Is Indiana RN allowed to give Ketamine for procedural sedation ??

RNCENCCRNNREMTP · Sep 21, 2005

Talk about beating a dead horse this has gone from a mildly educating thread into a pissing contest.
Can conscious sedation be performed safely in ER settings? yes
Is it always safe? NO allot of times not
Are there nurses pushing drugs even with mds involved which the have no understanding of how they work and have no business pushing? A resounding yes
I have worked with nurses whose logic was "I got a doc so they can intubate if something goes wrong." (Yeah this is a recipe for disaster)
Any conscious sedation that ends in a vented pt and icu admit, I would bet dollars to doughnuts fails to meet standard of care for both the physician and nurse and I hope your charting is bullet proof when the lawyers come calling.
All things even I have been involved with conscious sedation numerous time without event the goal of conscious sedation is to provide MILD sedation were a pt maintains spontaneous respirations and an intact airway. In both ERs I worked, it required additional training and education on monitoring, and drugs used. Both facilities required a rn acls cert (pals if needed) at bedside for administering of drugs and monitoring of pt. Separate from staff helping with procedure usually reduction of fx, or dislocation occasionally i/d of abscess. Prior to procedure pt on cm/nipb/pusle ox, 2lnc, iv with crystalloids at kvo suction on, ambu at bedside, reversal agents and airway equipment at bedside not across the er. As of yet never needed reversals or ambu. At both facilities, we have primarily premeditated with morphine or demerol and phenergan on arrival. To help with pain control and help pt position better during x-ray. We usually dose again with narcotics and give a small dose valium, ativan or versed depending on md then repeat 1mg doses as needed. Let me restate again one rn with sole purpose of monitoring pt pre/during/post procedure. The goal of conscious sedation is not to gork the pt so they don't flinch. I have never heard of diprivan for conscious sedation here only pts RNs use it on in my hospital is vented pts in the icu.
In a court of law, a rn pushing rsi drugs or paralytics and sedatives such as diprivan can be made to look like a fool on the stand. When they hold up the vial and ask you to read the warning on it, which states something to the effect of only for use by persons skilled in airway management or for intubated pts only. I as a rule of thumb I try to think about the ability to defend my actions. The only time I could defend pushing these are a vented pt or for rsi with a md who I feel confident can obtain an airway standing at the head of the bed. Nurses in hospital are not allowed to intubate 99.9% of the time in hospital. ACLS does not qualify you intubate most nurses who are allowed to intubate are allowed prehospital and for rn/paramedics when you cross that line into a hospital most states do not allow you to intubate while working in hospital. If your are the "only one around" my question and the plaintiffs attorney is does the hospital have a code blue/1 whatever policy? Where are the ER attendings? Where is RT (most hospitals I have worked for several RT who are legal covered to intubate in hospital but only in arrest situations cannot give paralytics...as are most paramedics prehospital only flight teams around here are set up with rsi drugs)?
Again I believe conscious sedation can be handled safely in the ER but from reading allot of the post on here people are placing their pts well-being, and their license on the line needlessly.

THis is almost exactly how I set up for a conscious sedation in my ER.

All drugs needed (including reversing agents if applicable) at bedside. All airway equipment at bedside, checked and working. All monitors on and recording. An RN dedicated to just the sedation and monitoring. An MD for the procedure, sometimes 2. An RN or tech to assist with the procedure.

Never said that an RN was pushing the drugs in a vacuum, only started out by saying that an RN can give ketamine for sedation. Then everything went crazy.

RNCENCCRNNREMTP · Dec 13, 2005

Some quotes from a critical care listserv regarding sedation:

In most sedation situations, obstruction leading to lack of ventilation rather than total apnea is more common, although certainly apnea can occur.

In most of the "rescue" situations to which I have been called, the procedure lasts much longer than 2 minutes. Typically, it is an endoscopic procedure or a minor surgical procedure being done under "conscious sedation." As the patient moves in response to stimulus, the operator calls for increasing doses of sedation; as the level of sedation increases, the saturation falls due to obstruction/hypopnea.

The person monitoring responds by increasing inspired O2 concentration rather than opening the airway and/or assisting ventilation. The cycle continues until the patient "crashes" due to complete obstruction or apnea and resulting hypoxia/hypercarbia despite recent adequate O2 saturation - "he was fine just a minute ago."

I think this is the danger of mindlessly increasing O2 concentration in response to decreased O2 saturation.

Most of these disasters can be avioded by 1) simple,basic airway management and 2) avoiding what is essentially a general anesthetic by undertrained personnel.

Steve Anderson, MD

I couldn't agree more. In one of my more controversial & provocative talks labelled a "Is hypoxemia really dangerous" I stress the following. In a hypoxemic patient, the worst thing you can do is give O2, watch the sats go up, & walk away. The actual treatment is to identify & reverse the cause. And yes, use a little O2 till that recovery occurs.

