GI Diprivan thread

heart queen · Oct 12, 2004

propofol, ie. diprovan given by RN's vrs. anesthesiologists is an ongoing debate and will be for some time.

Diprovan, although my favorite drug, if given by unfamiliar nurses, with inadequate monitoring can be life threatening. At the same time, it's brief effects, if dosed by an anesthesia score is completely safe... assuming the anesthesia scoring has been done, and a 1:1 exists.

This is why the debate is so heated... anesthesia recognise the severity of this rapid ventricular depressant, fat accumulating drug. While there are some nurses, I'm sure a limited few, that can create a very scary situation, where anesthesia is then called to either correct, or intubate a patient. The myocardial suppression can be very fast, as well as very severe. I'm sure anesthesia, feels that their close monitoring is IDEAL. Although never cost effective...where propper training fo RN's can produce the same result.

IMHO, proper training and education can produce a safe situation for the patient, providing the MD screens the patient personally, using the anesthesia scoring system to alert staff to any high risk patient. Protocols then need to be in place to protect our patients and insist on anesthesia for this high risk group. If we do this, on a continium, the debate will lesson.

again IMHO

apaisRN, RN, CRNA · Oct 12, 2004

I push propofol for intubation in MICU, often with etomidate. The patient's monitored and the pulm fellow and attending are there to intubate, both very skilled at it. Is this an okay situation? It's usually only 1-5 cc. Anesthesia does come very quickly on the occasions when intubation isn't smooth.

rn29306 · Oct 12, 2004

The arguement is concerning non-anesthesia RNs pushing Diprivan for ELECTIVE procedures (Specials Radiology and GI) to unintubated patients with only a GI MD in the room. No one is challenging the postion of RSI in the units, ER, or flight programs or the use of diprivan for intubated patients for vent management. I just thought you guys would like to see the thread and voice your opinions about the specific case stated above.

sway · Oct 12, 2004

I'm not sure I understand where the "GI" thread you speak of is located, but more importantly, I'm interested in learning more about the administration of Propofol. I give it all the time at work, usually to our post open heart patients, or other people on vents needing sedation. Usually these patients have swans, so I'd probably notice any cardiac depressive effects pretty early. Still, I'm not sure exactally what to look for specific to Propofol. What are the early warning signs if you don't have a swan? Have I been practicing nursing on the scandalous edge of critical care all this time? Will people write me nasty letters and threaten my family now? Please educate.

And by the way, what's "IMHO"?

Passin' Gas · Oct 12, 2004

Diprovan, although my favorite drug, if given by unfamiliar nurses, with inadequate monitoring can be life threatening. At the same time, it's brief effects, if dosed by an anesthesia score is completely safe... assuming the anesthesia scoring has been done, and a 1:1 exists.
This is why the debate is so heated... anesthesia recognise the severity of this rapid ventricular depressant, fat accumulating drug. While there are some nurses, I'm sure a limited few, that can create a very scary situation, where anesthesia is then called to either correct, or intubate a patient. The myocardial suppression can be very fast, as well as very severe. I'm sure anesthesia, feels that their close monitoring is IDEAL. Although never cost effective...where propper training fo RN's can produce the same result.
IMHO, proper training and education can produce a safe situation for the patient, providing the MD screens the patient personally, using the anesthesia scoring system to alert staff to any high risk patient. Protocols then need to be in place to protect our patients and insist on anesthesia for this high risk group. If we do this, on a continium, the debate will lesson.
again IMHO

1. IMHO: In my humble opinion

2. Propofol does cause myocardial depression, it also causes arteriolar vasodilation reducing SVR. Sympathetic activity is also diminished, damped baroreflex in response to decreased MAP.

3. Highly lipid soluble, fat accumulation occurs with long-term infusions i.e. 10 days in the ICU, not bolus dosing for a short procedure. In fact, the lipid solubility accounts for fast onset, the drug is then redistributed by CO to skeletal muscle and fat, decreasing the levels in CNS and this accounts for rapid awakening.

4. Anyone, I mean anyone, who administers this drug needs to be facile in airway management. None of this "I'm BLS and ACLS certified and can intubate the mannequin 1 out of 3 tries every two years." This drug needs to be administered in persons skilled in airway management including oral airways, nasal trumpets, bag-mask ventilation, and intubation. If you give the drug you need to be able to handle the effects of it.

Quote from package insert for propofol: WARNINGS For general anesthesia or monitored anesthesia care (MAC) sedation, propofol should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Patients should be continuously monitored, and facilities for maintenance of a patent airway, airtificial ventilation, and oxygen enrichment and circulatory resuscitation must be immediately available.

For sedation of intubated, mechanically ventilated adult patients in the ICU propofol should be administered only by persons skilled in the management of critically ill patients and trained in CV resuscitation and airway management.

