Is Indiana RN allowed to give Ketamine for procedural sedation ??

jwk · Sep 7, 2005

Paramedics can do far more with an airway than most RNs - save CRNAs,some APRNs, and some transport/flight RNs. Please, the Paramedic's bread and butter is airway - and ACLS.
Chip

You really don't want to go there.

I've been doing anesthesia 25 years (after being a paramedic before that). I have seen exactly 1 surgical airway in that time. Most cricoid sticks are done by paramedics in the field because they don't do enough intubations to retain their competency at the skill. "Paramedic's bread and butter is airway" - I don't think so. Nor is it the ER or ICU nurse or even the ER doc. Some may be better at it than others, but none will compare to anyone from your anesthesia staff. Yes, paramedics do intubate more than RN's, and on many patients, they do fine. Does that make them the experts? Nope.

jwk · Sep 7, 2005

You may be taught ABCs, but nurses are not taught airway management. Unfortunately, there is simply nothing further from the truth.
Speaking of reversals....
What's the reversal for Ketamine?
What's the reversal for Amidate?
What's the reversal for Propofol?
Traditional CS medicines (fent, benzos) have reversals and thus the relative safety margin..
This is not a personal attack on you in general. It takes experience to see that sometimes you don't know what you don't know. Anesthesia school teaches you many things, including the fact that as a staff RN I knew jack little about airway management. I have intubated both in-house and in the field (or rather in-car) on several instances as a staff RN. I thought I was on top of my game. WRONG. The set up we have immediately available as the table-top set up in the OR is outstanding. I'm talking about medicines already drawn up, sitting there. Not across the department, not in a pyxis. Inches from your hand is what I'm speaking of. I have a hard time believing that you have this set up for every CS case that you do when you give general anesthetics. And I've worked ER, I know how its done.
While there are some EMS companies that do allow a select few paramedics to perform RSI, check the studies done. Actually there were worse associated patient outcomes with performing RSI in the field rather than traditional EMS medications for intubation. Unrelenting hypoxia is a rather downer on your day, esp moreso for your patient. It all comes to the setup, preparation, and anticipation of a difficult airway, which neither EDs or EMS companies can perform to the extent that an OR does everyday.
I see where you are coming from. Intubation is relatively easy after about the first 30. That is what most anesthesia people will tell you. It's really not that hard of a task to learn. What is hard to manage is the difficult airway and how to flow from one scenario to another in the Difficult Airway pathway. Do you honestly do an airway assessment (or know how to) before you give a general anesthetic for CS to a patient? I have never seen this done outside the OR in all my years of doing ER and ICU before anesthesia school. One of the most difficult aspects of airway management (which they DO NOT teach in nursing school - that is a joke) believe it or not, is effective mask ventilation. Notice the word effective here. I have been to so many codes to intubate where an RT is shoving .9 - 1.2 liters down someone with every ventilation (word used very lightly) with such pressure that there is no way in hell that it is going into the lungs. What happens next? I attempt to intubate and next thing there is about 700 mls of usually coffee ground emesis in the oropharynx that despite going in with suction and a blade, aspiration occurs and you might as well get a body bag then. One thing you John Wayne nurses will have happen, because it happens to us on a semi-regular basis, is the can ventilate - cannot intubate scenario and your MD had better be able to do this effectively without inflating the gastric until either: 1. anesthesia shows up, or 2. the general anesthetic you just gave (which has no reversal BTW), wears off. Lord help you if you get into a cannot-ventilate, cannot-intubate. Even FOI cannot help, esp if you used ketamine as the agent.
There is a reason drugs are listed as general anesthetics. Staff RNs are not CRNAs or anesthesiologists, nor are you trained in advanced airway management. Simple truth, not a prejudiced statement against nursing.
But what you are doing is pushing these drugs without training. Who do you think the ED calls for difficult airways, if the MD is smart about things? That's right, anesthesia. CRNAs usually show up, and again, there is a reason for that also.
One of my classmates worked in California and was actually on the CS team which did adminster general anesthetics in the ED. His view on airway management before CRNA and after CRNA are drastically different. He thought he could manage an airway before school also. Experience teaches you things - sometimes you just don't like the answer.

