Propofol - page 7
I wondered if anyone of you as RN's use propofol? Only the anesthesia people are using it. When anesthesia is used they use propofol. We as Rn's are pushing the Demerol, Versed, Morpheine,... Read More
Oct 12, '04In what world are patients on dopamine drips on the floor? Certainly not mine. I was taught that dopamine is a powerful drug with a lot of potential for harm. I'd hate to see it used on an unmonitored patient, or one on a floor with 1:6 ratios (which is good these days!).
Oct 12, '04Someone's previous post regarding RNs giving propofol in the absence of a secure airway:
" EVERY SCENARIO I HAVE DISCUSSED INVOLVES AN MD BEING AT THE BEDSIDE"
Unless the MD was an anesthesiologist, you are strongly mistaken that this individual will be able to appropriately treat adverse anesthesia related events - difficult airway, ect. GI docs know as much about anesthesia as my mechanic understands about quantum physics.
To administer general anesthetic agents to patients without protected airways requires CRNA, MD, or AA after your name.
Some things to consider:
- Propofol is the most destabilizing intravenous anesthetic.
- Tidal volume reduced more than respiratory rate, thus in the presence of
an adequate rate, minute ventilation may remain inadequate allowing
hypoxemia to ensue.
- Propofol decreases the ventilatory drive in response to hypoxia AND
- Don't get caught up in the fallacy that easy titratability always translates
- In addition to reading the package insert regarding appropriate
administration, take a second to review the AANAs and ASAs joint
statement regarding propofol dministration
AANA-ASA Joint Statement Regarding
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.Last edit by charles-thor on Oct 12, '04
Oct 12, '04Quote from 2rntishYour own statements show you for what you are. You don't care what state law says. You're going to do whatever the hell you want to do because you know everything there is to know. You really don't care if your acts are legal or not.
You stand on legalaties, I will stand beside pt care. You side with the board, I will work with the Drs who are comforting and caring for pts. You make sure all the i's are dotted, I will try to make sure the meds are available to pass.
I work in the real world where nurses do what they have to do. Us, good ol boys, unethical, cowboy, practicing outside the board guidelines, and whatever else I have been called will continue to take care of pts the best we can.
Why don't you just start doing surgery? I'm sure you've seen plenty of procedures. Hey, why do you even need the GI doc? By now you've seen thousands of black snakes going up people's butts, so I'm sure you could do it yourself. Oooooops, perforated the bowel doing the biopsy? I'm sure you could take the patient to the OR, do the laparotomy and close the bowel. You've seen this done, right?
Quite simply, you are a danger to your patients and a poor example of a nursing PROFESSIONAL. You don't know your limitations, nor do you care. If you cared about your patients, you wouldn't be doing procedures for which you don't have the appropriate training and putting them at risk.
You think because a GI doc is standing there that everything is fine. You are so amazingly wrong. I remember when Versed was introduced in the late 80's. I can't tell you how many respiratory arrests we responded to in the GI unit because the GI doc OR THE RN PUSHING THE MEDS AT THEIR DIRECTION overdosed the patient on versed. They were giving 10 or even 20 mg at a pop - hey, it's just like valium, right? What's the big deal? You think that GI doc standing next to you can bag a patient or pop in an ETT? I doubt it. The last time they attempted it was either in med school or an ACLS class.
Sooner or later, you'll get in over your head on this. There will be no one there to bail you out. Attorneys will line up to take the case, and there will be no shortage of expert witnesses pointing out that you were working beyond your legal scope of practice, and that you were administering a drug which the manufacturer makes explicitly clear should only be used by anesthesia professionals unless that patient's airway is already secure.
I have no doubt none of us will change your mind. You know everything - you've made that clear. None of us have made that claim - unlike you, we know what we know, we know what we don't know, and above all, we know and respect our limitations.
Oct 12, '04I've had endo + colonoscopies several times over the past 10 years with Fentanyl and Versed given without problems. After my recent experience of not being able to be intubated by TWO anesthesiologists and 2 CRNA's-- 10 attempts over 1 1/2 hours, I can understand why the CRNA's and OR nurses feel so strongly about this issue.
All it takes is ONE unable to ventilate/unable to intubate patient and your career is down the drain. I sure hope all the nurses administering Propfol to a non-intubated patient are carrying their own for an institution will not back you up in a lawsuit. Manufacturer drug recomendation, professional association standards and state BON regulations are what will be used as standards against you in a court of law.
PATIENT SAFETY/ADVOCACY is being abandoned here ---part of our Nursing Standards of Practice "First do no harm...".
Oct 12, '04In all seriousness, this has got to be a joke just to get anesthesia riled up. I cannot honestly believe that in the US in this day and age that the things mentioned by this person actually happen:
1. LPNs doing IV CS
2. Non anesthesia provider (NAP) RNs doing over 10,000 cases with non-intubated pts pushing diprivan and only having 2 incidences where respiratory was called.
3. MDs changing Nurse Practice Laws (hell would freeze over before this happened in our state)
This utter lack of regard for nursing, medicine, and the law are unparralled in modern healthcare. It started off as perhaps a misguided issue, now it is just absurd beyond reason. This thread reminds me of a poster who attempted to reason with one of the subspecialties that inducing severe pulmonary edema by intentional volume overloading ARDS patients would actually help these patients recover.
