Propofol

SuperSGirl · Oct 11, 2004

first of all, conscious sedation is a term of the past. moderate sedation is the politically correct term.

fentanyl chest rigidity occurs usually when the doses aren't spaced out or too large of a dose is given. when our gastroenterologist first started using fentanyl, they wanted the relaxation to take place as fast as it did with the use of demerol. having worked in the operating room for 10 1/2 years before coming to endoscopy, i knew this. the docs would push for me to give more, he's not relaxed, etc. but i would say give it time. after several nurses caved under pressure and had to bag with no help (chest rigidity) and then reverse the patients with thank god, nothing horrible having happened to the patient, the docs now listen. it's all about education and being a patient advocate. i space my fentanyl doses about 3-5 minutes a part and never push more than 50mcg at a time. after i reach 150mcg, i go to 25mcg. the use of fentanyl in combination with versed makes the drug even more dangerous. i rarely give more than 5 mg of versed total for an endoscopy. i am thankful for the knowledge i gained from the anesthesiologist in the o.r. and i have respect for all narcotics, benzos, and anesthetic drugs.

i now work with the veteran population and anybody in healthcare knows that veteran patient's are walking train wrecks for the most part. they take tons of antidepressants, antipsychotics, narcotics, benzos, seizure meds. we have to be extremely careful about avoiding reversal. we have less than 1 reversal a month due to the docs having respect for the nurses and the nurses having respect for the drugs. i am the ultimate patient advocate and a great thing about working in the vamc is that the docs are employees too. we have atropine, ephedrine, neosynepherine, epinephrine readily available. there are oral airways, laryngoscopes w/blades, nasal airways, an ambu bag on our cart. fortunately, our physicians are trained well in intubation and (knock on wood), we haven't had to intubate anybody ever. bottom line: there are those who know their limits and those that push them which is the fine line between moderate sedation and general anesthesia.

bringing the use of diprivan to our unit would be suicide for the staff and the patients. not to mention the immediate side effects that occur, the lipid content itself would be contraindicated in most of our patients.

if we are unable to achieve adequate safe sedation to perform the test, our docs recommend a colonoscopy with general anesthesia in the operating room.

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

SuperSGirl · Oct 11, 2004

first of all, conscious sedation is a term of the past. moderate sedation is the politically correct term.

fentanyl chest rigidity occurs usually when the doses aren't spaced out or too large of a dose is given. when our gastroenterologist first started using fentanyl, they wanted the relaxation to take place as fast as it did with the use of demerol. having worked in the operating room for 10 1/2 years before coming to endoscopy, i knew this. the docs would push for me to give more, he's not relaxed, etc. but i would say give it time. after several nurses caved under pressure and had to bag with no help (chest rigidity) and then reverse the patients with thank god, nothing horrible having happened to the patient, the docs now listen. it's all about education and being a patient advocate. i space my fentanyl doses about 3-5 minutes a part and never push more than 50mcg at a time. after i reach 150mcg, i go to 25mcg. the use of fentanyl in combination with versed makes the drug even more dangerous. i rarely give more than 5 mg of versed total for an endoscopy. i am thankful for the knowledge i gained from the anesthesiologist in the o.r. and i have respect for all narcotics, benzos, and anesthetic drugs.

i now work with the veteran population and anybody in healthcare knows that veteran patient's are walking train wrecks for the most part. they take tons of antidepressants, antipsychotics, narcotics, benzos, seizure meds. we have to be extremely careful about avoiding reversal. we have less than 1 reversal a month due to the docs having respect for the nurses and the nurses having respect for the drugs. i am the ultimate patient advocate and a great thing about working in the vamc is that the docs are employees too. we have atropine, ephedrine, neosynepherine, epinephrine readily available. there are oral airways, laryngoscopes w/blades, nasal airways, an ambu bag on our cart. fortunately, our physicians are trained well in intubation and (knock on wood), we haven't had to intubate anybody ever. bottom line: there are those who know their limits and those that push them which is the fine line between moderate sedation and general anesthesia.

bringing the use of diprivan to our unit would be suicide for the staff and the patients. not to mention the immediate side effects that occur, the lipid content itself would be contraindicated in most of our patients.

if we are unable to achieve adequate safe sedation to perform the test, our docs recommend a colonoscopy with general anesthesia in the operating room.

