Do you follow the AANA-ASA statement re: Safe Admin of Propofol?

[Gottago]

"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...failure to follow these recommendations could put patients at increased risk of significant injury or death." This was a joint statement released by AANA and ASA, and is consistent with the drug package insert.

My question comes down to this: who administers propofol, when it is given, during endoscopic procedures at your facility? Is it the doctor, who is simultaneously involved in the endoscopic procedure, or another healthcare provider?

[AmyRN303, BSN, RN]

In my facility it is a CRNA who is responsible solely for anesthesia.

[IrisRN.blogspot]

You have asked great questions that in the end come down to the Institution's policies, your regulatory and governing body. I am a nurse in Ontario and I monitor patients who are sedated during endoscopy procedures and that is my only role. Propofol is a dangerous drug as you know with no reversal agent. In deeper sedated states respiratory function and blood pressures can drop inducing high risks of poor cerebral&cardiac perfusion, as well risks for hypoxia. My college leaves the authority, competence and safety to the RN's judgement.

For propofol to be safely administered for patients many questions arise:

Pre-assessment:

Is the patient cleared from a cardiologist if they have history of palpitations, fainting episodes, arrhythmia?

Is the patient's blood pressure controlled and safe for the procedure?

(Sudden drop in blood pressure can put a patient at risk for heart failure, attack, or stroke if the blood pressure not safely titrated)

Does the patient have Diabetes and is their blood sugar at a safe level to start?

(hypoglycemia is harder to manage than hyperglycemia)

Does the patient have sleep apnea or any respiratory problems such as Ashtma, COPD? even a common cold?

(depressed respirations in anesthesia can cause risks for pneumonia or even obstruction in airway during the procedure requiring intubation or a solid jaw thrust)

Endoscopy Physicians/Surgeons are focused on the procedure. I questions their ability to deeply sedate a patient and do the procedure at the same time. If an emergency occurs are they going to drop the scope and intubate the patient?

A doctor could easily measure the initial bolus of a patient's need to start a procedure, but to question if there is responsible personnel that is able act upon an emergency (drop in SpO2, drop in blood pressure, need for fluid resuscitation, or vasopressors, glycopyrrolate) . Cause and effect you see. Our clinic has an Anesthesiologist who administers the dosage and the ACLS certified RN monitors the patient if they need to step away.

Pain management for the patient:

The sole purpose of sedation is to make the patient comfortable. Endoscopy can be fairly painful but i've also seen some patients tolerate with mild sedation (Usually a combination of midazolam and fentanyl). Everyone is different based on their pain threshold, physiology and past surgical procedures.

It may be difficult for nurses shift the old paradigms of authoritative physicians and promote a collaborative environment, but in order to advocate safely for the patients we must try.

[brownbook]

An anesthesiologists (we don't have any CRNA's) gives propofol in our GI dept. It is such an expensive use of their expertise. We are out patient surgery/GI clinic, almost every patient is an ASA 1. Just does not seem cost effective when a CRNA could do the job.

[MissChrissy]

I work as a tech in our endoscopy center and I also work in Accreditation....and that would NOT go over well with the powers that be. Ive been in the procedure room many times, and Ive seen when things go wrong and I could not imagine only having the GI physician both administer the medication, closely monitor vitals and perform the procedure.

The majority of the time we have our anesthesiologists administering propofol, CRNAs are used if an anesthesiologist can not make it that day.