Oct 12, '04I work in ICU where we standardly use Diprivan for vent pts, as most of us agree, this is an accepted use of the drug. There is no way ever I would push Diprivan for a "conscious sedation" procedure, (by the way Diprivan does not produce a conscious sedation to begin with) but since so many other valid points are being ignored here, I'm sure that will too. My point is I would NEVER push Diprivan NOR WOULD ANY MD I WORK WITH EVER ASK ME TO!!!
I guess basically my point boils down to I agree with patient safety issues, anesthesia being prepared to give the drug because of their hard earned education, the posts pointing out RNs are not covered doing what they know they shouldn't be doing even if ten MDs are in the room--it is still wrong, and the other posts stating the consequences of any such case ever going to court. Even if all that weren't enough to dissuade GI nurses pushing Diprivan, what would you do if out of the thousands of cases you have with no problems ONE patient has problems from the INCORRECT ADMINISTRATION OF DIPRIVAN? And this ONE PATIENT is YOUR PATIENT?
Would you feel guilty at all knowing your actions could potentially cost a patient's life? I don't know about you, but I, like hopefully all the other nurses here went to nursing school to HELP patients. I am a nursing advocate and all for moving the profession forward, but not at the EXPENSE of the PATIENT, and not because some MD pitches a fit, and tells me "so and so nurse" will give the drug the MD wants to use. My only other comment is that I'm glad I don't live in your state where the rules of the board of nursing are so blatantly disregarded when it suits your purpose. Nothing justifies Diprivan used this way (as a push in GI labs)- no matter who is doing it, or who is present. NOTHING.
P.S.- It also saddens me that leaders in nursing have given valuable insight/reasons as to why they are experts in anesthesia and can safely give Diprivan appropriately, but it is thrown back in their faces that they only want to bill, or rub it in that they have more education. For someone who claims to want to move nursing forward, why would you thumb your nose at those who are helping move nursing forward, with their EDUCATION?
Oct 12, '04For those of you who think Propofol is safe, please read the following abstract. I believe the FDA will soon be looking at the safety of this agent.
1: Anaesthesist. 2004 Sep 23 [Epub ahead of print]
Related Articles, Links
[Propofol infusion syndrome]
[Article in German]
Motsch J, Roggenbach J.
Klinik fur Anasthesiologie, Universitatsklinikum Heidelberg.
Propofol infusion syndrome has not only been observed in patients undergoing long-term sedation with propofol, but also during propofol anesthesia lasting 5 h. It has been assumed that the pathophysiologic cause is propofol's impairment of oxidation of fatty acid chains and inhibition of oxidative phosphorylation in the mitochondria, leading to lactate acidosis and muscular necrosis. It has been postulated that propofol might act as a trigger substrate in the presence of priming factors. Severe diseases in which the patient has been exposed to high catecholamine and cortisol levels have been identified as trigger substrates. Once the development of propofol infusion syndrome is suspected, propofol infusion has to be stopped immediately and specific therapeutic measures initiated, including cardiocirculatory stabilization and correction of metabolic acidosis. To increase elimination of propofol and its potential toxic metabolites, hemodialysis or hemofiltration are recommended. Due to its possible fatal side effects, the use of propofol for long-term sedation in critically ill patients should be reconsidered. In cases of unexplained lactate acidosis occurring during continuous propofol infusion, propofol infusion syndrome must be taken into consideration.
Oct 12, '04unfortunately, you are overstepping your bounds. if i had your name, i would not hesitate to report you the board of nurses. you may have no respect for legal issues in healthcare but it is nurses like you that create the legal issues/problems. you need to read the ana code of ethics and follow them.
nurses in icu not defbrillating patient in need is not even on the same page as a nurse stepping outside of their realm of practice.
i hope that is not too late for you to start standing up for what is right before it is too late and you hurt somebody and/or lose your nursing license.
posting attacking remarks is not necessary.
we are not thinking like lawyers, we are thinking like ethical nurses.
Quote from 2rntish....
too many miles between us. i will go my way, you go yours. there are happier threads to follow.
you stand on legalaties, i will stand beside pt care. you side with the board, i will work with the drs who are comforting and caring for pts. you make sure all the i's are dotted, i will try to make sure the meds are available to pass.
i work in the real world where nurses do what they have to do. we no longer have time for back rubs and foot soaks. nursing has changed, some of us have as well. i don't like computer documentation, i think it is unsafe. what about barcoding...times are a changing. us, good ol boys, unethical, cowboy, practicing outside the board guidelines, and whatever else i have been called will continue to take care of pts the best we can.
i just saw john wayne aggressive icu nurse...i used to work with a passive icu nurse that was scared to do anything including defib a pt without a dr there. get a grip.
and read the dip literature very closely and see if it is your interpretation or what the manuf actually states. think like a lawyer since you seem to be drooling over my subpeona. does it say a nurse cannot do it in a monitored situation???Last edit by NRSKarenRN on Oct 13, '04
Oct 13, '04We're not worried about the drug - we're worried about people like you giving it.Last edit by NRSKarenRN on Oct 13, '04 : Reason: Removed quoted post re personal attack
Oct 19, '04Quote from stevieraei 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."
one more thing about this endo lab in southern oregon--it is not jcaho accredited. i think that says something.
i live in oregon. i am not going to "rest easy" until the practice of nurse administered propofol at this facility ceases. i have written the oregon board of nursing and key politicians. we'll see what happens.