Non anesthesia provider providing anesthesia

Zachary2011 · Apr 17, 2006

[

I don't understand why these RN feels like that need to be pushing the envelope with their licenses, it's not like they are getting paid more money for that service. It is all too risky for me. I would rather leave it up to the trained aesthesis. Just my opinion.

In the ERs I work at, 1 in Fort Worth and one farther south, The ER Docs want Diprivan to be drug of choice for all CS, and this POST I have been really trying to pay close attention to and learn from. We give Diprivan fairly frequently for reductions., cardiac conversions ...etc......... I made it a point to ask the Medical Director if I should be worried about its administration. He said you have a far less monitoring time post drug dose then w/ versed and morphine of which is what we usedto use........ 8 mins as opposed to 2-6 hours of drug effect. He said all else is same, have ambu bag, intubation box, at bedside and monitor vitals just as you would w/ versed. Please , if anyone can tell me why I should be concerned............... now keep in mind I am not a CRNA, I am an RN and I am aware of dosing, side fx, poss. complications,and I am very comfortable with handling complications should the arise etc. however much of the CRNA knowledge, ie; chemical make-up, exact physiology etc. is over my head. I would just like to be able to tell our docs why I shouldnt give diprivan when they all seem okay with our nurses doing that. Thanx for any help

susswood · Apr 17, 2006

I am very comfortable with handling complications should the arise etc.
Really? Including aspiration? You should be concerned because these patients have FULL STOMACHS and obtunding airway reflexes with the amount of sedation required to do reductions etc. makes them at very high risk for aspiration. Aspiration pneumonia can be FATAL (did you see the earlier post by Yoga.... about the child... was that in this thread...?). I guarantee that you are not taking appropriate precautions against aspiration.
What is it with everyone? Why would anyone want to practice outside of their scope? Afraid to say no to the docs? Afraid to stand up for your patients? Are you a patient advocate or not?
If you push propofol on a non-intubated patient in doses large enough to do reductions.... etc, then you are practicing anesthesia and you are making a stupid, unsafe decision for yourself and your patients.
EVERY PATIENT DESERVES PROPER ANESTHETIC CARE FOR THESE PROCEDURES.
Ask yourself if it is what YOU would want.
p.s. I think we lost Mike

austin heart, BSN, RN · Apr 17, 2006

I would just like to be able to tell our docs why I shouldnt give diprivan when they all seem okay with our nurses doing that. Thanx for any help

For one thing, you are in Texas. If you look at the rules and regulations set forth by the Texas BNE pushing Diprivan for sedation on a non-intubated patiant is out of the scope of practice of a RN. That alone is enough to keep me from doing it. Why would you want to risk going before the BNE and loosing your license just because your ER doc says that it is safe to be doing what your doing. Doctors could give a flip about what we can and can not do if it suits their purpose and there is a good chance they don't even know that it is against the nurse practice act for us to be doing it.

I went and found my post in the last propofol thread that was going on and I am ganna copy and paste it because is sums it up for me..............

Quoted word for word from the Propofol Injectable Emulsion package insert located in the Pyxis of my ED, in BOLD letters....."Warning, for general anesthesia or monitored anesthesia care (MAC), propofol should be administered only by persons trained in administration of general anesthesia and not not involved in the conduct of the surgical/diagnostic procedure."

I guess I was sick the day they gave the lecture that trained us RN's to administer general anesthesia. If we are expected to do that they should be paying me more. :rolleyes:

MmacFN · Apr 17, 2006

Hi.

No i havent been lost just dont see any point in discussing this further. I have replied to a few questions via PM.

As for the issue of experience and opinions in regards to how dangerous a drug like diprivan can be, sure I am well aware of the dangers and I absolutely take into account the experience of long term learned providers. However, I didnt ask for opinion, I asked for evidence to back up opinion.

What I have left out from this discussion was the fact that i agree with the general concensus. While I feel prepared to manage a patient (based on the nature of my current job) if something should happen, 90% of ER and ICU RNs would not be, that fact alone is why i oppose the use of diprivan in the ER, or ICU for that matter (where there is a common practice of bolusing pts on drips even though clearly not legal and highly dangerous). When i challenged the practice in a CQI meeting the response was (and correctly so) to bring evidence to the table which proves my ascertions. I can tell you (for those who "are too busy" to do a 5 minute search on pub med) there are absolutely 0, none nadda nil, articles written, research done or evidence against the use of diprivan in the outpatient GI setting let alone an ER where there are more appropriate resources.

