Can I bolus this patient? A legal / practice question about sedatives and narcotics - page 8

by simvee 20,457 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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    Interesting debate. I had the same problems with Cerner-maybe the bolus should be a seperate PRN order so we can chart them appropriately. At my new hospital, all of our patients on narcotic drips have PCA pumps, if they are on a vent and sedated (usually with propofol here), they have a basal and a bolus order with no demand settings. That way all of our boluses are recorded and accounted for on the PCA. Its a very small oncology ICU though and its not feasible to do that on a large scale. But it has made me more conscious of my boluses. Although, I've seen nurses accidently type in 1000 mcgs of Fentanyl instead of 100...just CYA whatever you're doing cause no one else is going to do it for you!
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    Quote from IDoNotGiveOut
    .
    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.
    ]

    I've worked in a few different ICUs, in 2 different states, and bolusing from the bag; without charting, and without orders (other than titration) is *always* how its been done. By all the nurses. In all the hospitals.

    A quick 25 mcgs of fent prior to suctioning, or a quick versed bolus before a trip to CT is perfectly fine. If it's due to a need for increased sedation then they get a bolus along with a rate increase. Ive done it in front of the MD, pharmacy, my nurse manager...in fact, we worked with pharmacy and our smart pumps to set bolus limits on the pumps.


    Everyone needs to chill: Good-freaking-grief!!
    Last edit by CCL RN on Oct 8, '11
    MomRN0913 and mmutk like this.
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    I have never heard of Propofol on a PCA?! Does anyone else do that?
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    Quote from mmutk

    I have never heard of Propofol on a PCA?! Does anyone else do that?

    There are some facilities that are placing these meds on PCA pumps to regulate and account for these high abuse meds. The pumps are NOT used by the patient. They are set at a basal rate with the "boluses" administered by the staff at a pre-set amount to end the casual "just a touch" for suctioning. The patient does not self administer....they are for narcotic control on usage and waste.
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    Just an example. Nurses in my icu will bolus 3 ml or so of propofol for an agitated situation like you described an in front of the pulmonologist at some point mentioned she had to "give the patient some love". End result physician freaked an now no longer will allow propofol drips on his intubated patients(its hell).

    Of course its wrong, dont do it, ive seen in surgery the CRNA wouldnt (cant? Idk) push the propofol, was passed to the anesthesiologist to push.
    Esme12 likes this.
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    Quote from FCMike11
    Of course its wrong, dont do it, ive seen in surgery the CRNA wouldnt (cant? Idk) push the propofol, was passed to the anesthesiologist to push.
    That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it just needs someone with advanced airway management skills to push it in a non-intubated patient (something that a CRNA, Anesthesiologist, or AA all possess).
    Esme12 likes this.
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    Quote from aCRNAhopeful
    That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it just needs someone with advanced airway management skills to push it in a non-intubated patient (something that a CRNA, Anesthesiologist, or AA all possess).
    Right exactly why I tried not to assume much, maybe I wasn't looking that specifically and the MD just happened to be closer to the iv site. Main reason I noticed he walked in at the beginning of the case, pushed propofol then immediately left.
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    Quote from aCRNAhopeful
    That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it that a CRNA, Anesthesiologist, or AA all possess).
    I agree.......sounds like someone got caught with their hand in the cookie jar......


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