Diprivan: push or not to push

[time4meRN]

So, here's the question of the day in our ER. I work in Ohio, can't find the answer in the OBN web site. Can we push anesthesia meds or not. Our consious sedation comp. says we can never push Diprivan. Our Docs say, no, as long as it's moderate to light sedation or in an intubation (emergent)...it's ok. Every nurse has a different answer. It used to be we could " titrate" the med by using the pump. You know use 999 for a total of 5 ml. to a ramsey of 4 to 5. But our new pumps will keep the memory that we are using an anesthesia med. So , nurses are getting ywritten up when the infor is down loaded and high titration levels are found. So my opinion is that I don't push any anesth. med. I leave it up to some one else. Any one have info or where to find the info. We were told that the hospital has checked it out, and it's OK with them. But, I don't much care if it's ok with them, If the Ohio Board of Nursing says no than it's plain and simple, it means no.

[cardiacRN2006, ADN, RN]

Regardless of what the Dr says, if your competency/P&P says no then it's no.

We can't do it in my state at all...

[Magsulfate, BSN, RN]

IF the patient is on a ventilator, and the doc says give it, then I give it. If the patient is vented and coming out of sedation and is risking patency of lines and tubes (ETT) and there is an order to titrate for sedation, then yes, I can push a few cc's in, depending on the patient's blood pressure at the time.

As far as conscious sedation, if I am assisting the doc in a procedure, and since I have passed our facilities competency test on conscious sedation, I can push the amt of diprivan that the dr orders. I keep in mind the standard dose for conscious sedation, and it is lower than that of sedation in a ventilated patient. You definately don't want the patient to stop breathing without a patent airway.

It all comes down to,, follow your facilities policies and procedures.

[dawnclnc]

Just read the manufacture label. Do you have a license or training in general anesthesia? If not I would not suggest pushing this drug. If a Dr. is going to push this drug he/she had better be competent and capable to rescue the airway. I actually like this drug and think that it is safer than many of the alternative procedural sedation drugs however,.....What are you going to say to the attorney on the stand when asked if you're trained in general anesthesia? Just something to think about.

[kmoonshine, RN]

Some state BON's will not allow propofol to be used by nurses, unless the med is being used for sedation on a pt who is intubated. Propofol induces general anesthesia and many interpret that to mean that only anesthesiologists should be giving the med.

If the pt is intubated and on a propofol drip, I would think that titrating it according to pharamacy parameters would be ok.

If something bad were to happen when a nurse is pushing propofol, then the nurse would find themself trying to explain to the BON why they were practicing anesthesiology without a license. Propofol IV push can sedate someone too much, bringing someone from conscious sedation to general anesthesia - and you better know how to intubate then. Plus, there's no reversal agent for propofol so if a pt gets too much med and loses ability to protect their airway - then you're looking at intubating the pt and you better have a skilled doc right at the bedside.

You should contact your state BON and ask if propofol can be administered by nurses, and if so, what are the parameters for administration (pump only, no IV push, intubated only, etc).

[GilaRRT]

Regardless of what the Dr says, if your competency/P&P says no then it's no...

Agree. The issue has been resolved IMHO. The BON SOP is simply a set of guidelines that facilities and providers can use to create their policy. Theoretically, an RN could work up the the fullest extent of the BON SOP; however, the facility can choose to set limitations. If a facility has policies that state the RN cannot perform a procedure, the RN simply cannot and should not perform the said procedure, regardless of what the BON SOP says.

With that, a facility cannot have a nurse perform a procedure that is outside of the BON SOP. The RN can work up to the fullest extent or in a more restricted manner, but never outside of the SOP.

[Indy, LPN, LVN]

Our facility policy says titrate, not push, and if drip is begun it should be on a vent patient. (all obvious things, I know.)

Anesthesia brings their own diprivan and they push it themselves during and/or before the rapid intubation.

I always wonder why they call it rapid; I've never seen it done leisurely.

Considering that it can have profound cardiac consequences, I like to have backup for sedation and/or pain for a vent patient, so that diprivan isn't the only med we rely on. When changing the line out, once my clamp came loose and my patient happened to be really sensitive to the extra 5cc he got. He lived and I about had bunny rabbits. Basically I don't have much of a means of rescuing a patient if I decide to push or bolus a drug that can actually kill them, so no, I won't be pushing diprivan. I would be much more comfortable giving big ole honking ativan boluses on a vent patient than I would pushing diprivan.

[VU RN BSN]

Here in Florida, I've always been told an RN is not allowed to administer an IV push / IV bolus of Diprivan.

A critical care nurse in the ICU can care for an intubated patient on a ventilator who is being sedated with a propofol drip and they are allowed to titrate that propofol drip, per physician's orders.

A CRNA (nurse anesthetist) can give an IV push of Diprivan.

[FlyingScot, RN]

It took me about 5 seconds to find the answer on the web-site. In the ER, procedural conscious sedation is considered moderate sedation. According to the BON an RN may administer an anesthetic agent as long as they have been properly trained according to their facility's policy. There is no specification regarding the manner in which the anesthetic agent is delivered. The guidelines cover the type of monitoring that is the RN's responsibility. Beyond that it is up to the individual facility. In my facility we could push Propofol for moderate sedation as long as the physician was in the room and the appropriate safety precautions were observed. The same went for intubation.

[meandragonbrett]

The Ohio BON allows propofol IVP to be given by RNs. I would not give propofol IVP to somebody who is not intubated or about to be intubated. Yes, it has a short half life and wears off quickly but some people are extremely dose sensitive (much more than giving fentanyl and midazolam). I've seen people needing to be bagged after as little as 20-30mg.

[FlyingScot, RN]

I need to clarify my previous post. According to the OBON an RN may administer and anesthesia agent for a moderate sedation only. Deep sedation can only be done by an appropriately trained anesthesia practioner. I gave it frequently in the ER, rarely had problems with respiratory suppression (maybe twice in seven years) and always had a physician in the room for the entire time the patient was sedated. The times we had to bag it was maybe two breaths and that was it. We had intubation equipment immediately at hand as well as the appropriate personnel. My ER was in a busy suburban hospital with an annual visit rate of about 95,000 so we had at least two but often more intubations per day. Our physicians were comfortable and competent with intubations, our nurses and RT's as support staff were as well. In additon my administration of Propofol was within the OBON's scope of practice and I know the drug inside and out. I was not uncomfortable with giving it but at the same time was not cavalier about it either. I think a lot depends on the type of facility you are in. There is an "ER" in southern Ohio that is one room in a building attached to an old farmhouse (okay they could expand to two if they put a cot in the storeroom) I doubt it would be appropriate for Propofol to be used in that situation since they had no RTs after 11PM and no anesthesia department at all.

[kathygray]

I agree with you 100% ... Do what the boards say.