What I attempted to do was show you all the exact reason why it will not only continue, but has become standard practice. Those who are pro-diprivan and use it in GI outpatient and in the ER have done near 50 peer reviewed and repeated studies which prove their standpoint that giving diprivan in the outpatient GI lab (or the ER) is safe and has a low risk of negative pt impact. These studies all back up each other in conclusions of saftey.

The standard practice in medicine (and in regards to medico-legal liability), to change standards or practice is to conduct peer reviewed studies which can be independantly confirmed. In order for a hypothesis to be correct the investigator must show statistical significance for the hypothesis along with a risk vs benefit analysis via the numbers of the study. There are only 3 things which make a study valid enough to change practice

1) N value (the number of subjects in the study)

2) P value which is basically the probability of getting something more extreme than your result (null hypothesis)

3) Independant studies showing the same outcomes with signifigant P and N values under similar circumstance.

Now. The burden of proof is always on those who want to change "standards of care" or "Common practice". This has been done by the GI and ER people. In order to change this evidence based practice, the burden of proof now lies with the dissenting opinion, the CRNA and MDAs. To date, there has been no evidence presented by either group which would suggest there are any pt saftey issues with this practice.

Now, before you go off on all the risks of this medication use, remember, it dosent matter what you say since its opinion ONLY and the evidence simply does not bear out your hypothesis. If it was that common to have aspiration, hypotension causing extremis etc (with the current dose administration used in these settings) then it would have come up in the studies, there would already be litigation vs an ER/Hospital and Doc/RN in regards to this issue (which would quickly be pointed out publically by the AANA and ASA as evidence). Alot of them in fact since even states where RNs cannot push the med, the ER physician can and does, this is considered common practice and standard of care in the ER now by ACEP and is taught as such in EM residencies (and GI).

So, while i certainly respect the opinions on the list the evidence (to date) does not bear out their hypothesis. My personal opinion is that there have been alot of lucky patients, however, my opinion did not matter in the CQI meeting (which included the hospital lawyer and risk management because i made a massive stink about the issue). I also quickly pointed out the package insert and read it verbatim along with some of the info from the website (as many refer to here). The concensus of both risk management and the legal counsel for the hospital (after reviewing evidence and statements from the ASA/AANA, ACEP/ENA along with the GI ppl) came to the conclusion that there is more than sufficient evidence (and no liability issues for the hospital) to both continue the use of diprivan in he outpaitent GI lab and the ER as currently practiced. It was noted there was no evidence to suggest this was in anyway compromising patient care or saftey. This same conclusion has been found at just about every facility in the state (there was a list where it was used without anesthesia). I was the only dissenting opinion in the whole group.

Now let me tell you, hospitals are not interested in adding liability for ANYTHING when they can avoid it. Diprivan used in concious sedation was run by JACHO and approved. The lawyers did a case law search which came out with no statistical signifigance between litigated cases involving anesthesia or GI/ER groups. For those of you who suggest the hospital "bends the rules" you just havent been involved in risk management meeting before. The hospital has nothing to gain by allowing policy switch from MS/FENT/VERSED to Diprivan/Narcotic in concious sedation. The ER docs have no power as they are a contracted group so it wasent threats from them. It does not make the hospital more money. The reason the policy was changed was because it clearly made many procedures easier on the patient as well as decreased the time for patient recovery from the medication. To put it in perspective, this is a hospital that does not allow EJ insertion in the ER without a 4 hour training class and 10 successful insertions in the presence of an EJ qualified RN and the ER Doc. Then once checked off can only insert an EJ on the order of an ER physician and is his/her presence (as an example). The same hospital decided to reject a proposal from the ER management and the ER physicians suggesting that a trained flight RN (there are about 4 of us that work there) would be allowed to intubate at night time during respiratory and cardiac arrests when the ER physician was unavaliable (in another code etc and could not leave). There is no anesthesia in the hospital at night. So it seems clear they are not about to take many risks.

Anyway. I have to say I was quite dissappointed with the responses i got on this topic as i thought this would provide me with ammunition. I can essentially sum them up in a few words, Opinion, Insulting and Dismissive (even though im sure many didnt intend it that way and are simply passionate). It is all about evidence, the onus is now on us to prove the opinion.