Do you mean that the supplemental NC O2 and pulsox lulls

> people into a false sense of security and they don't recognize

> hypoventilation until the sats crash?

Yes. Hypoventilation or airway obstruction. Many cases documented

of SpO2 at 100% with pCO2 in the 80's up to > 200's.

> Are you implying that on O2 with hypoventilation the sats

> crash faster than the same situation on room air?

In this setting (i.e. presumably healthy person undergoing sedation

for a procedure, such as colonoscopy), if the pt, say, becomes

apneic due to sedation, there will be a certain rate of decline of

the pO2. What the SpO2 does depends on the pO2. If the pt is

wearing oxygen, the SpO2 will decline only after a substantial drop

in the pO2, which will occur after a certain amount of time has

elapsed, whereas if the pt is breathing room air, the SpO2 will

decline immediately.

> As long as the sats are good, what is the catastrophe of the

> hypercarbic/hypoventilatory state that you are discussing?

It is a maxim in anesthesia that hypercarbia is clinically

irrelevant in the absence of hypoxemia. Hypercarbia does raise

arterial and pulmon arterial pressure, but outside of that is

clinically insignificant.

The simple way of avoiding these catastrophes, with 100% certainty (and assuming no gross, willful negligence) is to enforce one hard and fast rule -- no oxygen during sedation, unless an anesthetist is giving the sedation.

Leo

Within the next 5-10 years (closer to ten), administration of

supplemental oxygen will be recognized as the single greatest risk

factor to the health of pts during procedural IV sedation. Lets

talk then.

Leo

Kidrn911 · Dec 14, 2005

I have worked in a Pediatric ER in Indianapolis.

At my facility we were allowed to give the Ketamine, atropine, Versed cocktail if we were Pals and preferrably ENPC certified. I personally think one must have at least PALS to sedate.

This is the same as the pediatric ER I bwork at in Chicago as well.

When my 10 year old daughter was busted in the forehead with a baseball bat I demanded that they sedate her. Ther was no way she could have tolerated sutures without sedation. They used Propofol in Indiana, but sedated her in the OR via with an Anesthiologist and plastic surgeon.

She went in to the OR 2:15 pm we walked out at 3:30 pm. That was awesome

jwk · Dec 14, 2005

Some quotes from a critical care listserv regarding sedation:
In most sedation situations, obstruction leading to lack of ventilation rather than total apnea is more common, although certainly apnea can occur.
In most of the "rescue" situations to which I have been called, the procedure lasts much longer than 2 minutes. Typically, it is an endoscopic procedure or a minor surgical procedure being done under "conscious sedation." As the patient moves in response to stimulus, the operator calls for increasing doses of sedation; as the level of sedation increases, the saturation falls due to obstruction/hypopnea.
The person monitoring responds by increasing inspired O2 concentration rather than opening the airway and/or assisting ventilation. The cycle continues until the patient "crashes" due to complete obstruction or apnea and resulting hypoxia/hypercarbia despite recent adequate O2 saturation - "he was fine just a minute ago."
I think this is the danger of mindlessly increasing O2 concentration in response to decreased O2 saturation.
Most of these disasters can be avioded by 1) simple,basic airway management and 2) avoiding what is essentially a general anesthetic by undertrained personnel.
Steve Anderson, MD
I couldn't agree more. In one of my more controversial & provocative talks labelled a "Is hypoxemia really dangerous" I stress the following. In a hypoxemic patient, the worst thing you can do is give O2, watch the sats go up, & walk away. The actual treatment is to identify & reverse the cause. And yes, use a little O2 till that recovery occurs.
Do you mean that the supplemental NC O2 and pulsox lulls
> people into a false sense of security and they don't recognize
> hypoventilation until the sats crash?
Yes. Hypoventilation or airway obstruction. Many cases documented
of SpO2 at 100% with pCO2 in the 80's up to > 200's.
> Are you implying that on O2 with hypoventilation the sats
> crash faster than the same situation on room air?
In this setting (i.e. presumably healthy person undergoing sedation
for a procedure, such as colonoscopy), if the pt, say, becomes
apneic due to sedation, there will be a certain rate of decline of
the pO2. What the SpO2 does depends on the pO2. If the pt is
wearing oxygen, the SpO2 will decline only after a substantial drop
in the pO2, which will occur after a certain amount of time has
elapsed, whereas if the pt is breathing room air, the SpO2 will
decline immediately.
> As long as the sats are good, what is the catastrophe of the
> hypercarbic/hypoventilatory state that you are discussing?
It is a maxim in anesthesia that hypercarbia is clinically
irrelevant in the absence of hypoxemia. Hypercarbia does raise
arterial and pulmon arterial pressure, but outside of that is
clinically insignificant.
The simple way of avoiding these catastrophes, with 100% certainty (and assuming no gross, willful negligence) is to enforce one hard and fast rule -- no oxygen during sedation, unless an anesthetist is giving the sedation.
Leo
Within the next 5-10 years (closer to ten), administration of
supplemental oxygen will be recognized as the single greatest risk
factor to the health of pts during procedural IV sedation. Lets
talk then.
Leo

