Non anesthesia provider providing anesthesia

KeithEMU · Apr 14, 2006

Susswood, your questions are easy work for anyone who actually is professional enough to know a med before they give it. This is not evidence, simply a what if that could easily be applied to any number of procedures done within the hospital.

Not so sure I want to jump in on this at all, but I am really enjoying this thread.

Mike, I know you said you have been pushing propofol, so therefore you should legally know the package insert. You have not, however, answered the question.

You are keeping the thread heated though :) Good thread.

MmacFN · Apr 14, 2006

This is directly from the monogram which im holding in my hand. Your arguing semantics with me here. I know the difference but its irrelevant.

DIPRIVAN Injectable Emulsion is a sterile, nonpyrogenic emulsion containing 10 mg/mL of propofol suitable for intravenous administration. Propofol is chemically described as 2,6- diisopropylphenol and has a molecular weight of 178.27.

Propofol is very slightly soluble in water and thus, is formulated in a white, oil-in-water emulsion. The pKa is 11. The octanol/water partition coefficient for propofol is 6761:1 at a pH of 6-8.5. In addition to the active component, propofol, the formulation also contains soybean oil (100 mg/mL), glycerol (22.5 mg/mL), egg lecithin (12 mg/mL), and disodium edetate (0.005%); with sodium hydroxide to adjust pH. The DIPRIVAN Injectable Emulsion is isotonic and has a pH of 7-8.5.

In regards to how they are used in the ER, Diprivan is what is used for closed reduction.

In order to satisfy this question here are your answers. BTW, im not a "sedation" RN.= and none of this is germane to the conversation but since u seem to be stuck on it here goes.

Do you know the difference between propofol and Diprivan?

Diprivan is the injectible option for propofol (emulsion) . It is what is commonly used in the ER.

Do you know the contraindications for propofol administration?

allergy to propofol or any of the emulsion components, pregnancy, nursing moms, hypotension.

Do you know the appropriate dose of propofol for anesthesia, sedation etc.?

For sedation, dip is titrate to effect drug. However, when we are talking about specific dose ranges they are 5 µg/kg/min (0.3 mg/kg/h) titrate up for effect. 10 or 20 mg is for deep rapid sedation and anesthesia; very dangerous.

What does redistribution mean?

Where the drugs ends up. For instance, propofol has a rapid redis. to non nervous tissue from the brain, this is primarily why the half life is so short in regards to sedation.

What is the context sensitive half-time for propofol?

Elimination about 60 min, distribution = abput 4 min. Im not sure off my head about the "context sensitive"

What is functional reserve capacity?

The functional residual capacity (FRC): the amount of air that stays in the lungs during normal breathing. I have never heard of functional reserve capacity.

Is a decrease in 02 sat an early or late sign of hypoxia?

Certainly late. anxiety and tachycardia are intitial signs of hypoxia.

Are you prepared to deal with cardiovascular collapse?

Absolutely. I manage these patients independantly in my daily practice as do ER physicians.

When was the last time you mixed up and used levophed?

Today in the aircraft.

What is the ACLS dose for epi?

I am regional faculty for ACLS and PALS. its 1 mg.

Do you know what laryngospasm is and how to treat it?

Cord shutting togeather, the Tx is PPV and then lido sprayed on the cords for relaxation. Ive treated it multiple times in dry drowing kids.

Is your wall suction ready to go?

Whos isnt?

Your patient is a full stomach-do you understand the implications of that?

Increased risk for aspiration and decreased inspiratory reserve volume.

Your patient is obese-do you know what that does to gastric emptying time?

not a clue, dosent effect me in my practice.

Do you know if your patient had GERD?

Usually my patients an unconcious. It isnt the OR.

Whaere is the cricoid ring located?

the cric ring is the only circular ring it is below the crio thyroid membrane (where i cric ppl).

What are the ASA fasting guidelines?

Again, this is of no relevance to the ER and an emergent procedure. The ASA has no power in the ER.

How do you repond to and treat acute aspiration?

Peep to effectively "pop" open the alveoli to avoid Ventilation perfusion mismatch. I do it all the time on drowning victims.

Do you know what qualities of stomach aspirate make it more or less lethal?

Again, not relevant to my current practice.

