taking it to the grave with me.

    The OP needs to get management involved to include IT. If that crappy software can't let you add customized fields, then get rid off it and get a better program. And get the director involved as well. Never trust a doc. Just b/c they bring you breakfast everyday, does not mean they will cover your ass. They will sell you as fast as you can blink.

    Good luck.
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    dont you have to do totals every hour? Any doc sees the volume which is off the pump and knows how much the pt got. At least all our SICU attendings did. second in peds yes you chart the time of the bolus, but in adults you chart the score of the scale you used to bolus then a post assessment. How would you defend yourself in court without record of the symptoms/scores on which you based your bolus's. That is why you bolus and titrate up. Pts are stimulated every hour or two. Do you want to be intubated and be awake or appropriately sedated?


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