Absolutely 100% correct. This argument is almost identical to the one about endoscopy nurses giving propofol. It shouldn't happen.

chip193 · Sep 8, 2005

You really don't want to go there.
I've been doing anesthesia 25 years (after being a paramedic before that). I have seen exactly 1 surgical airway in that time. Most cricoid sticks are done by paramedics in the field because they don't do enough intubations to retain their competency at the skill. "Paramedic's bread and butter is airway" - I don't think so. Nor is it the ER or ICU nurse or even the ER doc. Some may be better at it than others, but none will compare to anyone from your anesthesia staff. Yes, paramedics do intubate more than RN's, and on many patients, they do fine. Does that make them the experts? Nope.

I did go there and I will stand by the statement. My whole statement.

And I never said that Paramedics were better than anesthesia at airways.

Kindly keep the whole quote or at least the context correct.

Chip

jwk · Sep 8, 2005

I did go there and I will stand by the statement. My whole statement.
And I never said that Paramedics were better than anesthesia at airways.
Kindly keep the whole quote or at least the context correct.
Chip

Ummm, if you look again, I copied your entire post in my response. Your exact quote, and the one I take issue with, was "Please, the Paramedic's bread and butter is airway"

Cali Nurse · Sep 12, 2005

Did anyone else read the article addressing mod sedation in the Sept ENA newsletter? Very interesting and includes a list of agents that the ENA/ACEP support for use in procedural sedation. Includes (but not limited to): etomidate, propofol, ketamine, fentanyl, and midazolam. I've never worked in a facility that approved etomidate or propofol for CS, but the others we use regularly.

jewelcutt · Sep 17, 2005

What I find the most frightening here is the lack of knowledge related to anesthetic drugs now being used as sedative agents. Everything aside, if you are giving a drug you should know exactly how it works, duration, side effects, etc. and be able to deal with the side effects. These anesthetic drugs, even in conscious sedation doses (which are very close to anesthetic doses), have serious implications related to the airway. Everyone always thinks they are airway experts when they really haven't scratched the surface of how to deal with them. Who wouldn't you give ketamine to? What do you give before to prevent hallucinations? And how does ketamine work? Ketamine can be a horrible drug and give a large surge in sympathetic stimulation, which is very bad for cardiac patients. I'm not trying to insult anyone, or go in depth with questions, but these are basic questions that need to be asked with these drugs. It is not acceptable to just intubate someone when they start to desaturate, it is unsafe practice and very preventable if adequately trained people are administering these drugs. Just like we as nurses did in nursing school and in our careers, we should always know the drugs we give before we give them. Just because an MD orders a drug or is at the bedside doesn't mean they know that much about that drug. How many times do you hear stat respiratory calls to endoscopy, or codes in CT, decompensation in the ICU.... what do you think is the main reason for these? I just really encourage people to think about the implications. I can remember giving so many "sedative" drugs with MDs at the bedside and watching the patients decompensate. I can also count numerous times that nurses have given and thought vec was a nice sedative agent that keeps your vented patient still. The bottom line is that these practices are not safe. I know research is being done, but the jury is still out.

drunkintruck · Sep 17, 2005

Patient care is first, I dont care what you are a medic a nurse whatever.

Ketamine is classified as a General Anesthetic. It however does resume normal pharyngeal-laryngeal reflexes....

When given IV the onset is 30 seconds, and it lasts about 5-10 mins.

This medicine is not well titrated for effect the loading dose is .5 mg/kg/min.

IT MOST DEFINATELY is not the most dangerous anesthetic.

As a medic I have used Etomidate and Succinylcholine very nice combination, if the pt needs constant sedation (if they exhibit symptoms of "bucking" the tube)

Prehospital it is VERY dangerous to do RSI (Rapid Sequence Intubation) there is nothing rapid about it actually, first off you need to make sure that you can intubate the patient, if you can not basically its back to an OPA and a BVM.

To summarize this, there are many drugs that are dangerous, such as morphine, or dilaudid... how do I know this,,, cause I am allergic to it and I went into cardiac arrest. All medicine are dangerous and should be delivered with care, nurses are not numnuts well most arent.

Someone said there are reversal agents, this is true for many there is, but for many there is Flumazinil (I think thats how to spell it) Narcan (Nalaxone).

