Propofol

2rntish · Sep 3, 2004

If anyone is still on this thread....We use it every day in our Endo rooms.

RN pushes, Doc is in room (in dept somewhere) We avg 40-50 cases a day. I can recall 2 that required intervention (resp support) or reversal. Was it the Versed, Demerol????

If it is used in other facilities with no reactions, why not use it?? We use to have a policy that pts on Dopamine gtts (titrated or not) in ICU. Now, every other pt on med/surg has a dop gtt.

We may need to broaden our horizons.

And kmchugh, what are you trained for that the ER nurse with10-20 years experience is not??? I am not selling your education short butI think you may be selling others education/experience short.

NCgirl · Sep 3, 2004

So, just how are you reversing propofol these days? And do you really think an experienced ER nurse is on the same level with a CRNA? Please tell me you are just joking, or either trying to stir up drama, because if not, then you are scaring me!!!

2rntish · Sep 3, 2004

Kinda slow today. Don't be scareed.

adidas99 · Sep 8, 2004

.....

TMPaul · Sep 8, 2004

Holy Cow!! Have none of you guys taken ACLS? I would LOVE to be able to give Propofol. The patient wakes up in seconds. It has a half life of 1.8 minutes!!! I would rather bag a pt for 1.8 minutes than give an 85 y/o 85 lb lady 125mcg of fent and 5 mg of versed!!!!!! Then have to reverse her!
I understand there is an Endo lab in southern Oregon that trains RNs in GI to administer propofol---would love to go there!!!
When I worked in the Midwest as a recovery room nurse we had a procedure room for ECTs, and the Drs started the propofol and we managed it during and post procedure. I NEVER had a problem with airway (if that is the concern)--only with people waking up TOO FAST!
Don't sell yourself too short, RNs keep people alive all the time. All the nurses in our GI lab have ICU/ER experience and ACLS. We need to expand our expertise, not limit it. As long as we are appropriately trained and supervised by an MD, there is no reason to fear administering a medication that enhances the patients comfort and safety during procedures.

We use it for rapid intubation.

TMPaul · Sep 8, 2004

If you want to administer propofol, go to anesthesia school. It is is a potent anesthetic that can cause cardiac depression, hypotension, respiratory depression and loss of a protective airway. I give it every day and am always impressed with its unpredictablity and potency. Also, it is listed as an anesthetic and should only be given by professional anesthetists. See the package insert. It would be interesting to see how a jury would respond to an non-anesthetist administering an anesthetic.
Sorry guys, I feel stronly about this issue.
YogaCRNA

It's used in Advanced Trauma Life Support. We were taught how to use it to do RSI. I personally haven't used it and hope I never have to.

stevierae · Sep 11, 2004

Librasun, Thanks for your support in the use of
propofol for sedation. I am a nurse that works at the
GI lab you described in southern Oregon. With proper
monitoring (EKG, SAO2, NIBP and ETCO2) Propofol is not
only safe but also very effective. For instance
narcotic using patients (we never see them) need large
amounts of narcotics and benzos just to control the
patient. If we are into an ERCP for 30 to 40 min
nothing is more frustrating then having a patient
twist and turn dislodging the cannula the MD just got
into the duct.
Our administration of propofol is small incremental
doses in which the patient's airway is not compromised
and total comfort is achieved. I can't say that
patients don't desaturate but I haven't noticed a
discernable difference in patients receiving propofol
as compared to Fentynl and Versed. Here we don't just
use propofol, as the MD's that do, must be
credentialed in deep sedation. Some of our MD's are
not, and don't use propofol so I have a pretty good
grasp on the use of both.
If we give our patient instructions prior to the
procedure with Versed there is a retrograde amnesia.
With propofol there is no retrograde amnesia, and as a
bonus the patient is wide-awake about 15 min. after
the last dose of propofol.
In conclusion propofol is safe and effective in the GI
lab setting when used by properly trained RN's, MD's
and well monitored here in southern Oregon we have
administered propofol to about 25,000 patients without
any adverse effects.
I encourage you to visit http://drnaps.org for more
Information about training and Nurse Administered
Propofol Sedation. Thanks again for your support.
sorry I first placed this as a new thread and it isn't.

