Is RN allowed to push anesthesia meds under direction of MD?

rnprincess · Jun 9, 2005

Hmmm. I don't know about PA? But in AZ you would be practicing medicine without a liscence! Have you checked your board of nursing scope of practice guidelines. It is probably searchable info you can get online? I do not know though. Good luck earning points with the boss.

kabarnes · Jun 9, 2005

As far as I know RNs are only supposed to titrate propofol on a IV pump while a patient is mechanically ventilated. If a patient needs propofol for conscious sedation and does not have an artificial airway an RN should definately not be pushing propofol. But, I am not really sure if an RN can push a small bolus of propofol while the patient is on the ventilator.

chansonsrna · Jun 9, 2005

Well I can speak from my ICU experience that at our institution in Omaha we regularly titrate propofol drips for sedation of the mechanically ventilated patient. Yes, at times we do bolus, ie extensive dressing changes in addition to additional analgese. We also give versed, vallium, (with a physician at the bedside during concious sedations) and occasionally do neuromuscular blockade (NMB) (vecuronium, cisatricurium drips) especially in cases of ARDS without toleration of high PEEP. As part of our annual competencies we are tested over our understanding of interventions etc. I consider all of the above meds anesthesia meds, and would assume is within scope of practice in PA assuming additional training is given/institutional protocols condone. Hope this helps.

Mobeeb, RN · Jun 9, 2005

The following is from the Pennsylvania Board of Nursing:

21.17. Anesthesia.

The administration of anesthesia is a proper function of a registered nurse and is a function regulated by this section; this function may not be performed unless:

(1) The registered nurse has successfully completed the educational program of a school for nurse anesthetists accredited by the Council on Accreditation of Education Programs of Nurse Anesthesia of the American Association of Nurse Anesthetists.

(2) The registered nurse is certified as a Registered Nurse Anesthetist by the Council on Certification or on Recertification of Nurse Anesthetists of the American Association of Nurse Anesthetists.

(3) The certified nurse anesthetist is authorized to administer anesthesia in cooperation with a surgeon or dentist. The nurse anesthetist's performance shall be under the overall direction of the chief or director of anesthesia services. In situations or health care delivery facilities where these services are not mandatory, the nurse anesthetist's performance shall be under the overall direction of the surgeon or dentist responsible for the patient's care.

(4) Except as otherwise provided in 28 Pa. Code 123.7© (relating to dental anesthetist and nurse anesthetist qualifications), when the operating/anesthesia team consists entirely of nonphysicians, such as a dentist and a certified registered nurse anesthetist, the registered nurse anesthetist shall have available to her by physical presence or electronic communication an anesthesiologist or consulting physician of her choice.

(5) A noncertified registered nurse who has completed an approved anesthesia program may administer anesthesia under the direction of and in the presence of the chief or director anesthesia services or a Board certified anesthesiologist until the announcement of results of the first examination given for certification for which she is eligible. If a person fails to take or fails to pass the examination, the person shall immediately cease practicing as a nurse anesthetist. If the applicant, due to extenuating circumstances, cannot take the first scheduled examination following completion of the program, the applicant shall appeal to the Board for authority to continue practicing.

(b) For purposes of this section, ''cooperation'' means a process in which the nurse anesthetist and the surgeon work together with each contributing an area of expertise, at their individual and respective levels of education and training.

Source

The provisions of this 21.17 adopted October 22, 1976, effective October 23, 1976, 6 Pa.B. 2677; amended September 16, 1983, effective September 17, 1983, 13 Pa.B. 2827. Immediately preceding text appears at serial page (81100).

Notes of Decisions

Willful Violation

The provisions of 49 Pa. Code 21.17 (relating to anesthesia) are wilfully violated even though a physician is present at the time the anesthetic is administered if the nurse administers the anesthetic without the physician's direction or awareness. McCarl v. State Board of Nurse Examiners, 396 A.2d 866 (Pa. Cmwlth. 1979).

begalli · Jun 9, 2005

Good question.

Technically, propofol is considered both anesthesia and a hypnotic sedative. So it begs the question of whether or not your institution acknowledges both labels.

I have a feeling (subjective - not proof) that when we have propofol at the bedside as a drip, it's use is considered a sedative, otherwise, we wouldn't be able to manage it as RN's according to our nurse practice act. The bedside dosages we use are not (in most cases) anesthesia doses. (btw, I'm in CA)

But then we do manage neuromuscular blocking agents. We never push etomidate, vec, succs, cis, or any of those for something like rapid induction for intubation, anesthesia does. But we do have ventilated patients paralyzed on vecuromium or succinylcholine gtts that we titrate to a train of four.

As an RN, I can give small boluses of propofol (usually not more than 10 - 20 mcgs), the patient is always intubated and already on the drip and the doc is usually in the room. I know that I rarely run a propofol drip or I never have an order for a drip more than 100mcg/kg/min - I think that gets into the anesthesia dose.

Did I confuse this more or what?!?!??!

I'm certainly confused!! :uhoh21: I suppose it's a bit irresponsible of me to not know for sure so I will look into this myself for my state.

