Propofol

gaspassah · Feb 29, 2004

in full disclosure i am an anesthesia student. i feel as others that in the realm of patient safety certain guidelines should be followed. in the realm of being a nurse and caring about the profession and those that practice it i will now voice my concern. i just visited the propofol website to look up the package insert.

http://www.diprivan-us.com/sedation/index.asp?shownav=sedation

then go to the prescribing section. must have adobe acrobat.

in bold letters it is to be administered only by anesthesia trained personel. there is also a section on icu patients.

now my point.

if you administer propofol outside of the package insert instructions (ie conscious sedation / rn administered) you will be crucified by any half orifice attorny in court if a detrimental outcome for a patient is visited. it doenst matter if an md was there and intubated etc. if a patient is harmed using a drug outside of it's intended purpose you run a huge risk of losing your license.

what you do is your business, how you act in your profession is your business, patient safety is everybody's business.

i had a preceptor tell me just friday, no matter how sure or confident you are in a patients airway you must know that you can ventilate by mask.

what will you do if you cant ventilate a patient that stops breathing?

just my humble 2 cents

d

yoga crna · Feb 29, 2004

I can't believe ER personnel (includings MDs) are giving propofol to patients with a full stomach. YOU DON'T KNOW WHAT YOU DON'T KNOW. I will be pleased to make myself available to plaintiff attorneys in lawsuits against RNs who administer anesthesia, without benefit of a FORMAL education. A weekend course--you must be kidding.

I give propofol every day as a CRNA with 44 years experience. Each patient reacts differently to the drug and while its short action has advantages, a patient in an intermediate stage of anesthesia is a set-up for vomiting and aspiration, restlessness and hypertension.

To the person who had the nerve to post about anesthesia professionals getting paid for administering anesthesia, my answer is: of course I want to get paid for placing patients in an anesthetized state and even more important, waking them up. I value my work and want to get compensated for its value. I got over the "nursing mentality" of hard work and little pay a long time ago.

Without apology,

YogaCRNA

athomas91 · Mar 1, 2004

amen, amen and amen

stevierae · Mar 1, 2004

I am an operating room nurse with over 25 years experience, and I do not feel that OR nurses--or endo nurses--should be giving conscious sedation, and definitely NEVER propofol. All the "training"--inservices, rather--they can give us in the world does not equate to the training any CRNA or anesthesiologist has, particularly in airway management, and the fact is that we are not trained to handle one level deeper than conscious sedation--that is, general anesthesia.

Check out the ongoing thread of mine in the CRNA section entitled "OR Nurses Giving Conscious Sedation--Why Should We?" I would welcome your comments.

Also, if you have no other objections to putting your license on the line, think about it--they just don't pay us enough to do a CRNA's or anesthesiologist's job.

An article follows for your general interest. As usual it, took a patient death to effect change to an ongoing dangerous practice.

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."

NCgirl · Mar 1, 2004

Ditto on Yoga's remarks, and Athomas. I was previously a CCL nurse giving "conscious sedation", and just being in my second semester of anesthesia school has drastically changed my thinking on RN's and sedation. If you want to give propofol and play anesthetist, then apply to anesthesia school. Otherwise, be ready to spend ALOT of time on the stand in court.

susswood · Mar 1, 2004

Last week in the ER the MD demanded that I push propofol for sedation to reduce an ankle dislocation. I gently refused, explaining that I was not comfortable, can't we use a different drug, etc... The MD threw a fit and complained endlessly to the team leader (who did not stand behind me), and got some other nurse (who laughed at me) to do it. The procedure went without incident, but I am glad I didn't do it, especially now that I have found a hospital policy which specifically states that propofol can only be administered by MD's or Anesthesia providers.

Not having found support from my "peers" at work, I'm thankful for this thread. I have just been admitted to a CRNA program, and will be pushing propofol soon enough...until then, I'll keep my license, thank you very much!

kmchugh · Mar 2, 2004

Ansthesiologists and CRNAs want to be involved just so they can charge for another patient fee.

