1. I am a new graduate RN and I work in the Phoenix area. I am now off of orientation and will now have to make decisions for myself. This said, I was wondering if anyone knew the actual AZ State Board of Nursing policy on giving a bolus of Diprivan. This happens a lot in the hospital I work in for intubation purposes. The Doctor is standing less that a foot away from me and the IV pump, the doctor is also sterile for the procedure. He then tells whichever RN is standing at the bedside to bolus the patient 10cc's in order to help with intubating the patient. I have seen several nurses do it but then again some say you do it and then don't talk about it, since Diprivan is a form of anesthesia. All I really care about is my license and where I would stand in a "legal issue," with this. Can anyone help me with this?

    Thanks in advance,
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    About naturallyred

    Joined: Nov '05; Posts: 12; Likes: 5
    Intensive care; from US
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  3. by   RNfaster
    i am only a pre-nursing student. but i found some data you might be interested on the arizona nursing board site:

    32-1661. administration of anesthetics by registered nurse; definition
    a. a licensed registered nurse may administer anesthetics under the direction of and in the presence of a licensed physician or surgeon if the nurse has completed a nationally accredited program in the science of anesthesia.
    b. as used in subsection a, "presence" means within the same room or an adjoining room or within the same surgical or obstetrical suite.

    http://www.azbn.gov/scopeofpractice.asp - contact info you might want to try...

    i also found some interesting articles below. it sounds as though you have a valid concern, especially since you are being asked to administer a bolus, something that the jan. 2007 article notes is more likely to be restricted. bottom line --it looks to me as though you should check with the az nursing board, and then touch base with someone about your institutional policies. maybe this doctor isn't aware of some of the restrictions the article below seems to indicate are in effect.

    dangers inherent in nurses' administration of propofol by catherine spader, rn - jan. 29, 2007
    diprivan, known generically as propofol, is an intravenous sedative-hypnotic agent that's classified as an anesthetic. available since 1989, propofol is in widespread use outside the or -- in eds, icus, radiology and endoscopy settings, physician offices, and ambulatory surgery centers -- because of its sedating properties.
    nevertheless, the question of who's qualified to administer the drug, under what circumstances, and for how long are important details being addressed by organizations seeking to both improve patient safety and lessen nurses' liability concerns.
    yeas and nays
    propofol is well-liked especially because of its advantages over commonly used sedatives like midazolam (versed) and diazepam (valium): it has a quicker onset and shorter duration of action, which means patients wake and recover more quickly. it also reduces the need for opioid analgesia, sparing patients the misery of the nausea and vomiting that often accompany analgesia.
    still, experts in anesthesia are concerned that propofol's perks may be overshadowing its danger -- namely, the potential to take patients rapidly and unexpectedly from a state of conscious sedation to one of general anesthesia, which can include apnea.
    what's more, there's no agent available to counteract an overdose. according to an april 2006 news release from pennsylvania's patient safety authority, more than 100 reports had been submitted indicating that, in untrained hands, propofol could be deadly. sixteen percent of these reports were classified as serious events, including four patient deaths in which propofol may have played a role. in many cases, practitioners involved in administering the drug were poorly trained -- not only in propofol's use, but in that of any other heavily sedating drug.
    to address patient safety and liability issues, the american association of nurse anesthetists and the american society of anesthesiologists have developed a joint position statement on propofol administration (see sidebar, "should staff rns administer propofol?"): "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 precludes staff nurses from administering the drug. still, the aana/asa statement provides for one exception: it allows appropriately educated and trained nurses to administer propofol to intubated, ventilated patients in critical care settings.
    from sedation to anesthesia
    the staff of virginia hospital center take the aana/asa position statement seriously. "as nurses," says short, "we need to be aware that propofol does have the potential for adverse effects, and we need to know our institution's policies and how it to safety administer it."
    as recommended, appropriately qualified staff nurses may administer propofol as an iv drip infusion for sedation purposes only for intubated, mechanically ventilated patients who are properly monitored. staff nurses may not administer propofol as an iv bolus in any setting. in addition, all rns who administer sedation agents must have current acls training and must have completed an in-house critical care course involving completion of a competency-based orientation that includes propofol and a pharmacology exam.
    when administering any sedative or narcotic agent, nurses need to understand its dosing, action, onset, and duration of action, as well as the levels of sedation and anesthesia, which range from minimal sedation (anxiolysis), to deep sedation, to anesthesia (see sidebar, "the dangers of nap").
    nurses also need to remember that patient outcomes can vary greatly even when using an "appropriate" drug and dosage. assessments such as age, weight, history of liver or kidney disease, and history of narcotic tolerance, must be considered when choosing drugs and dosages. nurses who administer sedative agents also should know how to use reversal drugs and how to maintain an airway. sedated patients also require continuous monitoring of heart rate, blood pressure, apnea, and oxygen saturation.
    the safe administration of propofol also has special cautions. hypotension is a potential side effect, and nurses must learn to titrate the infusion slowly to reach the minimally effective dose. because propofol is a lipid-based oil-in-water emulsion, it can elevate serum triglycerides, increasing the risk of pancreatitis. the drug can also falsely elevate pulse oximetry readings.
    "nurses also need to be aware that propofol has no pain control effects," says short. "the drug also supports bacterial growth, and tubing should be changed every 12 hours."
    "it took a lot of education," says gianelli, "but once the nurses started feeling comfortable with using propofol, the protocol had a positive impact on existing nursing practice at our hospital."
    in light of propofol's effectiveness and its popularity, experts stress the importance of making nurses in all specialties aware of how the drug falls into their scope of practice -- of if it doesn't.
    "as with any drug ... we're responsible for understanding the safe use of propofol," says suzanne burns rn, msn, acnp, ccrn, fccm, faan, faanp, a nurse and registered respiratory therapist, as well as a former member of the aacn board of directors. she's a professor of nursing and research program director for the mcleod hall school of nursing at the university of virginia health system, charlottesville.
    "scope of practice expands or contracts with education, experience, and training," burns says. "specialized training, such as that provided to critical care nurses, broadens their scope of practice. decisions about the administration of propofol require that the nurse be qualified, that required monitoring be assured, and that limitations of the practice arena be considered. always, patient safety comes first."