Take care

heartICU · Apr 17, 2006

I am curious - no one has mentioned what dose you are using. To all those who are using propofol in GI labs, ER, etc, how much are you giving? And on that NAPS website...it says "tiny incremental doses" are given....exactly what does that mean?

athomas91 · Apr 17, 2006

Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: A three year prospective study

Stojanka Gasparovic, Nadan Rustemovic, Milorad Opacic, Marina Premuzic, Andelko Korusic, Jadranka Bozikov, Tamara Bates

ISSN 1007-9327 CN 14-1219/R World J Gastroenterol 2006 January 14;12(2):327-330

--- this article specifically states in the discussion that GI assoc. in the United Kingdom and US have specific monitoring guidelines - and the article recommends that anesthesia should be the ones to administer and monitor the patient for safety sake. ---

_________________________________________

Propofol for deep procedural sedation in the ED.

Frazee BW, Park RS, Lowery D, Baire M.

Am J Emerg Med. 2005 Mar;23(2):190-5.

the findings of this study done in the ED - liked the use of propofol but found it "However, it produced a significant incidence of hypotension, hypoxemia, and apnea"

so...good for ER staff - bad for patient...?!?!

_______________________________________

Conscious sedation of children with propofol is anything but conscious.

Reeves ST, Havidich JE, Tobin DP.

Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA. [email protected]

Pediatrics. 2004 Jul;114(1):e74-6.

this is an article that clearly states conscious sedation in peds with propofol when measured w/ BIS shows they are much deeper than what is appropriate for CS and that propofol for sedation in peds should only be given by anesthesia.

_________________________________________

Risk management regarding sedation/analgesia.

Petrini J, Egan JV.

Division of Gastroenterology, Sansum-Santa Barbara Medical Clinic, CA 93105, USA. [email protected]

Gastrointest Endosc Clin N Am. 2004 Apr;14(2):401

this article seems to state that propofol sedation comes with risks and patient safety should come first for now until enough proof arises that nurses should be giving an anesthetic.

_________________________________________

Propofol: a gastroenterologist's perspective.

Vargo JJ.

Section of Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. [email protected]

Gastrointest Endosc Clin N Am. 2004 Apr;14(2):313-23

this article states how your endoscopist should have extensive and thorough knowledge about the sedatives given.... YEAH RIGHT...

________________________________________

http://www.astrazeneca-us.com/pi/diprivan.pdf

over and over again the manufacture states that whomever is using propofol should know basically everything on the insert - which i will definately argue that 99.9% of those outside of anesthesia pushing it do not know.

____________________________________________

http://www.safepropofol.org/SOMNIA%20PDF.pdf

a letter from congress denying the request to remove package insert instructions it SHOULD ONLY BE GIVEN BY THOSE TRAINED IN ANESTHESIA

_____________________________________________

ok.. i am tired... but for every article that says that propofol saves time and money - it states it comes with significant risks... and although the ENA and GI nursing assoc. support the use of propofol for CS - the manufacture doesn't nor does congress and therefore the LAW. all of the articles that i found that support views that nurses should be able to administer propofol are counting on the fact that the MD you are working with has an intimate knowledge of the medication which is a dangerous assumption that you all are making. they all also are geared toward patient recovery time and money - not patient safety. perhaps you can, but most nurses can not identify nor even tell you if there is a difference between respiratory effort and ventilation - none of the studies that have been cited in support have used ETCO2 detectors - therefore respiratory measuring parameters were defunct.

Just a CRNA · Apr 17, 2006

add my 25 years of anesthesia experience to those who say giving propofol in this cavalier fashion is beyond the scope of practice of rns. here is the section of the texas bne's position paper on the topic:

rns or non-crna advanced practice nurses administering propofol, ketamine, or other anesthetic agents to non-intubated patients

of concern to the board is the growing number of inquiries related to rns and non-crna advanced practice nurses administering propofol, ketamine, or other drugs commonly used for anesthesia purposes to non-intubated patients for the purpose of moderate sedation in a variety of patient care settings. it is critical for any rn who chooses to engage in moderate sedation to appreciate the differences between moderate sedation and anesthesia.

moderate sedation versus anesthesia

according to the professional literature "moderate sedation" is defined as a medication-induced, medically controlled state of depressed consciousness. included in the literature from various professional organizations is the caveat that, while under moderate sedation, the patient at all times retains the ability to independently and continuously maintain a patent airway and cardiovascular function, and is able to respond meaningfully and purposefully to verbal commands, with or without light physical stimulation. reflex withdrawal to physical stimulation is not considered a purposeful response. loss of consciousness for patients undergoing moderate sedation should not be the goal and thus pharmacologic agents used should render this result unlikely. if the patient requires painful or repeated stimulation for arousal and/or airway maintenance, this is considered deep sedation.