Here's what I don't understand--putting safety issues aside---

WHY do you want to do an anesthesia provider's job---FOR A NURSE'S PAY????

WHY????

I just don't understand why you'd take on the extra headaches and liability--with NO extra compensation. And, believe me, there is HUGE potential liability for you.

I am an operating room nurse and a legal nurse consultant. I, too, have very strong feelings on the issue of nurse administered propofol, and they are, in part, THAT PROPOFOL SHOULD NOT BE GIVEN, BY A NURSE, TO A NON-INTUBATED PATIENT!!!!!!!! EVER!!!!

There are nurses perfectly cabable of administering Propofol, yes. They are called CRNAs.

I LIVE in Oregon. I will be WAITING for the day when I see the Medford facility called on the carpet for unsafe patient care practices, and I will be VOLUNTEERING my services as a behind the scenes consultant--or as an OR nurse expert--OR assisting with expert location--to any attorney who wants to put a stop to this dangerous practice and shut your facility down.

In fact, maybe I can be the one to make a few calls and speed up the process.

I am really tired of "gonzo" nurses who don't know what they don't know, and think it makes them look important to do an anesthesia provider's job. If you are not capable of delivering one level higher than deep sedation--that is, general anesthesia; skilled intubation and all--then you should not be delivering deep sedation. I don't even think you should be delivering MODERATE sedation. That's an anesthesia provider's job.

I get tired, also, of hearing about your capability to "rescue." Yeah, yeah, we're all (operating room nurses)ACLS certified; nothing special about that. But you guys in endo labs seem to think that as long as you can deliver--or THINK you can deliver; based on what you learned in classes-- ACLS, it almost makes it OK to take unnecessary risks.

Why GET a patient to a point where he needs to be "RESCUED?" The fact that he ends up there in the FIRST place shows that YOU HAD NO BUSINESS DOING WHAT YOU DID THAT GOT HIM THERE!!!!!!!

Ususally "rescue" means that you have to call on someone--i.e., an ER doc, who has to drop what he is doing and come to YOUR "rescue" by intubating the patient for you and dealing with all the unnecessary problems that have been created--i.e., a period of anoxia or hypotension or both.

You've had no adverse effects to date? Famous last words....many a nurse who gave Propofol in a plastic surgery clinic has used that phrase--and maybe she DIDN'T have any "adverse effects," by sheer luck or the grace of God--until the day she DID, and her facelift patient died...

yoga crna · Sep 11, 2004

I agree. Just yesterday, I had an asthmatic patient have a bronchospasm with a test dose of propofol. It was scary for all of us, including the patient. She did all right. Propofol is a potent drug, that is an anesthetic. Unless you are a CRNA, you shoudn't administer anesthetices. Read the package insert and realize your liability for giving anesthesia without being educated or certified.

If any of you cowboys or cowgirls who are administering propofol would like to have an intelligent discussion on the following topics, let me know. This is just a small amount of information that must be in your head before administering propofol.

1. Oxygen hemoglobin dissociation curve when interpreting SpO2. How does the curve shift with hypotermia, hypercapnia and hypoxia.

2. What muscle relaxant to you give for rapid intubation?

3. How do you perform Sellick's Manuever and what do you want to accopmplish?

4. Discuss the synergistic and additive effects of propofol and narcotics, benzodiazepines and barbiturates.

5. What is the standard of care for propofol administration when given by an RN (non-anesthetist)? Hint--the same standard as a CRNA.

The most interesting discussion I have seen on the topic is by anesthesia students who gave propofol as an RN prior to going to anesthesia school. To a person, they said they had no idea of the pharmacology, physiology or had to obtain a quick airway in a difficult situation.

Let's make a deal, I won't do general nursing if you don't go anesthesia.

YogaCRNA

stevierae · Sep 11, 2004

5. What is the standard of care for propofol administration when given by an RN (non-anesthetist)? Hint--the same standard as a CRNA.
YogaCRNA

Exactly right. Don't think you can fall back and use the excuse that, when a tragic, irreversible complication--or even DEATH-- occurs, that you can all of a sudden falll back into your "just a nurse" mode and say, ""Well, we weren't TAUGHT that in our classes at (whatever your endo lab is called...)