    the debate about who should be allowed to administer propofol may continue, but one thing is clear: whenever propofol is used for sedation/anesthesia, it should be administered only by persons who are: (1) trained in the administration of drugs that cause deep sedation and general anesthesia, (2) able to intubate the patient if necessary, and (3) not involved simultaneously in the procedure itself.

    from ismp medication safety alert!
    propofol sedation: who should administer? - 12/05/2005
    another case involved a physician who thought he could safely administer propofol himself while performing a breast augmentation. unfortunately, his patient, a young woman, died of hypoxic encephalopathy because he failed to notice the patient's rapidly declining respiratory status, as had his surgical assistant, who was not qualified to monitor patients under deep sedation or anesthesia.[3]
    nurses have also been asked to administer "a little more" propofol if the patient moved after the anesthesiologist left the room. in these cases, the anesthesiologist would leave the propofol syringe and needle in the iv port after placing the block and leave the nurses in the room to monitor the patient alone. initially, the nurses reluctantly complied. later, they brought the issue to the attention of hospital leaders, citing that they were worried about the safety of this practice.[2]
    there are several compelling reasons why all healthcare providers should be worried about nurse-administered propofol.

    strict product labeling
    astrazeneca, the manufacturer of diprivan, states in its product labeling that the drug is intended for general anesthesia or monitored anesthesia care sedation, and that the drug should be administered only by persons trained in the administration of general anesthesia and not involved in the surgical/diagnostic procedure. (for sedation of intubated, mechanically ventilated adult patients in the icu, product labeling notes that the drug should be administered only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management.)

    unpredictable and profound effects
    propofol dosing and titration is variable, based on the patient's tolerance to the drug. profound changes can occur rapidly. a patient can go from breathing normally to a full respiratory arrest in seconds, even at low doses, without warning from typical assessment parameters.[2]

    no reversal agent
    unlike other sedation agents (e.g., midazolam, morphine), there is no reversal agent for propofol. adverse effects must be treated until the drug is metabolized.

    financial incentives
    unwillingness of insurers to reimburse anesthesia care for some procedures such as diagnostic endoscopy has increased the use of nurse-administered propofol.(1,2) untrained nurses may be caught in the middle of the debate and feel pressured to administer propofol.[2]

    legal barriers
    nurse-administered propofol falls under each state's nurse practice act. more than a dozen states specifically consider this function beyond the scope of nursing practice.[2]
    Last edit by RNfaster on Feb 8, '07
  4. by   cardiacRN2006
    Wow, the PP is long!

    To sum it up, you can NOT bolus propofol-ever.

    Docs will ask you to do so sometimes, but the only thing you can do is titrate up the dose (if they are on a gtt)

    NEVER chart that you bolused propofol either.
    Last edit by cardiacRN2006 on Feb 8, '07
  5. by   cblair
    I'm a recent graduate nurse, but before that I worked in a burn unit where RN's were able to administer propofol as a drip, and able to give boluses. I'm not sure if there are special provisions for specialty units, however, it was a common practice. Physicians did not have to physically be present as that would be impossible.