Lets not argue over what drugs we can or cant give, lets just know this, if you cant intubate and you decide to push ketamine alone your an idiot and should be banned from nursing, if your a medic and you use a combitube more than an ETT than WAIT till you get to the ER or have another medic do it, I am good at intubations but I have no problem asking someone else to do it.

Just keep your pants on everyone and do whats right for the patient. Have a good night and god bless.

I would also like to add I did RSI once, and I was scared out of my mind. I used etomidate and Succs, and then in the ER they used propofol or milk of amnesia propofol is a great drug for those of you that dont use it or dont know what it is, it can be titrated like dopamine for example, if the pt is waking up you can increase the dose, infact it is sometimes given on a sliding scale depending on conciousness, remember we are sedating people for a reason not for fun.

RNCENCCRNNREMTP · Sep 17, 2005

What I find most frightening is the assumption that:

#1 Conscious sedation and general anesthesia are the same thing (they are NOT)

#2 That nurses cannot recognize a failing airway

#3 That nurses, since they cannot intubate, cannot fix a failing airway.

All 3 are wrong. We started out talking about using some drugs for conscious sedation that clearly do have a great role in that procedure and then we segued into who can and cannot intubate and if you cannot intubate then you should not be using these drugs. Hogwash.

NUrses who are trained well in the practice of conscious sedation know that these drugs have a role in the procedure and can titrate them, with the doctors direction, to achieve good sedation with intact airway protective reflexes. I do not need to know how to intubate (even though I do and have for almost 25 years) to keep an airway open.

Laryngospasm you say from ketamine? Well then a little positive pressure ventilation until it passes or then yes, the doctor paralyzes and intubates (or I do depending upon the situation).

Drops in the SpO2? My first (and your first) action better not be to put on O2, open the airay and do a little positioning or stimulating or maybe even some reversing agent (when possible). Falling SpO2 is the early sign of increased CO2 and adding more O2 is not going to help that at all, need to ventilate better. If you add more O2 sure their SpO2 may come up but you still have that problem you completely ignored, increased CO2.

Simple procedures are far and away what are required when the sedation gets a little deep; open the airway, position the head, stimulate, reverse, then add some O2 and then consider, if still having issues, to start bagging them and then finally consider an ETT. But far more often than not, those simple procedures that every conscientious nurse knows will be more than enough.

Like all drugs we give we need to know about them, that is a given and a prime rule for drug administration, but do not disparage me because I am not a nurse anesthetist that I have no business using these drugs. Even if I could not physically or lrgally intubate a patient, I am still comfortable with all sedation drugs at my disposal, because I have been taught how and when to use them and what to do when things go a bit or a lot awry!

jwk · Sep 19, 2005

What I find most frightening is the assumption that:
#1 Conscious sedation and general anesthesia are the same thing (they are NOT)
#2 That nurses cannot recognize a failing airway
#3 That nurses, since they cannot intubate, cannot fix a failing airway.
All 3 are wrong. We started out talking about using some drugs for conscious sedation that clearly do have a great role in that procedure and then we segued into who can and cannot intubate and if you cannot intubate then you should not be using these drugs. Hogwash.
NUrses who are trained well in the practice of conscious sedation know that these drugs have a role in the procedure and can titrate them, with the doctors direction, to achieve good sedation with intact airway protective reflexes. I do not need to know how to intubate (even though I do and have for almost 25 years) to keep an airway open.
Laryngospasm you say from ketamine? Well then a little positive pressure ventilation until it passes or then yes, the doctor paralyzes and intubates (or I do depending upon the situation).
Drops in the SpO2? My first (and your first) action better not be to put on O2, open the airay and do a little positioning or stimulating or maybe even some reversing agent (when possible). Falling SpO2 is the early sign of increased CO2 and adding more O2 is not going to help that at all, need to ventilate better. If you add more O2 sure their SpO2 may come up but you still have that problem you completely ignored, increased CO2.
Simple procedures are far and away what are required when the sedation gets a little deep; open the airway, position the head, stimulate, reverse, then add some O2 and then consider, if still having issues, to start bagging them and then finally consider an ETT. But far more often than not, those simple procedures that every conscientious nurse knows will be more than enough.
Like all drugs we give we need to know about them, that is a given and a prime rule for drug administration, but do not disparage me because I am not a nurse anesthetist that I have no business using these drugs. Even if I could not physically or lrgally intubate a patient, I am still comfortable with all sedation drugs at my disposal, because I have been taught how and when to use them and what to do when things go a bit or a lot awry!

