Non anesthesia provider providing anesthesia

Zachary2011 · Apr 18, 2006

i just want to thank everyone for all the information, i can say now i will no longer push diprivan on a non-intubated pt. except for rsi ( we rarely use diprivan for rsi except sometimes for burn pts) i will continue to hang the gtts post intubation and draw my line there. i had no idea legally i was on such thin ice, so much literature by lww and even ena supported the use of diprivan for cs. i have certain rules i go by as a nurse, 1) pt safety, 2) tx pts with the best care and with all my heart 3) being my pts. advocate,, i love my job and honestly feel nursing chose me, i treat all who come in through the door as i would want to be treated.

i do think there is still a chance that diprivan may become the drug of choice for difficult reductions and for cs, but untill the laws clearly state and i am educated extensively with a certificate allowing me to administer it i will never do it again. also if i had to goto crna school to push it on a non-intubated pt. i think ill just keep asking the docs. for morpine, valium, versed, or whatever else................. thank you all rns, crnas(of whom i really appreciate you all sharing some of your knowledge with me).

again. thank you

athomas91 · Apr 18, 2006

Mmac-

the problem is - that you are right - nursing bodies - such as the Emergency Nurses Association - are putting out statements that completely support nurses in using propofol in an ED setting. So - it isn't that I disagree with the support you are finding - I find a problem with individual nursing bodies completely defying other (and in this case more advanced) Nursing associations such as the AANA in their practice statement regarding the use of propofol.

the AANA needs to address these issued with Nursing Associations first and come to a consensus as to what is appropriate and legal - then when a doc orders a med in the ER or in a GI suite - they will know exactly where they stand.

The fact that AZ nursing board and the ENA support the use of propofol is in direct opposition of the AANA and ASA position statement as well as the manufacture insert which congress supports - this dichotomy isn't healthy for any practicing nurse because who knows who will stand behind you when the cards fall...

be careful..and good luck.

yoga crna · Apr 18, 2006

Isn't anyone else on this board concerned about ER and GI patients having full stomach and the administration of anesthesia drugs? I totally cringe when I read pf propofol administration for closed reductions, etc in the ER.

Anesthesia 101--protect the airway. I have personally seen at least five cases in my career of deaths from aspiration of stomach contents. Just for kicks, some of you should rent the old movie, The Verdict with Paul Newman. It is based on a true story about aspiration under anesthesia.

I totally believe that complications of this technique by non-anesthesia providers are under-reported. I do know that resolution of lawsuits from medical malpractice are generally three to five years after the incident. Stay tuned.

yoga crna

rayman · Apr 18, 2006

Zachary, I am glad you learned something. I learned too and hopefully others have as that is why many people come to the boards. It gets nasty sometimes, but it can be a learning experience.

MmacFN · Apr 18, 2006

well said thomas

Well, lucky for me I am seldom in the position where im asked to do it since i do not work there full time. I totally dislike the fact that 2 nursing associations are vs each other. Its hard enough for nursing and its advanced practices to get along with physicians let alone internal problems.

Its a sad situation for sure. I just try and do what i can for my patients and keep myself safe as well.

have a good one!

Mmac-
the problem is - that you are right - nursing bodies - such as the Emergency Nurses Association - are putting out statements that completely support nurses in using propofol in an ED setting. So - it isn't that I disagree with the support you are finding - I find a problem with individual nursing bodies completely defying other (and in this case more advanced) Nursing associations such as the AANA in their practice statement regarding the use of propofol.
the AANA needs to address these issued with Nursing Associations first and come to a consensus as to what is appropriate and legal - then when a doc orders a med in the ER or in a GI suite - they will know exactly where they stand.
The fact that AZ nursing board and the ENA support the use of propofol is in direct opposition of the AANA and ASA position statement as well as the manufacture insert which congress supports - this dichotomy isn't healthy for any practicing nurse because who knows who will stand behind you when the cards fall...
be careful..and good luck.

MmacFN · Apr 18, 2006

the whole idea is scary.

