Do Endo RN's give anesthesia ??

GI Jackie · Nov 28, 2006

I have been an endo nurse now for 7 1/2 years. We currently have anesthesia that provides our sedation for our procedures. That being said, if anesthesia is pulled for whatever reason we can and will give sedation for GI procedures. I work in a hospital setting, we do inpatients and outpatients. Our hospital requires that all GI RN's have BLS as well as ACLS and we have to maintain competency in an annual conscious sedation course. I personally am very comfortable giving sedation to most patients. I believe that there are definite advantages to having anesthetists giving sedation. One big one is that in Oklahoma, they can give medications that I cannot give, ie propofol. It is listed as a general anesthetic and therefore is only recommended to be administered by trained anesthesia providers. When we give sedation we use Fentanyl/Versed or Demerol/Versed. Another reason would be of course that is what they get paid to do. I do not receive any additional compensation for taking on the liability of sedation and my facility cannot charge for my services. I think just from my experience here and talking with other endo staff, we are a rare facility that has the luxury of anesthetists 99.9% of the time.

moliuchick, RN · Dec 16, 2006

I'm thinking about going to work in a private Endoscopy center.
After reading several of these posts, I am getting the impression that "regular" RN's do the concious sedation administration.
Can this be true? In the hospitals, only a CRNA, Anesthesiologist or Intensivist gives these meds. Can someone enlighten me on this issue.
Also......that other jobs/activities do endo center nurses perform?
Thanx for your help

In my endo center, besides performing consciou sedation in the procedure room. We also give IV, do consent, possible anema when pts are not clean in the preop. If we work in the post-op, we will have to monitor pts vital sign and discharge pts. Most Pts don't have complications and the job that we do is pretty easy.

passgasser · Dec 23, 2006

The simple answer to your question is yes, in many places Endo RN's are administering anesthesia. The fact is that any time you give propofol IV push to a non-intubated patient, you are administering anesthesiia. And if you are an RN who is not a CRNA, you are not qualified to do so, disclaimers about "annual competencies" and "ACLS certification" not withstanding. These RN's are taking an enormous risk with their licences, with their liability, and worst of all, with their patients' lives.

So, why are they doing so? In the end, it isn't about patient comfort (though that may be the nurse's goal), nor is it about saving the patient money. It is about maximizing the profit for the GI doc, period. If he or she can convince the RN that they can safely give an anesthetic, they can charge for the sedation as well as for the procedure. Worse, I've never yet met a GI doc who was competent to administer an anesthetic, so if there is a severe problem, the doc won't have the slightest idea what to do. Leaving the RN, and worse, the patient, swinging in the breeze.

core0 · Dec 26, 2006

The simple answer to your question is yes, in many places Endo RN's are administering anesthesia. The fact is that any time you give propofol IV push to a non-intubated patient, you are administering anesthesiia. And if you are an RN who is not a CRNA, you are not qualified to do so, disclaimers about "annual competencies" and "ACLS certification" not withstanding. These RN's are taking an enormous risk with their licences, with their liability, and worst of all, with their patients' lives.
So, why are they doing so? In the end, it isn't about patient comfort (though that may be the nurse's goal), nor is it about saving the patient money. It is about maximizing the profit for the GI doc, period. If he or she can convince the RN that they can safely give an anesthetic, they can charge for the sedation as well as for the procedure. Worse, I've never yet met a GI doc who was competent to administer an anesthetic, so if there is a severe problem, the doc won't have the slightest idea what to do. Leaving the RN, and worse, the patient, swinging in the breeze.

There are two issues here. One is the use of medication to give "conscious sedation". Multiple BON's have determined that the use of Propofol follows this protocol. There is a fair body of evidence that nurse administered Propofol can be used in GI procedures without problems. To say that nurses are not qualified and "risk to license" is simply fear mongering.

The second portion deals with why Propofol is used. I will conceed that Propofol gives more consisten amnesia than Fetanyl/Versed. This is the primary reason that it is used. There are studies that show you have less turnover time with Propofol and studies that show it is unchanged. The real reason that Propofol is coming to the forefront is that patients are asking for it.

David Carpenter, PA-C

passgasser · Dec 27, 2006

There are two issues here. One is the use of medication to give "conscious sedation". Multiple BON's have determined that the use of Propofol follows this protocol. There is a fair body of evidence that nurse administered Propofol can be used in GI procedures without problems. To say that nurses are not qualified and "risk to license" is simply fear mongering.
The second portion deals with why Propofol is used. I will conceed that Propofol gives more consisten amnesia than Fetanyl/Versed. This is the primary reason that it is used. There are studies that show you have less turnover time with Propofol and studies that show it is unchanged. The real reason that Propofol is coming to the forefront is that patients are asking for it.
David Carpenter, PA-C

Your first error is to assume that you may use propofol for "conscious sedation." In any clinically useful dose, propofol renders the patient unconscious and unresponsive, and therefore exceeds the boundaries of "conscious sedation."

