Cosmetic Surgery Death after RN (not CRNA) Administered Propofol

[stevierae]

As usual, it took a patient death to effect change to a dangerous practice. This is why I, an operating room nurse, am so adament about getting the practice of RNs giving conscious sedation stopped, and the reason for my thread about OR nurses--and endoscopy nurses-- giving conscious sedation. This dangerous practice simply needs to stop. As evidenced by an ongoing thread in the gastroenterology nursing section, apparently--at least in some facilities-- endo RNs administer propofol as part of "conscious sedation."

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."

[traumaRUs, MSN, APRN]

In our level one ER we do conscious sedation. However, propofol is handled only in the ICU/OR.

[stevierae]

In our level one ER we do conscious sedation. However, propofol is handled only in the ICU/OR.

The ICU is different--those patients are on ventilators; either intubated or trach'd. They HAVE protected airways. They also have, accessible 24-7, RT, pulmonologists, intensivists, and sometimes anesthesiologists.

[alansmith52]

i agree the basic fact is that no one...... no patient should be given propofol if their not tubed. or have an anesthesia provider present.

my old facility there was an adverse reaction just like the one mentioned in the case above.... patient wasn't on a vent. and the prop was pushed by and icu nurse in CT.

[Brenna's Dad]

I've been curious how sublingual propofol will affect conscious sedation practice, since this is the area it is specifically being developed for.

[Brenna's Dad]

What??? None of you have heard of the development of sublingual Propofol??? Bahh, I know this possibly cant be true.

How the do you think sublingual Propofol spray will affect conscious sedation?? What kind of dose do you think will be administered?? Will one spray too many put you in the loss of airway category?? What will the DOA be?? Will this be the IV nurse's best friend ??

[kestrel1121]

I have heard of it BDad but I don't know yet much about it. I would think that sublingual vs. IV propofol will have same problematics ( I'm thinking the only major diff will be in onset and duration of action). I think the use of it will be determined mostly by cost effectiveness of it vs. the usual conscious sedation meds used ( ie fentanyl/versed etc). As far as use in the ICU I can see it being very helpful for intubated pts needing procedures (bronchs, CT, MRI etc) but without MUCH info and anesthesia standby I wouldn't feel comfortable giving it to someone without a protected airway for all the previous mentioned probs w/airway mgmt and C.S.

[New CCU RN]

The ICU is different--those patients are on ventilators; either intubated or trach'd. They HAVE protected airways. They also have, accessible 24-7, RT, pulmonologists, intensivists, and sometimes anesthesiologists.

NOOOOO Way.... not all ICU patients are trached or intubated........ we often do procedures requiring conscious sedation on non-intubated patients... cardioversions, TEE's, scopes, etc.

[New CCU RN]

What??? None of you have heard of the development of sublingual Propofol??? Bahh, I know this possibly cant be true.

How the do you think sublingual Propofol spray will affect conscious sedation?? What kind of dose do you think will be administered?? Will one spray too many put you in the loss of airway category?? What will the DOA be?? Will this be the IV nurse's best friend ??

I have never heard of it, but just wondering...if it is sublingual won't it take longer to show affects, thus increasing the risk of being given too much? It is often the case the if there isn't immediate gratification the docs are shouting for more meds... (in my personal experience)

[stevierae]

NOOOOO Way.... not all ICU patients are trached or intubated........ we often do procedures requiring conscious sedation on non-intubated patients... cardioversions, TEE's, scopes, etc.

Not with Diprivan you don't--and if you DO, you shouldn't--dangerous practice without a protected airway--but, if you are simply taking your chances and depending on the RTs, pulmonologists and intensivists to bail you out in case of a crisis, I guess that's your decision--but why take on that responsibility and risk your license by doing something that they simply do not pay us enough to do, and that others are better trained, and better paid, to do?

Just read about an anoxic brain injury suffered during a TEE--RN gave Propofol even though the O2 sat read 70%--in an ICU, non-intubated patient--WHY? I guess she will tell her story in court--

[New CCU RN]

Not with Diprivan you don't--and if you DO, you shouldn't--dangerous practice without a protected airway--but, if you are simply taking your chances and depending on the RTs, pulmonologists and intensivists to bail you out in case of a crisis, I guess that's your decision--but why take on that responsibility and risk your license by doing something that they simply do not pay us enough to do, and that others are better trained, and better paid, to do?

Just read about an anoxic brain injury suffered during a TEE--RN gave Propofol even though the O2 sat read 70%--in an ICU, non-intubated patient--WHY? I guess she will tell her story in court--

I don't disagree that it is a risky thing to do and needs more guidelines as there is such a fine line. I was responding to your quote about saying in an ICU the patients all have a protected airway, bc that simply is NOT the case... that is all.

I am just stating what I have seen. Personally, I have never given Dip on a non tubed patient, but many, many nurses in my unit have. It is in my unit a norm. I always request the MD give it and document med given by Dr so and so.....

Would you please provide that article you read about the nurse giving the Dip on a patient w/ O2 sat of 70%... I would be interested in reading it.

[stevierae]

I don't disagree that it is a risky thing to do and needs more guidelines as there is such a fine line. I was responding to your quote about saying in an ICU the patients all have a protected airway, bc that simply is NOT the case... that is all.

I am just stating what I have seen. Personally, I have never given Dip on a non tubed patient, but many, many nurses in my unit have. It is in my unit a norm. I always request the MD give it and document med given by Dr so and so.....

Would you please provide that article you read about the nurse giving the Dip on a patient w/ O2 sat of 70%... I would be interested in reading it.

Actually, my reply regarding protected airways in ICU was in reference to a post by newnurse2003, who stated that it is part of her job description to give Propofol to her intubated patients--and I was responding to her post by saying:

That's different--by her own description, the patients SHE is giving Propofol to already have protected airways--either by virtue of being intubated or trach'd--and have RT, pulmonologists, and intensivists--and sometimes anesthesiologists-- available 24-7--unlike cosmetic surgery and endo patients.

It's not an article--it is a plaintiff medical malpractice case another LNC colleague is currently reviewing (I am an LNC.)