What I do know and trust, is that absolutely 100% my ICU would never let me do anything that was out of my scope. My managers and the CNS are well aware that we, the bedside RN's, are doing what I describe with these drugs.

chansonsrna · Jun 9, 2005

The following is from the Pennsylvania Board of Nursing:
21.17. Anesthesia.
The administration of anesthesia is a proper function of a registered nurse and is a function regulated by this section; this function may not be performed unless:
(1) The registered nurse has successfully completed the educational program of a school for nurse anesthetists accredited by the Council on Accreditation of Education Programs of Nurse Anesthesia of the American Association of Nurse Anesthetists.
(2) The registered nurse is certified as a Registered Nurse Anesthetist by the Council on Certification or on Recertification of Nurse Anesthetists of the American Association of Nurse Anesthetists.
(3) The certified nurse anesthetist is authorized to administer anesthesia in cooperation with a surgeon or dentist. The nurse anesthetist's performance shall be under the overall direction of the chief or director of anesthesia services. In situations or health care delivery facilities where these services are not mandatory, the nurse anesthetist's performance shall be under the overall direction of the surgeon or dentist responsible for the patient's care.
(4) Except as otherwise provided in 28 Pa. Code 123.7© (relating to dental anesthetist and nurse anesthetist qualifications), when the operating/anesthesia team consists entirely of nonphysicians, such as a dentist and a certified registered nurse anesthetist, the registered nurse anesthetist shall have available to her by physical presence or electronic communication an anesthesiologist or consulting physician of her choice.
(5) A noncertified registered nurse who has completed an approved anesthesia program may administer anesthesia under the direction of and in the presence of the chief or director anesthesia services or a Board certified anesthesiologist until the announcement of results of the first examination given for certification for which she is eligible. If a person fails to take or fails to pass the examination, the person shall immediately cease practicing as a nurse anesthetist. If the applicant, due to extenuating circumstances, cannot take the first scheduled examination following completion of the program, the applicant shall appeal to the Board for authority to continue practicing.
(b) For purposes of this section, ''cooperation'' means a process in which the nurse anesthetist and the surgeon work together with each contributing an area of expertise, at their individual and respective levels of education and training.
Source
The provisions of this 21.17 adopted October 22, 1976, effective October 23, 1976, 6 Pa.B. 2677; amended September 16, 1983, effective September 17, 1983, 13 Pa.B. 2827. Immediately preceding text appears at serial page (81100).
Notes of Decisions
Willful Violation
The provisions of 49 Pa. Code 21.17 (relating to anesthesia) are wilfully violated even though a physician is present at the time the anesthetic is administered if the nurse administers the anesthetic without the physician's direction or awareness. McCarl v. State Board of Nurse Examiners, 396 A.2d 866 (Pa. Cmwlth. 1979).

I am curious if the above provisions pertain to inhaled anesthetics and and not some IV sedation the reason I say this is because I feel the term Anesthesia meds are VERY broad and encompasses paralytics, sedative hypnotics, and analgesics. As mentioned by a previous poster some dosing that anesthesia may use in for example intubation are significantly higher than than doses with which staff nurses titrate/bolus in the ICU/Critical Care setting.

TiffyRN, BSN, PhD · Jun 9, 2005

There is an extensive and lively discussion about propofol on the GI nursing forum. I think it could be enlightening for you. I think the basic thought is that giving it as a continuous drip on an intubated patient is not a problem, the controversy comes with giving it IV push or even bolus. I'll reserve my opinion except to say I've been told the drug information insert states that the person administering needs to be skilled in advanced airway management (intubation) so that eliminates most typical RN's.

Small warning; the propofol thread is quite long. . .

https://allnurses.com/forums/showthread.php?t=13194

tvccrn, ASN, RN · Jun 9, 2005

I attended a conference on sedation a little over a year ago and the classification by the maker of propofol is anesthestic. In our facility, nurses may use propofol in infusion form and ONLY on vented patients in the ICU's. We do use it for some procedures in our interventional radiology area for our peds cases but then the intensivist has to be the one administering the med. Unfortunately, my state doesn't have standards of practice for conscious sedation, so our facility policies reign supreme.

begalli · Jun 9, 2005

I attended a conference on sedation a little over a year ago and the classification by the maker of propofol is anesthestic.

DIPRIVAN is indicated for:

Induction of general anesthesia in adult patients and pediatric patients > 3 years of age
Maintenance of general anesthesia in adult patients and pediatric patients >2 months of age
Intensive Care Unit(ICU) Sedation for intubated, mechanically ventilated adults.

http://www.diprivan.com/

HillaryC, RN, CRNA · Jun 9, 2005

All,
Does anyone know if in the state of PA it is within a RN's scope of practice to push anesthesia meds such as propofol. I am posting this question for my boss so if anyone knows the answer please reply. Thanks for the help. It will gain me some extra points with the boss. :) siobhan

I don't know about PA, but in my hospital (in DC), we're allowed to titrate propofol gtts, but not allowed to bolus it. I had a pt. on propofol that was getting intubated, and the intensivist asked me to open the PLUM tubing so it was wide open, and he drew 5cc (50mg) with a syringe and then pushed it himself. I guess bolusing using the IV pump would have been too complicated :)

pricklypear · Jun 9, 2005

But then we do manage neuromuscular blocking agents. We never push etomidate, vec, succs, cis, or any of those for something like rapid induction for intubation, anesthesia does. But we do have ventilated patients paralyzed on vecuromium or succinylcholine gtts that we titrate to a train of four.
.

We give norcuron and pavulon all the time as boluses - I've never seen a gtt of that stuff- to keep patients motionless. A gtt would be so much more convienient. We (the nurses) give succs and versed for almost every intubation on the unit.