in a state of deep sedation, the patient's level of consciousness is depressed, and the patient is likely to require assistance to maintain a patent airway. deep sedation occurring in a patient who is not appropriately monitored and/or who does not have appropriate airway support may result a life-threatening emergency for the patient. this is not consistent with the concept of moderate sedation as defined in this position statement or the professional literature.

although propofol is classified as a sedative/hypnotic, according to the manufacturer's product information, it is intended for use as an anesthetic agent or for the purpose of maintaining sedation of an intubated, mechanically ventilated patient. the product information brochure for propofol further includes a warning that "only persons trained to administer general anesthesia should administer propofol for purposes of general anesthesia or for monitored anesthesia care/sedation." the clinical effects for patients receiving anesthetic agents such as propofol may vary widely within a negligible dose range. though reportedly "short-acting", it is also noteworthy that there are no reversal agents for propofol.

the board defines "monitored anesthesia care" in rule 221.1(9) as:

". . . situations where a patient undergoing a diagnostic or therapeutic procedure receives doses of medication that create a risk of loss of normal protective reflexes or loss of consciousness and the patient remains able to protect the airway for the majority of the procedure. if for an extended period of time the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic."

the patient receiving anesthetic agents is at increased risk for loss of consciousness and/or normal protective reflexes, regardless of who is administering this medication. again, this is not consistent with the concept of moderate sedation outlined in the professional literature.

though the rn or non-crna advanced practice nurse may have completed continuing education in advanced cardiac life support (acls) and practiced techniques during the training program, this process does not ensure ongoing expertise in airway management and emergency intubation. the american heart association (aha) cautions acls providers about attempting tracheal intubation in an emergency situation since "repeated safe and effective placement of the tracheal tube, over the wide range of patient and environmental conditions encountered in resuscitation, requires considerable skill and experience. unless initial training is sufficient and ongoing practice and experience are adequate, fatal complications may result."1 it is also important to note that no continuing education program, including acls programs, will ensure that the rn or non-crna advanced practice nurse has the knowledge, skills and abilities to rescue a patient from deep sedation or general anesthesia. furthermore, it is the joint position of the aana and asa that, "because sedation is a continuum, it is not always possible to predict how an individual patient will respond." these organizations state that anesthetic agents, including induction agents, should be administered only by qualified anesthesia providers who are trained in the administration of general anesthesia.

therefore, it is the position of the board that the administration of anesthetic agents (e.g. propofol, brevitol, ketamine, and etomidate) is outside the scope of practice for rns and non-crna advanced practice nurses except in the following situations:

when assisting in the physical presence of a crna or anesthesiologist
when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist)
when administering these medications to patients who are intubated and mechanically ventilated in critical care settings
when assisting an individual qualified in advanced airway management, including emergency intubation procedures

while the physician or other health care provider performing the procedure may possess the necessary knowledge, skills and abilities to rescue a patient from deep sedation and general anesthesia, it is not prudent to presume this physician will be able to leave the surgical site or abandon the procedure to assist in rescuing the patient.

in the absence of an anesthesia provider or practitioner skilled in advanced airway management/intubation, if the rn or non-crna advanced practice nurse chooses to administer anesthetic agents (e.g. propofol, brevitol, ketamine, etomidate, etc) as ordered for purposes of moderate sedation to non-intubated patients, he/she must have demonstrated the following competencies:

advanced life support, with an emphasis on current competency in population specific advanced airway management.
knowledge of anatomy, physiology, pharmacology, oxygen delivery, cardiac arrhythmia recognition and complications related to moderate sedation and medications
knowledge of medications to include but not be limited to side effects, toxic effects, allergic reactions, desired effects, unusual/unexpected effects, reversal agents, and changes in the patient's condition that contraindicates continued administration of the medication
knowledge, skills and abilities to identify deviations from the norm, including but not limited to thorough patient assessment skills
knowledge of the indications for and contraindications to moderate sedation

so there you have it. in texas, at least, rns don't have a leg to stand on if a complication occurs while they are administering any drug such as propofol, ketamine, etomidate, etc. saying that the doc is standing by while you administer the med doesn't matter. the fact that you "do it all the time" doesn't matter. the fact that you tubed a mannequin in acls class doesn't matter. hopefully mcmac, between this post and the thoughtful post by athomas you will realize that you are wrong. as a couple of folks have noted, why would you push the envelope on your practice, when your state bne says you are flying alone? we have a lot of experience, a lot more than you. we are telling you that it is only a matter of time before something terrible happens; you overstep the bounds of nursing practice; a patient suffers; and you lose your license and your future. we've shown you the source articles and a quote from a typical state bne position paper. is it really worth it? you decide.