Total crap and totally outside the mainstream, although I've seen this perspective from a couple of well-known anesthesiologists as well.

jwk · Dec 14, 2005

When my 10 year old daughter was busted in the forehead with a baseball bat I demanded that they sedate her. Ther was no way she could have tolerated sutures without sedation. They used Propofol in Indiana, but sedated her in the OR via with an Anesthiologist and plastic surgeon.

At least they did it with appropriate personnel.

Kidrn911 · Dec 14, 2005

Well it was done at a community hospital instead of a speciality hospital. I personelly feel quite confident in sedating and manaing airways

qanik · Dec 15, 2005

I will make a brief comment in reference to another post. There has been alot of good post here. Seems to be some brains on this board which is always a good thing. I mention my background only as I am trying to prove that I have seen it from many ends. I have been a paramedic for 21 years a nurse for 16 (the last 10 as a flight nurse) and a new CRNA. I won't get into who can do what I will leave that up to you and yours. What I would like to comment on as I mentioned in a previous post is this. While in CRNA school I did my research project on Conscious sedation and its liability. I will challenge you who are doing Conscious sedation as an RN or Medic WITH MD orders and conscious sedation protocols to look up adverse outcomes liability when there is a bad outcome- (aspiration, hypoxic event, arrest, etc) What always happens is the same. A lawyer presents the definition of conscious sedation from the AANA or other anesthesia professional group. Then the question gets asked- Was the patient able to answer questions appropriately during the procedure? Could they follow all commands appropriately? Kind of hard to say yes when they aren't breathing and had to be bagged briefly. In most cases they are settled out of court. You WILL be named whether you are the MD the RN or the Medic when something goes wrong. several articles have also found that up to 80% of conscious sedation protocols are written in such a manner that if they were followed and charted perfectly the hospital would still be held liable for poor outcomes. Just a thought to keep in the back of your head. None of us want to end up on the stand someday. Last, as many of you already know there was another conscious sedation death involving an RN and propofol last week- please be careful

Respectfully,

qanik

jwk · Dec 15, 2005

I will make a brief comment in reference to another post. There has been alot of good post here. Seems to be some brains on this board which is always a good thing. I mention my background only as I am trying to prove that I have seen it from many ends. I have been a paramedic for 21 years a nurse for 16 (the last 10 as a flight nurse) and a new CRNA. I won't get into who can do what I will leave that up to you and yours. What I would like to comment on as I mentioned in a previous post is this. While in CRNA school I did my research project on Conscious sedation and its liability. I will challenge you who are doing Conscious sedation as an RN or Medic WITH MD orders and conscious sedation protocols to look up adverse outcomes liability when there is a bad outcome- (aspiration, hypoxic event, arrest, etc) What always happens is the same. A lawyer presents the definition of conscious sedation from the AANA or other anesthesia professional group. Then the question gets asked- Was the patient able to answer questions appropriately during the procedure? Could they follow all commands appropriately? Kind of hard to say yes when they aren't breathing and had to be bagged briefly. In most cases they are settled out of court. You WILL be named whether you are the MD the RN or the Medic when something goes wrong. several articles have also found that up to 80% of conscious sedation protocols are written in such a manner that if they were followed and charted perfectly the hospital would still be held liable for poor outcomes. Just a thought to keep in the back of your head. None of us want to end up on the stand someday. Last, as many of you already know there was another conscious sedation death involving an RN and propofol last week- please be careful
Respectfully,
qanik

Well said. :yelclap:

Any chance you could provide a link to a news report of this recent incident?

nursemomruns · Dec 16, 2005

Just curious - what do you think should be done in hospitals that don't have 24-hour anesthesia coverage when conscious sedation is needed?

jwk · Dec 17, 2005

Just curious - what do you think should be done in hospitals that don't have 24-hour anesthesia coverage when conscious sedation is needed?

Fentanyl/Versed works well. Conscious sedation using propofol is an oxymoron.

RNCENCCRNNREMTP · Dec 17, 2005

Total crap and totally outside the mainstream, although I've seen this perspective from a couple of well-known anesthesiologists as well.

It must not be total crap if a couple of well known anesthesiologists subscribe to it. I agree that this is new ground but I think it is physiologically reasonable ground.

I am not advocating a slug of a drug and walk away, but give the medication, monitor the patient and not get into the knee jerk reflex that the first thing the patient needs is O2. Perhaps all they need is a little stimulation, a little reversal, a little positioning.

THEN add O2 if still not improving along with repeating and augmenting the above.