Your second error is to rely on what BON's have determined is acceptable. There are also multiple BON's who have stated that administration of propofol IV push on an unintubated patient exceeds the practice boundaries of the staff RN. Bottom line here is that you need to read the package insert for propofol. It doesn't much matter which manufacturer you choose, because they all say the same thing: Propofol, when administered IV to an unintubated patient, is safe only in the hands of an educated, experienced anesthesia provider. So, if you have a bad outcome with RN administered propofol, you have no defense. After all, the manufacturer has clearly stated that the practice you are following is unsafe.

Your third (and perhaps most egregious) error is to point to the faster turnover times with propofol. In other words, I can get 'em in and get 'em out quicker, increasing volume, hence increasing profit. And by having an RN administer the drug rather than an anesthetist, I can further increase my profit by being able bill for the anesthesia services provided. Wonderful. You are sacrificing patient safety for the sake of money.

Your fourth error is to tell us all that your are OK with doing this because patients are asking for it. Patients ask for a lot of things that may not be in their best interest. They ask for these things assuming that you will provide it safely. Next time you discuss this with a patient, allow me to recommend you be honest with that patient. Tell them this: "We do have RN’s who administer propofol, which will render you unconscious. However, the manufacturer does not recommend this practice, and recommends that propofol be given to patients like yourself by experienced anesthesia providers. If we proceed with this course of action, there is an increased risk to yourself, because the RN is neither trained or experienced in provision of anesthesia, and if you get into trouble, the RN may not be able or adept at getting you out of that trouble. Additionally, the RN won’t have the requisite rescue drugs and equipment readily at hand, as an anesthesia provider would. In short, because we choose to have RN’s give anesthesia rather than educated, experienced anesthesia providers, your risk for a bad outcome, including aspiration, prolonged ventilation, brain damage, and death, rise significantly." Given the facts, see just how many of these patients wish to proceed.

VickyRN, MSN, DNP, RN · Dec 27, 2006

excellent article:

use of propofol in gastroenterology practice

in medicine and nursing, there are constant changes occurring. much of this is due to new advances in technology, pharmacology, and countless studies that help move these into practice. some of these changes are embraced by the medical community while others are shunned. is this because of lack of information or how or who is presenting the information?
currently, there seems to be a great deal of controversy regarding the use of propofol in the endoscopic setting. if propofol is used in the gastroenterology suite, who should administer the drug? should an anesthesiologist or certified registered nurse anesthetist (crna) administer the drug or can a nurse safely do this?

http://www.nursingcenter.com/library/journalarticle.asp?article_id=533174

passgasser · Dec 27, 2006

While the article posted does seem to give a balanced perspective without taking sides, it also demonstrates exactly why I and other anesthesia providers know RN administered propofol sedation is such a bad idea:

* It works well for patients, especially the hard-to-sedate ones and ASA class III or IV patients.

I don't know any anesthesia provider who would agree with such a blanket statement. The first question I would ask is why is the patient ASA III or IV? There are some patients, particularly cardiac patients, who will be ASA III or IV, for whom propofol at any clinically useful dose is a particularly bad idea. Making such a blanket statement is both foolish and dangerous.

It all goes back to what I and others have said: When it comes to the administration of propofol, or any other anesthetic drug, you don't even know what you don't know.

core0 · Dec 27, 2006

your first error is to assume that you may use propofol for "conscious sedation." in any clinically useful dose, propofol renders the patient unconscious and unresponsive, and therefore exceeds the boundaries of "conscious sedation."

that is an opinion. in doses used by anesthesia this may be the case, although i have seen anesthesia use propofol and keep it within the boundaries of conscious sedation (minimally depressed level of consciousness that retains the patient's ability to maintain a patent airway independently and continuously and respond appropriately to physical stimulation and verbal commands)

your second error is to rely on what bon's have determined is acceptable. there are also multiple bon's who have stated that administration of propofol iv push on an unintubated patient exceeds the practice boundaries of the staff rn. bottom line here is that you need to read the package insert for propofol. it doesn't much matter which manufacturer you choose, because they all say the same thing: propofol, when administered iv to an unintubated patient, is safe only in the hands of an educated, experienced anesthesia provider. so, if you have a bad outcome with rn administered propofol, you have no defense. after all, the manufacturer has clearly stated that the practice you are following is unsafe.

well since bon's determine the scope of practice, what other body would you use? yes there are bon's that state the use exceeds the practice boundaries for rn's and there are others that state that it is perfectly within the boundaries of the rn. these are usually backed up by varying degrees of research. as for the statement that it is only safe in the hands of an anesthesia provider, i am unable to find that in the package insert for diprovan. could you back this up please? actually a search of the words anesthesia provider turned up no hits. it seems the package insert is carefully neutral on who can give this. i will conceed this is an off label use at least for diprovan since the only indications are anesthesia and mac. however there are very few medications that are not used extensively off label. as far as "experienced anesthesia provider" most institutions require additional training for physicians and nurses before using propofol.