louloubell1 · Apr 17, 2006

.....What I have left out from this discussion was the fact that i agree with the general concensus. While I feel prepared to manage a patient (based on the nature of my current job) if something should happen, 90% of ER and ICU RNs would not be, that fact alone is why i oppose the use of diprivan in the ER, or ICU for that matter (where there is a common practice of bolusing pts on drips even though clearly not legal and highly dangerous). When i challenged the practice in a CQI meeting the response was (and correctly so) to bring evidence to the table which proves my ascertions. I can tell you (for those who "are too busy" to do a 5 minute search on pub med) there are absolutely 0, none nadda nil, articles written, research done or evidence against the use of diprivan in the outpatient GI setting let alone an ER where there are more appropriate resources.
What I attempted to do was show you all the exact reason why it will not only continue, but has become standard practice. Those who are pro-diprivan and use it in GI outpatient and in the ER have done near 50 peer reviewed and repeated studies which prove their standpoint that giving diprivan in the outpatient GI lab (or the ER) is safe and has a low risk of negative pt impact. These studies all back up each other in conclusions of saftey.....
The standard practice in medicine (and in regards to medico-legal liability), to change standards or practice is to conduct peer reviewed studies which can be independantly confirmed. In order for a hypothesis to be correct the investigator must show statistical significance for the hypothesis along with a risk vs benefit analysis via the numbers of the study. There are only 3 things which make a study valid enough to change practice
1) N value (the number of subjects in the study)
2) P value which is basically the probability of getting something more extreme than your result (null hypothesis)
3) Independant studies showing the same outcomes with signifigant P and N values under similar circumstance.....
.....Anyway. I have to say I was quite dissappointed with the responses i got on this topic as i thought this would provide me with ammunition. I can essentially sum them up in a few words, Opinion, Insulting and Dismissive (even though im sure many didnt intend it that way and are simply passionate). It is all about evidence, the onus is now on us to prove the opinion.

Okay, Mike, I'm sorry pal, but are your eyes brown, because you are completely full of BS. Please forgive me for the flaming that is about to ensue, but I can hardly stand it anymore. You keep pointing out how insulting other people's posts have been to you. Do you seriously think that your posts are not insulting? Seriously? You keep attempting to explain the subtle nuances of evidence based practice and statistical analysis to PEOPLE WHO ALREADY KNOW. Do you really think that your rudamentary explanations of material that is already known by any NA MS candidate or graduate is necessary, or is it just another example of the cockiness and condescending patronization that many of your 200+ posts display. How many times do you have to reiterate that you are a flight nurse, you are so skilled at intubation, you are totally familiar with anesthesia medications such as etomidate and propofol (which, btw I think your responses to susswood's questions clearly disproved), and oh, lest I forget, you have been published. If I had to count, I would say that more than half of your posts, in some manner or another, toot your own horn.

I don't believe you for a minute when you say (paraphrasing now...) "oh, what I left out is that I agree with the general consensus...I'm just trying to get you all to think." Seems to me that there are two possible motivations behind that kind of a statement. Either you are trying to save face, or you really, truly think that you possess some supernatural ability to critically think, to search medical literature, and dissect research findings, an ability that far outweighs the abilities of everyone else around you, and that without your truly gifted guiding force to guide the rest of us mere mortals, we would just practice... oh what did you call it... witch-doctor medicine.

Now, on the other side of the coin, I would like to tell you that I think you'll be a fine CRNA someday. You are driven and passionate, and I can respect that. But your road to getting to CRNA may be a living hell if you come across in person anything like you come across on this board. I know you've heard it before on other threads here, but your manner as displayed in this forum will not be tolerated well in the clinical area. I can guarantee that. Nobody likes a know-it-all. Your classmates won't like it, your instructors won't like it, and your precepting CRNAs won't like it.

Lou

MmacFN · Apr 18, 2006

Hey Heart.

The way the local ER was doing it was this:

- 2 micrograms/kg of fentanyl i.v

- continuous infusion of propofol at 0.21 mg/kg/min i.v. to the desired level of sedation. A maintenance infusion of 3-6 mg/kg/hr was administered during the remainder of the procedure.