I just dont understand why it is lawsuits arent common? FOr some reason they are dont seem to be happening, be it settlements with confidentiality orders or what. I think its probably just a matter of time.

Isn't anyone else on this board concerned about ER and GI patients having full stomach and the administration of anesthesia drugs? I totally cringe when I read pf propofol administration for closed reductions, etc in the ER.
Anesthesia 101--protect the airway. I have personally seen at least five cases in my career of deaths from aspiration of stomach contents. Just for kicks, some of you should rent the old movie, The Verdict with Paul Newman. It is based on a true story about aspiration under anesthesia.
I totally believe that complications of this technique by non-anesthesia providers are under-reported. I do know that resolution of lawsuits from medical malpractice are generally three to five years after the incident. Stay tuned.
yoga crna

heartICU · Apr 18, 2006

Hey Heart.
- 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.

That, my friend, is general anesthesia. Straight from Miller' 6th edition:

Maintenance of general anesthesia:

What combined with an opiate or nitrous, maintenance of general anesthesia is 50-150mcg/kg/min.

The dose you describe is an initial rate of 210mcg/kg/min, then decreased to 50-100mcg/kg/min.

Not to mention the fact that any concomitant condition (older age, comorbidities, etc) will drastically decrease the dose required to lose airway reflexes. Just something to think about.

susswood · Apr 18, 2006

Isn't anyone else on this board concerned about ER and GI patients having full stomach and the administration of anesthesia drugs?

Thanks yoga! That's EXACTLY what I have been trying to say. I even wrote a mulitiple choice pop quiz about it (which noone bothered to answer.... although I said SRNA's/CRNA's are not allowed )

Zach- good for you. I think it takes guts.

Mike- you keep moaning and groaning about evidence. Did I do a pubmed search before I posted here? No.... I read Barash, Stoelting, Nagelhout and Morgan and Mikhail (daily). I trust that THEY have done and analysed the research for me. BTW, in my opinion there is no quick pubmed search. Reading abstracts NEVER gets you the full information. You always need the full text..... that takes LOTS of time.

Regarding lawsuits-hospitals will almost always settle. It is cheaper for them to settle, and they avoid bad press. It takes years.... anyone out there who has been deposed can attest to this.

EMS/ICU/SRNA · Apr 18, 2006

Hey Mike, don't take this personally but it's just my U of Pitt education wanting to say something. In previous threads you kept throwing out the n numbers and the p values of the studies that you cited as proof that they were well conducted pieces of research. Just the edu talking: the p value is simply indicative of the statisical significance. The more subjects that are enrolled in your study,(n) the greater chance that you would detect a statisically significant difference (ie: cheerios reduce you cholesterol). These numbers speak nothing of the internal or external validity of the study. What everyone here was saying was that, depending on your motivation (read: pt turnover and $), there are numerous oppurtunities to skew the results. While I do not have the time or interest to critically appraise the studies that you cited, I do raise an eyebrow when such a large sample size is used and those conducting the research will benefit directly if their "findings" are what they had crossed their collective fingers for. Just wanted to let you know that there is quite a bit more to quality research than the n's and p's.

PS: Don't worry, you'll learn this in grad school

athomas91 · Apr 18, 2006

must be the pa education!!! i said the same thing...and the exclusion criteria for the study was rather significant...

rayman · Apr 18, 2006

17-18 pages in 10 days...is this a thread development record?

MmacFN · Apr 18, 2006

Hey heart

Well the dose is variable and the physician makes that call. The nurses never give the bolus the MD/DO has to do that. The policy is that one RN monitors the drip and another assists the physician.

That, my friend, is general anesthesia. Straight from Miller' 6th edition:
Maintenance of general anesthesia:
What combined with an opiate or nitrous, maintenance of general anesthesia is 50-150mcg/kg/min.
The dose you describe is an initial rate of 210mcg/kg/min, then decreased to 50-100mcg/kg/min.
Not to mention the fact that any concomitant condition (older age, comorbidities, etc) will drastically decrease the dose required to lose airway reflexes. Just something to think about.