And some nurses want to give propofol just so they can prove what "nursing studs" they are, regardless the risk they are taking with their patients. This is a stupid argument. If this poster had half as much knowledge as he has bravado (and that bravado is at the expense of patient safety), he'd never give anesthetic medications.

The truth is that I am paid a salary, and I work for the hospital. We have no anesthesiologists. We do anywhere from 10 to 30 endoscopies a week, and the sedation for them is administered either by myself or the other CRNA at the hospital. I get paid the same amount whether anesthesia does the "conscious" sedation or not. At our hospital, anesthesia providers exclusively administer the propofol, as well as fentanyl, ketamine, and a number of other anesthetic agents. Not because we get paid more, not because we can bill more for the service, but because we put patient safety first.

I was frankly shocked at some of you who said "I can give propofol safely, because I am ACLS certified." Guess what? I give propofol daily, several times a day, and my justification isn't that I'm safe because I know ACLS. In fact, if I need ACLS after administering propofol, then I made a big mistake.

Are you all aware that propofol can cause a dangerous drop in blood pressure? If you are, what medications do you have available that can treat that side effect? Because there are patients for whom a drop in BP can be lethal in a matter of minutes. Or that it can induce apnea? What will you do when you cause a patient to be apnic, and you can't ventilate them? Yes, that happens, and you better be ready to intubate them. The catch is that if you cannot ventilate someone with a bag/mask, they will probably be a difficult intubation. And I don't care how many dummies you have intubated at ACLS class, intubating a living human being is a completely different experience.

What are you going to do when you give someone 100 mcg of fentanyl, and induce chest rigidity? Look it up, it happens. The chest becomes so rigid that no amount of force on a bag will put air into the patient's lungs. When it happens, about your only option is to paralyze the patient and intubate them. When you give fentanyl, do you have a paralytic handy?

I really am not trying to belittle anyone. I simply want to get across that these drugs, for all the talk of short half lives and rapid emergence, have the ability to bite you, and bite you hard when you least expect it. And if you aren't prepared for this eventuality, the patient is likely going to die, notwithstanding your expertise in ACLS. CRNA's and anesthesiologists face these effects every day, and we are prepared for them. How many of you have atropine, ephedrine, neosynepherine, and succinylcholine readily available (i.e. drawn up and on the cart) when you administer these drugs? I do, every time. It isn't cheaper, but it's safer for the patient. If you have these drugs, do you know the appropriate dose for your patient?

The point is that when an anesthesia provider says that only people trained in anesthesia should administer anesthetic medications, it isn't out of a desire to enrich ourselves. It's out of a desire to see that patients are cared for safely. And if the endoscopist wants to proceed, having an RN, who is very good but not trained in anesthesia, administer deep sedation, who is really trying to make as much money as possible?

Kevin McHugh, CRNA

plumrn, BSN, RN · Mar 2, 2004

Very good post kmchugh. You may have saved another life, or more, today. (patient and nurse)

TraumaQueen · Mar 2, 2004

We use propofol in our unit on a lot of our ventilated traumas that we feel will be extubated early in the morning, because propofol wears off very quickly. We have a titration protocol, and generally we start the drip at 5-10 mcg/kg/min and titrate up from there to keep patient usually around a 3-4 on the Modified Ramsey scale. If we feel like we are using this drug for sedation on a long term basis, we obtain a lipid panel and monitor that on a regular basis.

I don't feel like this is a drug that should be used on patients that aren't already ventilated, and I have a personal experience to go along with that.... LifeTeam brought us a trauma with a head injury who was very combative en route, so they gave some ativan.... it didn't work, so they started a propofol drip.... when we were moving him to the table, they reported that he had no problems maintaining his own airway, even tho his GCS was probably around a 5-6, so they didn't intubate...... I asked, how much propofol they had him on.... they reported 50mcg/kg/min and a total of 6 mg of ativan.... I just wondered if anyone heard my jaw drop to the floor..... at any rate, I looked at the patient and noticed he had no chest rise..... he wasn't so much breathing..... so, we intubated him quickly. Once the propofol wore off, he had his own spontaneous breaths.... they could have killed him.