The initial "bolus" infusion MUST be initiated by the physician not and RN. The maintenance infusion was maintained by the RN.

I am curious - no one has mentioned what dose you are using. To all those who are using propofol in GI labs, ER, etc, how much are you giving? And on that NAPS website...it says "tiny incremental doses" are given....exactly what does that mean?

MmacFN · Apr 18, 2006

Good finds Thomas!

Im grabbing them now! Thanks!

I know the ER isnt using ETCO2 as they only have capnography for intubated patients, I believe there are new devices which can measure CO2 in the non-intubated, but i have not seen them myself.

Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: A three year prospective study
Stojanka Gasparovic, Nadan Rustemovic, Milorad Opacic, Marina Premuzic, Andelko Korusic, Jadranka Bozikov, Tamara Bates
ISSN 1007-9327 CN 14-1219/R World J Gastroenterol 2006 January 14;12(2):327-330
--- this article specifically states in the discussion that GI assoc. in the United Kingdom and US have specific monitoring guidelines - and the article recommends that anesthesia should be the ones to administer and monitor the patient for safety sake. ---
_________________________________________
Propofol for deep procedural sedation in the ED.
Frazee BW, Park RS, Lowery D, Baire M.
Am J Emerg Med. 2005 Mar;23(2):190-5.
the findings of this study done in the ED - liked the use of propofol but found it "However, it produced a significant incidence of hypotension, hypoxemia, and apnea"
so...good for ER staff - bad for patient...?!?!
_______________________________________
Conscious sedation of children with propofol is anything but conscious.
Reeves ST, Havidich JE, Tobin DP.
Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA. [email protected]
Pediatrics. 2004 Jul;114(1):e74-6.
this is an article that clearly states conscious sedation in peds with propofol when measured w/ BIS shows they are much deeper than what is appropriate for CS and that propofol for sedation in peds should only be given by anesthesia.
_________________________________________
Risk management regarding sedation/analgesia.
Petrini J, Egan JV.
Division of Gastroenterology, Sansum-Santa Barbara Medical Clinic, CA 93105, USA. [email protected]
Gastrointest Endosc Clin N Am. 2004 Apr;14(2):401
this article seems to state that propofol sedation comes with risks and patient safety should come first for now until enough proof arises that nurses should be giving an anesthetic.
_________________________________________
Propofol: a gastroenterologist's perspective.
Vargo JJ.
Section of Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. [email protected]
Gastrointest Endosc Clin N Am. 2004 Apr;14(2):313-23
this article states how your endoscopist should have extensive and thorough knowledge about the sedatives given.... YEAH RIGHT...
________________________________________
http://www.astrazeneca-us.com/pi/diprivan.pdf
over and over again the manufacture states that whomever is using propofol should know basically everything on the insert - which i will definately argue that 99.9% of those outside of anesthesia pushing it do not know.
____________________________________________
http://www.safepropofol.org/SOMNIA%20PDF.pdf
a letter from congress denying the request to remove package insert instructions it SHOULD ONLY BE GIVEN BY THOSE TRAINED IN ANESTHESIA
_____________________________________________
ok.. i am tired... but for every article that says that propofol saves time and money - it states it comes with significant risks... and although the ENA and GI nursing assoc. support the use of propofol for CS - the manufacture doesn't nor does congress and therefore the LAW. all of the articles that i found that support views that nurses should be able to administer propofol are counting on the fact that the MD you are working with has an intimate knowledge of the medication which is a dangerous assumption that you all are making. they all also are geared toward patient recovery time and money - not patient safety. perhaps you can, but most nurses can not identify nor even tell you if there is a difference between respiratory effort and ventilation - none of the studies that have been cited in support have used ETCO2 detectors - therefore respiratory measuring parameters were defunct.