Do you believe the MD you are pushing these drugs for knows all the answers to these questions?

Its an expectation of the job, though many are irrelevant in the emergent tx of an ER patient.

Are you prepared to defend yourself in court?

ive been an expert witness on many issues related to airway & trauma both in and out of hospital. I know exactly what is expected.

Do you think any doc will stand behind you in a court of law?

I wont need the doc, i do whats safe for my patients and can justify all my actions via my chart and EBM,

There. What an excercise in futility that was.

MmacFN · Apr 14, 2006

hey

I hear yah. However, internal closed reductions are a common procedure done in the ER. It is the pervue of the emergency phsyician to decide what is emergent and what is not. ASA AANA has no say in ER policy/procedure. I dont make the rules, i just follow them in this case.

Let me try this again. From the above statement, I understand that your ER docs had to have an inservice on how to use propofol in "emergent situations." So how does having the green light to use propofol in "emergent situations" allow the ED docs to use it for totally elective procedures such as reductions? I fail to see that aspect.
The ED is being given an inch and running with it.

jenniek · Apr 14, 2006

Here is a statement from the ASA regarding safe use of Propofol. The last paragraph states the AANA-ASA joint stance on the issue:

http://www.asahq.org/publicationsAndServices/standards/37.pdf

Interesting bit on the ASA president at the time testifying against the change in the Diprivan use and label change. Follow the red links.

http://www.asahq.org/news/news111705.htm

And a condensed version of the joint statement on Propofol administration by non anesthesia providers.

http://www.aana.com/News.aspx?ucNavMenu_TSMenuTargetID=62&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=761

MmacFN · Apr 14, 2006

Hey Keith

You know why im frustrated here?

It has everything to do with how people are quick to quote research to back up their opinions when it comes to the same conclusions, however; when there is research which dosent, they dismiss research as "irrelevant to clinical practice and saftey of the patient". This is a total farce and a cop out for having absolutely no evidence to back up their own opinions/claims.

I will be a CRNA some day. I will be pro CRNA. I will probably be arguing the same thing here as they are, however, i wont be arguing it if there is not evidence to back up my claims. Evidence based medicine overrules ALL opinions and observations. Anyone who is masters prepared should know that very well. When a research study comes under question, then other studies need to be done to refute or agree with the new info. If this wasent the case we would still be blood letting for fever, drilling holes in heads to let out the demons and doing frontal lobotomies on violent criminals.

It saddens me that the long term well respected professionals on here do not respect what research has done for both their profession, and humanity in general. Where do you think all the information you were taught came from? Opinions? Please, act like professionals and stop playing turf war with me, im not the enemy. Either justify your stance with evidence or admitt that there is none and clearly a study needs to be done.

Not so sure I want to jump in on this at all, but I am really enjoying this thread.
Mike, I know you said you have been pushing propofol, so therefore you should legally know the package insert. You have not, however, answered the question.
You are keeping the thread heated though :) Good thread.

jenniek · Apr 14, 2006

Your patient is obese-do you know what that does to gastric emptying time?

not a clue, dosent effect me in my practice.

Do you know if your patient had GERD?

Usually my patients an unconcious. It isnt the OR.

What are the ASA fasting guidelines?

Again, this is of no relevance to the ER and an emergent procedure. The ASA has no power in the ER.

Do you know what qualities of stomach aspirate make it more or less lethal?

Again, not relevant to my current practice.

If you are giving an anesthetic (this is not a sedative with reversal agent) GERD, aspiration, NPO status and obesity should be concerns of yours. The fact that you are not concerned about aspiration concerns me.....if you are giving an anesthetic, you need to protect for aspiration.

MmacFN · Apr 14, 2006

here is another article to review with references. Please refute it with references.

December 2004

Jeanne Lenzer

Robert Solomon, MD

What is the best sedative/amnestic agent for brief, but painful, procedures in the ED? Increasingly, emergency physicians say propofol fits the bill for many patients. Steven M. Green, MD, author of "Propofol for emergency department procedural sedation: not yet ready for prime time"1 in 1999 now says propofol can be an ideal agent for a number of procedures.