Once you take it upon yourselves to do an anestheisa provider's job, YOU ARE HELD TO EXACTLY THE SAME STANDARD OF CARE THAT A CRNA IS HELD TO!!

And guess what standard THEY are held to? EXACTLY THE SAME AS AN ANESTHESIOLOGIST!!!!

Trust me on this! Ask your own gastroenterologists!

If a family practice doc takes it upon himself or herself to do a colonoscopy, regardless of the training they claim they've had (less than 1% of FPs in the U.S. are credentialed to perform colonoscopy) and he or she ruptures the spleen, or causes some other rare but recognized--or NOT recognized-- complication that lands him or her in court, do you think he or she can fall back on the defense that, "Well, I'm just a family practice doc..." ABSOLUTELY NOT!!!!!

This individual is NOW held to the same standard of care that a gastroenterologist would be held to--and you can bet NO gastroenterologist--or no FP, for that matter--will speak up in his or her defense.

Do you really think they will stand up in YOUR defense, when you kill one of their patients? Don't believe it for a minute.

stevierae · Sep 12, 2004

I know that I have posted this before. What I want to know is--why does the gastroenterology lab in Southern Oregon--that prides itself on doing nurse administered propofol-- not have to follow these rules? Myabe they are in blatant violation of the rules, and just think that they are above them. Maybe they simply make their OWN rules.

10 to 1 I already know the answer--they are "qualified to rescue" when they have a near miss. It's the "near misses"--can you say "sentinel events?"-- that we never hear about.

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."

stevierae · Sep 12, 2004

i just took a look at the southern oregon gastroenterology lab site where they do nurse administered propofol.

i found it very interesting that the doctors were giving themselves all kinds of pats on the back for supposedly pioneering the technique in 1998, and were mentioned by name, but the 3 nurses involved were mentioned only by those words: "3 nurses."

gee, they didn't even deserve a mention by name for their part in (allegedly) making history and attracting patients from all over the world.

why didn't the docs just call them what they really are? "cheap labor." they should also define their job description this way: "expected to carry out the role of an anesthesia provider;

(whether crna or anesthesiologist)

be held to the standard of care of an anesthesia provider

(crna or anesthesiologist)

and accept all risks and responsibilities normally taken on by an anesthesia provider

(crna or anesthesiologist)

but do it at the same salary of any other registered nurse, without complaints."

here's a blurb off the site. the doctor with his reference to "having gone to heaven and being among the angels" (what---did they have to "rescue" him from a near death experience?!) when he woke up and felt the "loving presence" of the nurse" is enough to make you gag. the metaphor about the nurse as compared to a mother checking her baby's formula on her hand is even more saccharine. who wrote this nonsense?!!!!

"our protocol, on the other hand, involves nurse decision-making, within the confines of the protocol, to administer a tiny, incremental dose when called for by patient adversive movement and only if the breath is robust, as determined by the nurse's constant palpation

we have had no apnea, not do we expect this ever to happen.

were it to happen, we think the length of the apnea would be in keeping with our colleagues at the cleveland clinic.

since the nurse is palpating each breath and otherwise watching the patient like a hawk, and since propofol is white and opaque, one could envision a certain metaphor of a mother checking a baby's formula on her hand or wrist to make sure it is the proper temperature.

the nurse certainly exudes a loving presence to calm the patient, which is part of our protocol.

one local physician opened his eyes after his screening colonoscopy recently and told the nurse that he thought he had gone to heaven and was among the angels."

stevierae · Sep 13, 2004

here's one more official statement, for you gonzo nurses ---especially those at labs like the one in southern oregon--who think that the rules don't apply to them.

blown up to 500x its normal size, it will look excellent sitting in front of a jury, when you are called one by one to the witness stand to testify as to why you thought you could make your own rules.

aana-asa joint statement regarding

propofol administration*

april 14, 2004

because sedation is a continuum, it is not always possible to predict how an individual patient will respond. due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonistic medications, agents such as propofol require special attention.

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. this restriction is concordant with specific language in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.

similar concerns apply when other intravenous induction agents are used for sedation, such as thiopental, methohexital or etomidate.

*this statement is not intended to apply when propofol is given to intubated, ventilated patients in a critical care setting.