MmacFN · Apr 18, 2006

hey there

i dont live in texas and the nsg board here considers diprivan for the use in concious sedation as within the scope of practice for an rn. it does state that no rn can push the drug.

in anycase, as i said in the last post i have been discussing this with the cqi committee (the diprivan anyway) to try and change the policy (as i outlined there for heart).

what i just found out today (which will terrify you all) is that there is another local hospital which does diprivan iv push for all concious sedation. not the rn, but the er doc.

in anycase, i thank you for your post and insight.

add my 25 years of anesthesia experience to those who say giving propofol in this cavalier fashion is beyond the scope of practice of rns. here is the section of the texas bne's position paper on the topic:
rns or non-crna advanced practice nurses administering propofol, ketamine, or other anesthetic agents to non-intubated patients
of concern to the board is the growing number of inquiries related to rns and non-crna advanced practice nurses administering propofol, ketamine, or other drugs commonly used for anesthesia purposes to non-intubated patients for the purpose of moderate sedation in a variety of patient care settings. it is critical for any rn who chooses to engage in moderate sedation to appreciate the differences between moderate sedation and anesthesia.
moderate sedation versus anesthesia
according to the professional literature "moderate sedation" is defined as a medication-induced, medically controlled state of depressed consciousness. included in the literature from various professional organizations is the caveat that, while under moderate sedation, the patient at all times retains the ability to independently and continuously maintain a patent airway and cardiovascular function, and is able to respond meaningfully and purposefully to verbal commands, with or without light physical stimulation. reflex withdrawal to physical stimulation is not considered a purposeful response. loss of consciousness for patients undergoing moderate sedation should not be the goal and thus pharmacologic agents used should render this result unlikely. if the patient requires painful or repeated stimulation for arousal and/or airway maintenance, this is considered deep sedation.
in a state of deep sedation, the patient's level of consciousness is depressed, and the patient is likely to require assistance to maintain a patent airway. deep sedation occurring in a patient who is not appropriately monitored and/or who does not have appropriate airway support may result a life-threatening emergency for the patient. this is not consistent with the concept of moderate sedation as defined in this position statement or the professional literature.
although propofol is classified as a sedative/hypnotic, according to the manufacturer's product information, it is intended for use as an anesthetic agent or for the purpose of maintaining sedation of an intubated, mechanically ventilated patient. the product information brochure for propofol further includes a warning that "only persons trained to administer general anesthesia should administer propofol for purposes of general anesthesia or for monitored anesthesia care/sedation." the clinical effects for patients receiving anesthetic agents such as propofol may vary widely within a negligible dose range. though reportedly "short-acting", it is also noteworthy that there are no reversal agents for propofol.
the board defines "monitored anesthesia care" in rule 221.1(9) as:
". . . situations where a patient undergoing a diagnostic or therapeutic procedure receives doses of medication that create a risk of loss of normal protective reflexes or loss of consciousness and the patient remains able to protect the airway for the majority of the procedure. if for an extended period of time the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic."
the patient receiving anesthetic agents is at increased risk for loss of consciousness and/or normal protective reflexes, regardless of who is administering this medication. again, this is not consistent with the concept of moderate sedation outlined in the professional literature.
though the rn or non-crna advanced practice nurse may have completed continuing education in advanced cardiac life support (acls) and practiced techniques during the training program, this process does not ensure ongoing expertise in airway management and emergency intubation. the american heart association (aha) cautions acls providers about attempting tracheal intubation in an emergency situation since "repeated safe and effective placement of the tracheal tube, over the wide range of patient and environmental conditions encountered in resuscitation, requires considerable skill and experience. unless initial training is sufficient and ongoing practice and experience are adequate, fatal complications may result."1 it is also important to note that no continuing education program, including acls programs, will ensure that the rn or non-crna advanced practice nurse has the knowledge, skills and abilities to rescue a patient from deep sedation or general anesthesia. furthermore, it is the joint position of the aana and asa that, "because sedation is a continuum, it is not always possible to predict how an individual patient will respond." these organizations state that anesthetic agents, including induction agents, should be administered only by qualified anesthesia providers who are trained in the administration of general anesthesia.
therefore, it is the position of the board that the administration of anesthetic agents (e.g. propofol, brevitol, ketamine, and etomidate) is outside the scope of practice for rns and non-crna advanced practice nurses except in the following situations:
when assisting in the physical presence of a crna or anesthesiologist
when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist)
when administering these medications to patients who are intubated and mechanically ventilated in critical care settings
when assisting an individual qualified in advanced airway management, including emergency intubation procedures
while the physician or other health care provider performing the procedure may possess the necessary knowledge, skills and abilities to rescue a patient from deep sedation and general anesthesia, it is not prudent to presume this physician will be able to leave the surgical site or abandon the procedure to assist in rescuing the patient.
in the absence of an anesthesia provider or practitioner skilled in advanced airway management/intubation, if the rn or non-crna advanced practice nurse chooses to administer anesthetic agents (e.g. propofol, brevitol, ketamine, etomidate, etc) as ordered for purposes of moderate sedation to non-intubated patients, he/she must have demonstrated the following competencies:
advanced life support, with an emphasis on current competency in population specific advanced airway management.
knowledge of anatomy, physiology, pharmacology, oxygen delivery, cardiac arrhythmia recognition and complications related to moderate sedation and medications
knowledge of medications to include but not be limited to side effects, toxic effects, allergic reactions, desired effects, unusual/unexpected effects, reversal agents, and changes in the patient's condition that contraindicates continued administration of the medication
knowledge, skills and abilities to identify deviations from the norm, including but not limited to thorough patient assessment skills
knowledge of the indications for and contraindications to moderate sedation
so there you have it. in texas, at least, rns don't have a leg to stand on if a complication occurs while they are administering any drug such as propofol, ketamine, etomidate, etc. saying that the doc is standing by while you administer the med doesn't matter. the fact that you "do it all the time" doesn't matter. the fact that you tubed a mannequin in acls class doesn't matter. hopefully mcmac, between this post and the thoughtful post by athomas you will realize that you are wrong. as a couple of folks have noted, why would you push the envelope on your practice, when your state bne says you are flying alone? we have a lot of experience, a lot more than you. we are telling you that it is only a matter of time before something terrible happens; you overstep the bounds of nursing practice; a patient suffers; and you lose your license and your future. we've shown you the source articles and a quote from a typical state bne position paper. is it really worth it? you decide.