Recent studies of the use of propofol show that it can be used safely and effectively for procedures employed in the ED such as orthopedic manipulation, drainage of abscesses, and cardioversion.2;3

But conflicts with anesthesiologists and anesthetists about who should administer propofol have made some emergency physicians reluctant to pursue its use as an option for their patients.

The American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) issued a joint position statement on April 14, 2004 asserting that when propofol (Diprovan, AstraZeneca) is used for sedation or anesthesia "it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures." They also state that "failure to follow these recommendations could put patients at increased risk of significant injury or death."

It should be pointed out however, that the relevance of these deaths to the ED is not clear, as most propofol-related deaths occurred either in ICU with prolonged infusions not used in EDs, or in settings with inadequate monitoring and or resuscitation equipment, or the staff to respond to emergency situations.

William Dalsey, MD, chairman of emergency medicine at Kimball Medical Center in Lakewood, N.J., says it's important, when discussing who should administer propofol, to shift the discussion and ask: in view of all the agents available for use in the ED, "What is best for our patients?"

"Clearly," said Dr. Dalsey, "this drug has tremendous value. Emergency physicians use sedating agents because patients need them. If we can't use propofol we will be forced to choose another agent - one that might not be as good."

Despite the seeming obstacles to use, a number of EPs are successfully incorporating propofol into their repertoire of sedative agents.

Sharon Mace, MD, Chair, ACEP Pediatric Committee, said "We're seeing increasing usage of propofol in EDs. In our institution, our use of propofol has tripled in the last 4 to 5 years. There is wide use of propofol in the United States as well as in Europe. There is extensive literature on its safe and effective use in a variety of settings in addition to the ED, such as by gastroenterologists for outpatient GI procedures."

How are emergency physicians successfully procuring propofol for use in their emergency departments?

"The first step, Dr. Green told ACEP News, "is to know a lot about the drug. Do your research and put together a protocol explaining the manner in which the drug will be used." Other specialty groups, such as gastroenterologists, have useful data about the use of propofol by non-anesthesiologists. On March 8, 2004, three gastroenterology specialty groups issued a joint statement on sedation in endoscopy. The organizations concluded, "There are data to support the use of propofol by adequately trained non-anesthesiologists: Large case series indicate that with adequate training, physician-supervised nurse administration of propofol can be done safely and effectively."

J. Brian Hancock, MD, ACEP President, sent a letter on July 9th to the ASA and AANA expressing concern about their joint statement and asserting that "propofol can be safely used by emergency physicians in the emergency department." Dr. Hancock noted in his letter that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) "does not specify that only anesthesiologists or nurse anesthetists can deliver sedation."

However, some emergency physicians have already reported that hospitals are saying the JCAHO has adopted the ASA/AANA position on propofol and now has a standard indicating that emergency physicians cannot administer the drug in the emergency department.

"Teresa Stewart, JCAHO's Associate Director for the Office of Quality Monitoring, told us that her agency had not adopted that position on propofol," said Marilyn Bromley, ACEP's Director of Emergency Medicine Practice. "Joint Commission standards are not that prescriptive."

Properties of propofol

Propofol is particularly appealing for deep sedation in the ED because of its extremely rapid onset (40 seconds) and offset (5 to 15 minutes).3;4

Its sedative and amnestic qualities are excellent, says Andy Godwin, MD, who chaired the subcommittee of the ACEP Clinical Policies Committee that formulated the ACEP Clinical Policy on Procedural Sedation and Analgesia. Dr. Godwin told ACEP News, "It allows the physician to reduce a shoulder dislocation or cardiovert a patient, and the patient wakes right back up and says, 'When are you going to do it, Doc?'"

That kind of effective sedation can be a valuable addition to the agents already in use for similar procedures. Propofol has several advantages over other agents. It is substantially less likely than etomidate to cause myoclonus. It has antiemetic and euphoric properties. In patients with potential for elevation of intracranial pressure (ICP), propofol is a good alternative to ketamine because it lowers ICP.4 Propofol dosing does not have to be adjusted in patients with renal or hepatic failure.4

Common side effects of propofol can appear daunting at first. Apnea, bradycardia, hypotension, and the "propofol syndrome" occur in a large number of patients. Nonetheless, these effects are surprisingly manageable.