So you didn't already have them on O2 before you started? Knowing how NOT to get in trouble in the first place is at least as important as knowing what to do if you do get in trouble. FIRST rule of anesthesia - Oxygen is good.

HyperTension · Sep 19, 2005

It's unfortunate that this will be my first post on this forum in response to the above. Yes they are. It represents an individual who CHOOSES to further themselves in a field where a majority of nurses CHOOSES not to.

I'm an ADN, working on my BSN, CCRN, and CEN together with hopes to move onto CRNA. Individuals who hold those titles and are competent preceptors in their job are the ones I hope gain knowledge from. Just my .02 cents.

On a different note, I personally would not prefer to RSI a patient by myself. After 6 years of Level 2 / level 1 ED, and General ICU experience, I have done several intubations by myself, and yes, it does SLOWLY get a bit easier, but if the pt. has any type of trachael malformations, or lung disease, for just a fat juicy neck (to name a few), and you find these out after you initiate RSI without MD assistance, one can find themselves up poo creek without a paddle.

Knowlege and confidence are critical to maintaining patients with an unstable airway (either evolved prior to RSI or if you created it via the hospital chemistry set). You really SHOULD know about the drugs you are pushing vs. "he/she told me so". Not knowing / understanding can create the one thing all of us as nurses should stive to avoid: harming the patient.

RNCENCCRNNREMTP · Sep 19, 2005

So you didn't already have them on O2 before you started? Knowing how NOT to get in trouble in the first place is at least as important as knowing what to do if you do get in trouble. FIRST rule of anesthesia - Oxygen is good.

It is not anesthesia we are talking about here, where the patient will have a period of apnea after induction with GENERAL anesthetics and PARALYTICS and needs an O2 reserve.

This thread started about CONSCIOUS SEDATION and unless there is a prior physiologic need, you do not start them on O2 beforehand.

The drop in SpO2 during conscious sedation is an early indicator that the patient is hypoventilating and so a first response is to ensure a patent airway and stimulate (and possibly add a reversing agent if possible) to achieve effective ventilation which will blow off the CO2 AND increase the SpO2. The best of both worlds!

If your first knee-jerk response to a drop in SpO2 during CONSCIOUS SEDATION is to put the patient on O2 then you have not recognized the problem of a depressed ventilatory drive and the patient is at risk from harm from you not knowing what you are doing.

Yes O2 is good, but CO2 is bad and the main problem with most conscious sedations is the patient is too deeply sedated and is hypoventilating. First fix that and then add O2 if problem persists.

jwk · Sep 19, 2005

It is not anesthesia we are talking about here, where the patient will have a period of apnea after induction with GENERAL anesthetics and PARALYTICS and needs an O2 reserve.
This thread started about CONSCIOUS SEDATION and unless there is a prior physiologic need, you do not start them on O2 beforehand.
The drop in SpO2 during conscious sedation is an early indicator that the patient is hypoventilating and so a first response is to ensure a patent airway and stimulate (and possibly add a reversing agent if possible) to achieve effective ventilation which will blow off the CO2 AND increase the SpO2. The best of both worlds!
If your first knee-jerk response to a drop in SpO2 during CONSCIOUS SEDATION is to put the patient on O2 then you have not recognized the problem of a depressed ventilatory drive and the patient is at risk from harm from you not knowing what you are doing.
Yes O2 is good, but CO2 is bad and the main problem with most conscious sedations is the patient is too deeply sedated and is hypoventilating. First fix that and then add O2 if problem persists.

100% wrong. If you are administering conscious sedation to a patient and using propofol and NOT using O2, it is negligent, and you will find a long line of expert witnesses that will be more than happy to testify against you.

And in the case of propofol - reverse what? It can't be reversed.

This is absolutely the heart of the debate about non-anesthesia providers using propofol for conscious sedation. It is not about a turf war. It is about doing what is best for the patient. Is it best for the patient for an RN to be administering propofol for conscious sedation to a patient in the ER or endoscopy suite? Absolutely not.