5. 51 year old male for colonoscopy. Receding chin, full beard/mustache, moderately obese gets a 'little too much' propofol goes apneic. Patient becomes apneic, can't ventilate, no one in the room able to intubate since the 'bad airway' was not picked up by MD screening the patient nor by the RN 'knowledgable' in the administration of propofol. Anesthesia's all tied up in the OR (remember they're not needed). Hypoxia leading to a vegetative state in a 51 year old male with wife, two kids, and CEO of a financial firm will pay for all the anesthesia providers to cover the GI lab.

6. Proper training for RNs is called nurse anesthesia school.

PG

rn29306 · Oct 12, 2004

I'm not sure I understand where the "GI" thread you speak of is located, but more importantly, I'm interested in learning more about the administration of Propofol. I give it all the time at work, usually to our post open heart patients, or other people on vents needing sedation. Usually these patients have swans, so I'd probably notice any cardiac depressive effects pretty early. Still, I'm not sure exactally what to look for specific to Propofol. What are the early warning signs if you don't have a swan? Have I been practicing nursing on the scandalous edge of critical care all this time? Will people write me nasty letters and threaten my family now? Please educate.
And by the way, what's "IMHO"?

Go to the top of this page and pull down the list for Nursing Discussions. Click on the Nursing Specialty Forums. Go to Gastroenterology Nursing. This will show all the threads in the GI section. Click Propofol and read the subsequent posts.

rn29306 · Oct 12, 2004

1. IMHO: In my humble opinion
2. Propofol is not a myocardial depressant, it causes arterial vasodilation leading to hypotension
3. Highly lipid soluble, fat accumulation occurs with long-term infusions i.e. 10 days in the ICU, not bolus dosing for a short procedure. In fact, the lipid solubility accounts for fast onset, the drug is then redistributed by CO to skeletal muscle and fat, decreasing the levels in CNS and this accounts for rapid awakening.
4. Anyone, I mean anyone, who administers this drug needs to be facile in airway management. None of this "I'm BLS and ACLS certified and can intubate the mannequin 1 out of 3 tries every two years." This drug needs to be administered in persons skilled in airway management including oral airways, nasal trumpets, bag-mask ventilation, and intubation. If you give the drug you need to be able to handle the effects of it.
Quote from package insert for propofol: WARNINGS For general anesthesia or monitored anesthesia care (MAC) sedation, propofol should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Patients should be continuously monitored, and facilities for maintenance of a patent airway, airtificial ventilation, and oxygen enrichment and circulatory resuscitation must be immediately available.
For sedation of intubated, mechanically ventilated adult patients in the ICU propofol should be administered only by persons skilled in the management of critically ill patients and trained in CV resuscitation and airway management.
5. 51 year old male for colonoscopy. Receding chin, full beard/mustache, moderately obese gets a 'little too much' propofol goes apneic. Patient becomes apneic, can't ventilate, no one in the room able to intubate since the 'bad airway' was not picked up by MD screening the patient nor by the RN 'knowledgable' in the administration of propofol. Anesthesia's all tied up in the OR (remember they're not needed). Hypoxia leading to a vegetative state in a 51 year old male with wife, two kids, and CEO of a financial firm will pay for all the anesthesia providers to cover the GI lab.
6. Proper training for RNs is called nurse anesthesia school.
PG

Excellent reply. There is one particlular rn on the GI thread who boasts their hopsital has done over 10,000 cases of non-anesthesia provider (NAP) RNs

pushing diprivan on unintubated pts with only GI MD at bedside with NO complications. hmmmmmmmm....no. She claims a NAP RN giving unconscious sedation is safer than giving aspirin. wow. Also, they have LPNs doing regular conscious sedation. I guess JAHCO needs a reason to exist and here it is. This thread is even better than the CRNA vs AA vs MDA argument. Go over to GI specialty and please check this out. Even when shown the diprivan website and evidence of violation of the nurse practice acts, she refuses to see the big picture. Absolutely mind-blowing.

rn29306

sjt9721, BSN, RN · Oct 12, 2004

As much as I love the drug, I disagree with RNs using Diprivan as an agent in conscious sedation. I've used a drip on many, many patients who are intubated, etc. On-call (OB) anesthesia has responded to the ED before to push it for a few cardioversions and a lumbar puncture. But this drug, as detailed on the packge insert, is NOT a choice for conscious sedation.

I don't know what state we're talking about, but I believe my NPA limits this practice to CRNAs.

sjt9721, BSN, RN · Oct 12, 2004

Oh my...I just read several posts from that thread...:uhoh21:

jwk · Oct 12, 2004

Excellent reply. There is one particlular rn on the GI thread who boasts their hopsital has done over 10,000.....
This thread is even better than the CRNA vs AA vs MDA argument. Go over to GI specialty and please check this out.

Oh I gotta check this out!!!:chuckle

London88 · Oct 12, 2004

Passin Gas,

According to Barash propofol does have a direct myocardial depressant effect. It also decreases SVR causing it to produce a more profound hypotension than thiopental.