Apnea, which is not consistently defined across studies, occurred in 5 to 40 percent of patients4 but almost never required intubation.3 After a review of 8 published studies of propofol in emergency medicine, in addition to studies of its use in other settings, Dr. Green concluded that "preoxygenated patients [on 5 to 10 L/min supplemental oxygen] can tolerate respiratory depression and even frank apnea for 1 to 3 minutes, depending on age and underlying physical status, without an apparent oxygen desaturation or need for assisted ventilation."3

Dr. Green does recommend the use of capnography - as does the ASA - despite the fact that there is no evidence that such monitoring changes outcomes. "Hypercapnea alone is not dangerous at all," said Dr. Green. "It's hypoxia that's dangerous. But hypercapnea comes first and it can alert you to stop giving the drug"

Hypotension was also a problem that did not necessarily require intervention. Dr. Mace reports that significant hypotension is most common in hypovolemic patients, causing some clinicians to give a liter of normal saline empirically prior to administering propofol. However, she also said that in studies of procedural sedation, "the overwhelming majority of patients had clinically insignificant transient decreases in blood pressure requiring no interventions."

Aspiration is the most dreaded complication of propofol. Protective airway reflexes are potentially impaired as deep sedation approaches anesthesia. Intravenous dosing of propofol makes it very easy to cross the line between deep sedation and anesthesia, said Dr. Green.

For emergency physicians to develop a successful proposal for the use of propofol in their ED, they must "define their sedation endpoint," said Dr. Green. "What anesthesiologists are afraid of is that there will be brief moments of anesthesia. The difference between deep sedation and anesthesia is that there is some degree of a response to deep pain [in deep sedation] that is absent with anesthesia." To assess that fine line, said Dr. Green, doctors must ensure that response to deep pain is assessed every 30 to 60 seconds during sedation.

The "propofol infusion syndrome," responsible for the deaths of scores of patients, is associated only with prolonged, continuous use of propofol (usually over 48 hours at doses greater than 4/mg/kg/hour. The syndrome consists of rhabdomyolysis, hyperlipidemia, metabolic acidosis, and death. However, this problem is not an issue with the brief administration of the drug in emergency departments.

Although there is little dissent about the need for someone to be devoted solely to the administration of propofol while a physician performs the procedure, the emergency physicians interviewed for this article differed about whether the person administering propofol must be a physician.

Dr. Green emphasized that the drug is very potent and, until health care professionals develop familiarity with the drug and the management of its effects, it is probably best to use a physician for administration of propofol. That would mean that in some emergency departments - those with only one physician - the drug would not be used, even when it is the optimal choice.

Dr. Dalsey, past chair of the ACEP Clinical Policies Committee, said that most of the emergency department procedures where propofol would be used take only a few minutes and can be safely stopped if there is a problem. "I don't believe it takes two doctors to handle this drug," said Dr. Dalsey. "Most emergency physicians are well aware of the complications and can use it safely and effectively without another physician being present, if they have appropriate monitoring and a dedicated and well-trained nurse."

Reference List

Green SM. Propofol for emergency department procedural sedation--not yet ready for prime time. Acad Emerg Med 1999; 6(10):975-978.
Ducharme J. Propofol in the emergency department: another interpretation of the evidence. Can J Emerg Med 2001; 3(4).
Green SM, Krauss B. Propofol in emergency medicine: Pushing the sedation frontier. Annals of Emergency Medicine 2003; 42(6):792-797.
Mace SE. Propofol in: Mace SE, Murphy FP, Ducharme J(eds). Pain Management and Sedation in the Emergency Department. New York. McGraw-Hill, 2005

MmacFN · Apr 14, 2006

hey Jen

Im very concerned about aspiration. If its an issue i plan to control it with cricoid ring pressure and patient positioning. The problem is that all of these issues mentioned below are not often answered in the ER. These are often OR questions. As for how much aspiration is lethal, that depends on the co morbidities and age of the patient. There is no perfect answer as patients do not fit boxes. The best solution is to assume all aspiration is lethal and work to avoid it.

Your patient is obese-do you know what that does to gastric emptying time?
not a clue, dosent effect me in my practice.
Do you know if your patient had GERD?
Usually my patients an unconcious. It isnt the OR.
What are the ASA fasting guidelines?
Again, this is of no relevance to the ER and an emergent procedure. The ASA has no power in the ER.