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

2rntish · Oct 11, 2004

Sounds like the ICU where you worked either did not TRUST the nusing staff or you did not have much autonomy....or both...

My point with Diprivan Stevierae. Nothing could be more critical than having a catheter inserted through 2 chambers of the heart and into the pulmonary circulation system. Leave it wedged...major problems. Have it pulled back into the RA...major problems. It did take us a while to gain the Dr trust. They were the dinosaurs that thought nurses did bedpans and baths. Once some of the newer docs started letting us do these and saw that it was rather simple...things changed.

Is Diprivan more dangerous than a manipulating a swan??? Are the complications harder to deal with???

DO NOT misunderstand me please. I realize that Diprivan, like many other drugs, must be used in a closely monitored situation with competent staff but to say that a anesthetist MUST do it is a little old fashioned in my books.

DO understand that my view pertains to Cathlab, Endo, ER where the physician is on the scene.

2rntish · Oct 11, 2004

Sounds like the ICU where you worked either did not TRUST the nusing staff or you did not have much autonomy....or both...

My point with Diprivan Stevierae. Nothing could be more critical than having a catheter inserted through 2 chambers of the heart and into the pulmonary circulation system. Leave it wedged...major problems. Have it pulled back into the RA...major problems. It did take us a while to gain the Dr trust. They were the dinosaurs that thought nurses did bedpans and baths. Once some of the newer docs started letting us do these and saw that it was rather simple...things changed.

Is Diprivan more dangerous than a manipulating a swan??? Are the complications harder to deal with???

DO NOT misunderstand me please. I realize that Diprivan, like many other drugs, must be used in a closely monitored situation with competent staff but to say that a anesthetist MUST do it is a little old fashioned in my books.

DO understand that my view pertains to Cathlab, Endo, ER where the physician is on the scene.

rn29306 · Oct 12, 2004

It never ceases to amaze me what 2 more years of education does for some people. Yoga needs to realize setting in class is not the only way to learn good pt care. I know some MDs that spent more than 2 years in class that I wouldn't take my neighbors dog to.
Sometimes it is the "cowboys" that are out there saving lives while others discuss who has the best education.

Not to sound repetative of wordy, but is is straight from Astra-Zeneca, the maker of Diprivan:

1. Diprivan is a sedative/hypnotic agent that can be used for both induction and / or maintanance of anesthesia as part of a balanced anesthetic technique for inpatient and outpatient surgery.

2. When administered IV, as directed, Diprivan can be used to initiate and maintain monitored anesthesia care (MAC) sedation during diagnostic procedures.

3. Diprivan should only be administered to intubated, mech ventilated adult patients in the ICU....In this setting, Diprivan should only be administrated only by persons skilled in medical management of critically ill patients and trained in CV resuscitation and airway management (under the heading ICU care)

From http://www.astrazeneca-us.com/pi/diprivan.pdf

From a medical-legal standpoint alone, the manufacturer of Diprivan explicitly states that a non-anesthesia provider RN (NAP) has no leg to stand on in giving Diprivan during procedures involving non-intubated patients, regardless if there is a MD there or not.

In reviewing the state of Georgia and Tennessee's RN Scope of Practice, it would also appear that performing the above procedure by a NAP RN would result in operating outside the scope of practice. The state of Georgia outlines 6 decision-tree guidelines for determining scope of practice.

1. Is the activity/task in OCGA 43-26-1 (Nurse practice act of state of GA)?

I sincerely doubt it.

2. Is the activity/task supported by research, postion, and scope of practice standards by National Nursing Organizations or community or institutional related health field?

No, research does not support this, nor does the manufacturer support this view.

3. Is the activity/task consistent with organizational policies and procedures?

If it is then I would not want to work at this facility.

4. Do you possess the current knowledge and skill required to perform the activity/task and it is documented in your work environment?

While this is a generalization (and some will get offended by this), understanding physiology at a staff RN level and understanding physiology at a provider CRNA, PA, NP or MD level is vastly different and I don't think many people can honestly disagree with this statment. A weekend course in ACLS and a conference of propofol does not make a person ready to tackel the delivery of anesthesia care.

