Can I bolus this patient? A legal / practice question about sedatives and narcotics

Specialties MICU

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Hi, I'm a new RN in a trauma ICU. We use a LOT of pain drips and sedative drips. Typical patient has Versed and fentanyl on pumps with orders to titrate as needed to maintain sedation (MAAS score of 2-3). Sometimes they use propofol with the same order to titrate. Frequently we have specific orders to maintain, say, the Versed at no more than 6 mg/hr, so we do know when the surgeons or other docs want to limit sedative use. But otherwise, we titrate and bolus freely. For instance, if the patient's on 6 mg/hr of Versed, and gets agitated, we'll bolus 2-3 mg right then, and then consider increasing the drip if need be.

However, most of the nurses do not chart their boluses, and they've told me not to chart or document them. They're not sure that bolusing a patient is within our orders or our scope of practice.

My thing is, if you have an order to titrate, isn't a bolus like a momentary titration? A 5 mg bolus through a drip is the same as titrating up to 30 mg/hr for ten minutes and then titrating back down, right? These boluses are delivered slowly, through the pump.

The other contention many nurses have is that if you have to bolus, you probably should be titrating up anyway. But I don't really believe that. Say someone looks comfortable on 3 mg/hr, but when you stimulate them they get agitated and their vitals go nuts. I'd rather bolus then, and then let them rest and return to 3 mg/hr. It's that or jack them up to 5 or 6 mg/hr, doubling their dose indefinitely, even though they don't need it for all 60 minutes of every hour. We're not supposed to be anesthetizing these people anyway!

The problem with my approach is that the trauma team will round and see, from the charting, that the patient was comfortable on 3 mg/hr all night and we could possibly turn the sedation off, when in reality they needed a total of, say, 15 mg of boluses on top of that to keep them comfortable and turning the sedation off will lead to a self-extubation or something.

What do you think? I'd ask the docs but most of them are aware and don't care what the legal aspects are as long as patient care is accomplished. I'm afraid to ask the pharmacy because I don't want to get anyone in trouble.

Specializes in Emergency Dept, ICU.

I have never heard of Propofol on a PCA?! Does anyone else do that?

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I have never heard of Propofol on a PCA?! Does anyone else do that?

There are some facilities that are placing these meds on PCA pumps to regulate and account for these high abuse meds. The pumps are NOT used by the patient. They are set at a basal rate with the "boluses" administered by the staff at a pre-set amount to end the casual "just a touch" for suctioning. The patient does not self administer....they are for narcotic control on usage and waste.

Specializes in ICU.

Just an example. Nurses in my icu will bolus 3 ml or so of propofol for an agitated situation like you described an in front of the pulmonologist at some point mentioned she had to "give the patient some love". End result physician freaked an now no longer will allow propofol drips on his intubated patients(its hell).

Of course its wrong, dont do it, ive seen in surgery the CRNA wouldnt (cant? Idk) push the propofol, was passed to the anesthesiologist to push.

Specializes in CVICU.

Of course its wrong, dont do it, ive seen in surgery the CRNA wouldnt (cant? Idk) push the propofol, was passed to the anesthesiologist to push.

That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it just needs someone with advanced airway management skills to push it in a non-intubated patient (something that a CRNA, Anesthesiologist, or AA all possess).

Specializes in ICU.
That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it just needs someone with advanced airway management skills to push it in a non-intubated patient (something that a CRNA, Anesthesiologist, or AA all possess).

Right exactly why I tried not to assume much, maybe I wasn't looking that specifically and the MD just happened to be closer to the iv site. Main reason I noticed he walked in at the beginning of the case, pushed propofol then immediately left.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
That's interesting there must have been more to the story. CRNA's, MD's, and Anesthesiologist Assistants can all push propofol and do so thousands of times a day (maybe even per hour) it that a CRNA, Anesthesiologist, or AA all possess).

I agree.......sounds like someone got caught with their hand in the cookie jar...... :smokin:

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