Do you know what qualities of stomach aspirate make it more or less lethal?
Again, not relevant to my current practice.

If you are giving an anesthetic (this is not a sedative with reversal agent) GERD, aspiration, NPO status and obesity should be concerns of yours. The fact that you are not concerned about aspiration concerns me.....if you are giving an anesthetic, you need to protect for aspiration.

KeithEMU · Apr 14, 2006

Hey Keith
You know why im frustrated here?
It has everything to do with how people are quick to quote research to back up their opinions when it comes to the same conclusions, however; when there is research which dosent, they dismiss research as "irrelevant to clinical practice and saftey of the patient". This is a total farce and a cop out for having absolutely no evidence to back up their own opinions/claims.
I will be a CRNA some day. I will be pro CRNA. I will probably be arguing the same thing here as they are, however, i wont be arguing it if there is not evidence to back up my claims. Evidence based medicine overrules ALL opinions and observations. Anyone who is masters prepared should know that very well. When a research study comes under question, then other studies need to be done to refute or agree with the new info. If this wasent the case we would still be blood letting for fever, drilling holes in heads to let out the demons and doing frontal lobotomies on violent criminals.
It saddens me that the long term well respected professionals on here do not respect what research has done for both their profession, and humanity in general. Where do you think all the information you were taught came from? Opinions? Please, act like professionals and stop playing turf war with me, im not the enemy. Either justify your stance with evidence or admitt that there is none and clearly a study needs to be done.

I can understand what you are feeling. I have also seen you many times call for eveidence and very little has been posted. I also know how so much research uses statistical clustering to prove what ever point is predisposed in the mind of the writer. I also know there is an extreme legal danger in not following Information like package inserts.

Yes I realise that in your area, the BON and your hospital, as well as the MDA's for providing the inservice have made it in your scope of practice. It seems to me that you are very knowledgeable due to much of your experience. When it comes down to it, when it is cearly in your scope of practice it would be extremely hard to turn down an MD telling you to do a push.

I hope some day to be a CRNA as well, but I'm still on the starting blocks, so to say. Till then I don't think I could in good consience push this med, but that is my choice. One thing I think is very dangerious is doing something your improperly trained for in nursing. That is why Scope of practice is there to try to keep you from doing that. It seems to me very dangerious when the powers that be try to sidestep that in the name of convience or cost effectiveness. Much of the research you have posted seems to be to be a means to do just that. There are holes in it that make me uncomfortable. I don't think there has been really good resaerch posted stating the opposire stance either, but if it were me, or my family in that ER, I wouldn't want anyone but a CRAN or MDA giving me those types of drugs. Live is too precious to thow caution to the side in the name of conveince or cost.

jwk · Apr 14, 2006

Mike, why don't you just remain a flight nurse? Really. You know all there is to know about ER and flight nursing, by your own admission. Why on earth are you going to anesthesia school?

You're amazingly antagonistic towards an entire profession you claim that you want to be part of. I hope someday, for your sake, you start thinking like an anesthetist, because school is really going to be hell for you if you don't. Your responses to that list of questions, particularly the last few, show an arrogance and cavalier attitude that will not be well tolerated by your instructors. This same arrogance by "sedation nurses" and gastroenterologist, ER docs and even flight nurses who have seen and done everything on their own with no one else around, is what puts patients at risk. They have that same "not a clue, not relevant, doesn't concern me" attitude.

jenniek · Apr 14, 2006

hey Jen
Im very concerned about aspiration. If its an issue i plan to control it with cricoid ring pressure and patient positioning. The problem is that all of these issues mentioned below are not often answered in the ER. These are often OR questions. As for how much aspiration is lethal, that depends on the co morbidities and age of the patient. There is no perfect answer as patients do not fit boxes. The best solution is to assume all aspiration is lethal and work to avoid it.

So what patients do you prepare for aspiration?

Or is this not a concern because it is the ER and it's safe?

My concern is that you are giving an anesthetic on the ER, so you need to worry about anesthesia problems, even if you are only giving what you think is a "sedation" dose.

rayman · Apr 14, 2006

Hey Mike, oh stirrer of the shiat! :lol2: Need to pick up baby Miller and give it a look...might help you with some of those questions you missed pal.