5. Would a reasonable and prudent RN perform this activity in this setting?

Most RNs are against this in the first place. Answer is no.

6. Are you prepared to accept the responsibility for your actions?

Perhaps this is the best question of all to ask yourself, secondary to asking yourself "Am I going to accept the responsibility of my actions when this leads to a poor outcome for a patient?"

Answers to questions 2,3,4,5 are NO. This means operating outside the nurse practice acts for GA and there is no defense against operating in this manner.

http://wwww.sos.state.ga.us/acrobat/ExamBoards/RN/decision_tree2001.pdf

The state of TN at http://www.state.tn.us/sos/rules/1000/1000-01.pdf under heading rule 1000-1-.13 section F states:

Performing nursing techniques or procedures without proper education and training (is violation of TN scope of practice laws). Diprivan is an anesthetic and NAP RNs that administer this drug to unintubated patients are in violation of the nurse practice act.

I used to be an aggressive John Wayne ICU nurse. I was young and motivated, ready to learn. I acquired a small chunk of alphabet soup behind my name and did alot of things with a BSN. From working in the Atlanta area units and EDs to being a CCEMT-P trauma and critical care transport RN doing RSI and managing our on-board balloon pumps, I was in the middle of it all. First day on the job in EMS was intubating in a car with one hand through the passenger window and looking down and passing an OETT through a shattered windshield. My attitude completely changed simply being in SRNA school for 2 months while studying medical physiology (yes we had more than 2 months) but my point is that this is a universal suprise to all students in anesthesia. Most of us are in shock about how much we did not know as far as our actions in the units and exactly why it happened and exactly how a medical provider should treat it.

You are absolutely right about the statement concerning what "2 years of educations does for some people". Those two years opens eyes and calms the gunslingers in all of us. Egos are gone during the first semester of anesthesia school.

CNRAs in a court of law are held to the same standards as MDAs when providing patient care. While experience provides understanding on why something happens (but certainly not at a medical level), do you honestly think that NAP RNs have the understanding of physiology as CRNAs and MDAs? If a patient has a poor outcome, a NAP RN will be held to the same standards. Is a GI lab RN ready to accpet these responsibilities when in the obvious wrong in delivering this medication to an unintubated patient?

If you choose to respond, please keep this talk civil as I have attempted to.

sincerely,

rn29306

RN-BSN, ACLS, PALS, NRP, TNCC, CCEMT-P, SRNA

rn29306 · Oct 12, 2004

It never ceases to amaze me what 2 more years of education does for some people. Yoga needs to realize setting in class is not the only way to learn good pt care. I know some MDs that spent more than 2 years in class that I wouldn't take my neighbors dog to.
Sometimes it is the "cowboys" that are out there saving lives while others discuss who has the best education.

Not to sound repetative of wordy, but is is straight from Astra-Zeneca, the maker of Diprivan:

1. Diprivan is a sedative/hypnotic agent that can be used for both induction and / or maintanance of anesthesia as part of a balanced anesthetic technique for inpatient and outpatient surgery.

2. When administered IV, as directed, Diprivan can be used to initiate and maintain monitored anesthesia care (MAC) sedation during diagnostic procedures.

3. Diprivan should only be administered to intubated, mech ventilated adult patients in the ICU....In this setting, Diprivan should only be administrated only by persons skilled in medical management of critically ill patients and trained in CV resuscitation and airway management (under the heading ICU care)

From http://www.astrazeneca-us.com/pi/diprivan.pdf

From a medical-legal standpoint alone, the manufacturer of Diprivan explicitly states that a non-anesthesia provider RN (NAP) has no leg to stand on in giving Diprivan during procedures involving non-intubated patients, regardless if there is a MD there or not.

In reviewing the state of Georgia and Tennessee's RN Scope of Practice, it would also appear that performing the above procedure by a NAP RN would result in operating outside the scope of practice. The state of Georgia outlines 6 decision-tree guidelines for determining scope of practice.

1. Is the activity/task in OCGA 43-26-1 (Nurse practice act of state of GA)?

I sincerely doubt it.

2. Is the activity/task supported by research, postion, and scope of practice standards by National Nursing Organizations or community or institutional related health field?