MmacFN · Apr 18, 2006

Hey Lou

Okay, Mike, I'm sorry pal, but are your eyes brown, because you are completely full of BS.

I guess you have no way of knowing my motives, thats OK.

You keep attempting to explain the subtle nuances of evidence based practice and statistical analysis to PEOPLE WHO ALREADY KNOW.

Well, lou. The truth is many people spent alot of time stating that research is not important in the eyes of experience and that "statistics can mean anything you want them to". So i made the assumption that not everyone does know what makes good research or bad research. I simply posted the information. If everyone already knew, it would have been easy to look at the N and P values and see the results repeated in many of the other studies, but there are many people on the forum NOT masters prepared RNs but simply RNs who probably have had little interaction with stats since nursing school.

If I had to count, I would say that more than half of your posts, in some manner or another, toot your own horn.

Sorry if that upset you? Im proud of my career and my accomplishments. The background I have helps to give credibility to my statements. You do not have to believe that, you can simply ignore the posts.

I don't believe you for a minute when you say (paraphrasing now...) "oh, what I left out is that I agree with the general consensus...I'm just trying to get you all to think."

Hmm. Well i guess you would have to ask the people I talked to in PM long before this post since i told them my motivations. They may or may not choose to verify this, which is understandable based on the nature of this post. Again, you dont have to believe me lou, thats ok. Why dont you PM me and ill give you a call and we can discuss it directly so you can evaluate my intentions?

Seems to me that there are two possible motivations behind that kind of a statement. Either you are trying to save face, or you really, truly think that you possess some supernatural ability to critically think, to search medical literature, and dissect research findings, an ability that far outweighs the abilities of everyone else around you, and that without your truly gifted guiding force to guide the rest of us mere mortals, we would just practice... oh what did you call it... witch-doctor medicine.

Wow. How about this motivation. I am trying to do the best job for my patients and be proactive. I make an attempt to create discussion which is "devils advocate" in nature to elicit expert response based on evidence and experience on the topic.

As for witch-doctor medicine that is a common euphemism for practice which is not based in evidence. Saying "i do it this way because i think its best and thats what i was taught" *no evidence* (whatever "this" is) is witch doctor medicine. As for your other sarcastic comments, I did not say any of that. As for "saving face", what would the motivation for that be on an anonymous forum? I could simply leave and come back as a new user preaching the gospel as taught by "other random anonymous forum members"

Now, on the other side of the coin, I would like to tell you that I think you'll be a fine CRNA someday.

I hope to be, i know it will be a challenge.

But your road to getting to CRNA may be a living hell if you come across in person anything like you come across on this board. I

Hey Lou, I knwo what you mean. Went through that when i went from medic to RN and did fine, i know how to play the game. If i have come off as signifigantly arrogant then i apologise. It may be that I overreacted to some of the more nasty replies. I have not, at anytime, directly insulted any individual nor suggested they are unethical, uneducated or unsafe. I was pointed out in that manner but i tried not to sink to that level.

have a good one.