However, I think that it can be used responsibly. Naturally, you wouldn't start this drug on a patient that is already hypotensive, or a patient without an artificial airway already established.

The previous poster made lots of good points about sedation, and those pointers he made don't only apply to propofol or fentanyl, but you can cause apnea and hypotension with dilaudid, morphine, versed, ativan (not as much).... so all of these drugs should be administered with caution.

I am very rarely called upon to do conscious sedation during a procedure, as most of our patients will either go to the OR or Special procedures assist with the procedure if it's in the room. So, maybe my comments are out of line... I just wanted you to realize that there are areas where the use of propofol is perfectly acceptable and preferred.

Another thing to point out in regards to propofol that a lot of physicians don't realize is that it IS an anesthetic, not an analgesic..... so, it does nothing for pain. If you use it in the way we are using it, you may also need to supplement with pain meds, based on indicators such as respirations, heart rate, etc....

AnesthesiaBound · Mar 3, 2004

I honestly don't think that the nurses that are pushing propofol ( as well as other sedation meds) are listening to the arguments made by yoga, athomas, mchugh, etc.

There's a lot to consider when using these drugs, not just to keep an eye on chest expansion, sats, vitals,etc. You need to #1 know what to be looking for in adverse reactions #2 how these should be treated and #3 have the knowledge, experience to treat the problem correctly the first time.

The most important issue is liability. Not only to the patient's safety, but also legally. If you've got an endo doc screaming at you to push propofol and you do it against your nurse practice act, hospital's policy, etc, I guarantee you he won't stand up in court and take the blame ( even if this mattered - you are still liable for your actions). Be prepared to pay heavily for your mistakes if something happens and you and the doc can't handle it.

The best way to empower nurses ( if this is what some of you are after), is to educate them (this means anesthesia school for the use of anesthetics). It's great to expand your horizons and make yourself valuable, but keep patient safety first and operate under your practice act.

Remember, nobody is looking out for you, but you!

BJ

Kyli · Mar 4, 2004

Another pat on the back to kmchugh. Well said.

I mentioned earlier that under no circumstances do we nurses in our Endo Unit, give propofol. We have anaesthetists administer it, and have all necessary equipment in the room for the possibility of adverse reactions (ie; intubation equipment, paralytic agents and a whole variety of other drugs to deal with BP drops etc).

kmchugh · Mar 4, 2004

We use propofol in our unit on a lot of our ventilated traumas that we feel will be extubated early in the morning, because propofol wears off very quickly. We have a titration protocol, and generally we start the drip at 5-10 mcg/kg/min and titrate up from there to keep patient usually around a 3-4 on the Modified Ramsey scale.

This is fine. You are talking about a patient who is already intubated and ventilated. Chances are, anesthesia personnel started the propofol infusion. In any event, I don't really have any problem with the use of propofol as a sedating agent on a tubed and ventilated patient, but that's not the point of this discussion.

The point is that nurses not trained in anesthesia should not be using propofol for "conscious sedation" on patients who are not intubated and for whom we are counting on spontaneous respirations. Propofol is an anesthetic agent, and can be very useful in places like the endo room, or the ER. By the same token, when an anesthesia provider uses it, they are prepared for the eventualities that can come with the use of the drug (fentanyl as well), nurses are not. And we haven't even discussed all the possible issues! For example, no one has yet mentioned the fact that there are patients who will become apenic and lose airway reflexes with an "appropriate" dose of propofol. Just think of how disasterous this could be for a patient with reflux, something you all probably see in endo daily. The patient stops breathing, and the nurse tries to ventilate with a bag/valve/mask. But, the nurse has a little trouble, and uses a bit more pressure to ventilate, and forces air into the stomach of a patient who has reflux, and whose airway protective reflexes have been blunted by the same nurse, using propofol. See where this is going? Aspiration, and the potential for a minimum three week stay in the ICU on a ventilator, because someone wanted to use propofol, without proper education.

If you let a GI or ER doc browbeat you into using a drug that that has consequences that you are not prepared for, whose fault is that? Who will bear the brunt of the disciplinary action for that? You will.

Kevin McHugh, CRNA