No, research does not support this, nor does the manufacturer support this view.

3. Is the activity/task consistent with organizational policies and procedures?

If it is then I would not want to work at this facility.

4. Do you possess the current knowledge and skill required to perform the activity/task and it is documented in your work environment?

While this is a generalization (and some will get offended by this), understanding physiology at a staff RN level and understanding physiology at a provider CRNA, PA, NP or MD level is vastly different and I don't think many people can honestly disagree with this statment. A weekend course in ACLS and a conference of propofol does not make a person ready to tackel the delivery of anesthesia care.

5. Would a reasonable and prudent RN perform this activity in this setting?

Most RNs are against this in the first place. Answer is no.

6. Are you prepared to accept the responsibility for your actions?

Perhaps this is the best question of all to ask yourself, secondary to asking yourself "Am I going to accept the responsibility of my actions when this leads to a poor outcome for a patient?"

Answers to questions 2,3,4,5 are NO. This means operating outside the nurse practice acts for GA and there is no defense against operating in this manner.

http://wwww.sos.state.ga.us/acrobat/ExamBoards/RN/decision_tree2001.pdf

The state of TN at http://www.state.tn.us/sos/rules/1000/1000-01.pdf under heading rule 1000-1-.13 section F states:

Performing nursing techniques or procedures without proper education and training (is violation of TN scope of practice laws). Diprivan is an anesthetic and NAP RNs that administer this drug to unintubated patients are in violation of the nurse practice act.

I used to be an aggressive John Wayne ICU nurse. I was young and motivated, ready to learn. I acquired a small chunk of alphabet soup behind my name and did alot of things with a BSN. From working in the Atlanta area units and EDs to being a CCEMT-P trauma and critical care transport RN doing RSI and managing our on-board balloon pumps, I was in the middle of it all. First day on the job in EMS was intubating in a car with one hand through the passenger window and looking down and passing an OETT through a shattered windshield. My attitude completely changed simply being in SRNA school for 2 months while studying medical physiology (yes we had more than 2 months) but my point is that this is a universal suprise to all students in anesthesia. Most of us are in shock about how much we did not know as far as our actions in the units and exactly why it happened and exactly how a medical provider should treat it.

You are absolutely right about the statement concerning what "2 years of educations does for some people". Those two years opens eyes and calms the gunslingers in all of us. Egos are gone during the first semester of anesthesia school.

CNRAs in a court of law are held to the same standards as MDAs when providing patient care. While experience provides understanding on why something happens (but certainly not at a medical level), do you honestly think that NAP RNs have the understanding of physiology as CRNAs and MDAs? If a patient has a poor outcome, a NAP RN will be held to the same standards. Is a GI lab RN ready to accpet these responsibilities when in the obvious wrong in delivering this medication to an unintubated patient?

If you choose to respond, please keep this talk civil as I have attempted to.

sincerely,

rn29306

RN-BSN, ACLS, PALS, NRP, TNCC, CCEMT-P, SRNA

2rntish · Oct 12, 2004

I will try to stay civil because I do choose to repond. You are an idiot...I AM TEASING>>>LIGHTEN UP

Every scenario I have discussed involves an MD being at the bedside. Not some lowly CRNA. AGAIN TEASING...I respect these guys and gals as much as anybody on this board.

I am just sick and tired of people quoting 47 pages of crap that, if you read the PDR, a lowly RN would never be able to do anything.

I teach ACLS, PALS, NRP,TNCC. I know what is involved in these courses. I also I have several close friends who are CRNAs. I have a pretty good understanding of what is involved with their training. No one,including CRNAs, are guaranteed to be able to handle an emergency as a new grad. It takes years of "under the gun" training.

Hell, we are traing med aides in nursing homes and in the VA centers. Why do these pts rate such poor care.

The proof is in the pudding, we have given over 10,000 doses of Diprivan in Endo and Cath labs with fewer complications than given aspirin on the floor...with RN pushing and MD present.

If you choose to respond and can keep it shorter that most of my nursing textbooks, feel free.

Nice credentials by the way. I could add Regional Faculty behind most of mind but since I know what it means in the grand scheme of things. I won't.

This is an interesting topic. I enjoy it.

2rntish · Oct 12, 2004