your third (and perhaps most egregious) error is to point to the faster turnover times with propofol. in other words, i can get 'em in and get 'em out quicker, increasing volume, hence increasing profit. and by having an rn administer the drug rather than an anesthetist, i can further increase my profit by being able bill for the anesthesia services provided. wonderful. you are sacrificing patient safety for the sake of money.

you are making a lot of assumptions about me. i pointed out that there are studies that show things both ways. i think this is actually an argument against it. thank you for crediting me for sacrificing patient safety for the sake of money. or i can look at it this way. i save the patient $500 that you would charge for anesthesia services with no discernable difference in patient outcome (in the right patient population). oh and gi labs cannot bill for the rn sedation, it is part of the services so i guess i'm not that profit driven after all. i have tried to keep this civil, but the internet allows people to make broad assumptions and attack people that they don't know. (i will also point out that i don't do endoscopy and don't profit from them except in a general way when the practice does well).

your fourth error is to tell us all that your are ok with doing this because patients are asking for it. patients ask for a lot of things that may not be in their best interest. they ask for these things assuming that you will provide it safely. next time you discuss this with a patient, allow me to recommend you be honest with that patient. tell them this: "we do have rn's who administer propofol, which will render you unconscious. however, the manufacturer does not recommend this practice, and recommends that propofol be given to patients like yourself by experienced anesthesia providers. if we proceed with this course of action, there is an increased risk to yourself, because the rn is neither trained or experienced in provision of anesthesia, and if you get into trouble, the rn may not be able or adept at getting you out of that trouble. additionally, the rn won't have the requisite rescue drugs and equipment readily at hand, as an anesthesia provider would. in short, because we choose to have rn's give anesthesia rather than educated, experienced anesthesia providers, your risk for a bad outcome, including aspiration, prolonged ventilation, brain damage, and death, rise significantly." given the facts, see just how many of these patients wish to proceed.

once again i would ask you to show me any outcome studies that show that propofol on the hands of a well trained rn in moderate sedation is any different from that of a anesthesia provider? i am not aware that this data exists. there are a number of case studies that show that rn's can give it safely. i will also point you the position statement for all three gi societies on this:

three gastroenterology specialty groups issue joint statement on sedation in endoscopy

the sad thing is that i agree with you for the most part. i think that the data is still out on propofol and that there needs to be a randomized controlled study before it is used generally in gi. however, your obvious agenda and use of invective truly diminish you message.

david carpenter, pa-c

RNMommy2 · Dec 30, 2006

Where I "worked" the CRNA always pushed the IV conscious sedation because they were available. Prior to my leaving I had an incident that made me uncomfortable regarding this same subject. Because the CRNA is always there none of the RN's have been trained or oriented at all on pushing the IV CS. My supervisor and one other nurse have experience from other jobs doing this. Recently my supervisor and myself were the only nurses there and since we just had one pt the sup did not want to call in CRNA because she herself knew how to do this. Well, we go to get the pt and she asks me to do it because she has paperwork she needs to do since she was an hour and a half late to work that morning. I told her I would not mind at all going in with her but I had never been checked off and never oriented. She told me the MD would tell me what to push. I again refused to go in alone as I had no idea about dosages for meds to reverse and just overall no experience doing this. She got very huffy but did it and I went it with her. Just curious how much training those of you pushing CS got before being asked to do it yourself?

cardiacRN2006, ADN, RN · Dec 30, 2006

After reading several of these posts, I am getting the impression that "regular" RN's do the concious sedation administration.
Can this be true? In the hospitals, only a CRNA, Anesthesiologist or Intensivist gives these meds. Can someone enlighten me on this issue.

From a hospital viewpoint, the ICU RNs at my hospital take turns being the "procedure" nurse. So we do the conscious sedation for EGDs, colonoscopies, nephrostomy tube placements, Bxs, etc...In addition, when I'm not the procedure nurse, I will still have to perform CS on my own pt if they are having said test.

In my state, we cannot bolus propofol. It is outside our scope. Yes, we will be in trouble with the BON-that's not fear mongering!

GIRN · Jan 28, 2007

You were absolutely right in refusing to push meds for conscious sedation without the proper training. If there was a negative outcome you wouldn't have a leg to stand on in court when they asked you why you had pushed meds for which you had had no training. The training is imperative for all nurses because the doctors (I know I shouldn't generalize) may give the orders to push the meds, but they don't always stay on top of what reversal drugs are the right ones. Sounds like leaving the facility was a wise move if your supervisor was willing to let you provide CS without training.