Non anesthesia provider providing anesthesia

2luvnsg · Apr 19, 2006

Hey Mike,

I appreciate the feedback in response to my posting. I was feeling a little "out numbered" for having the opinion I have at my place of employment. I did mention that I have worked in other ICU's where the practice was that anesthesia is responsible for sedation during intubation in the ICU. What I failed to mention in my senario was that this event occurred during my second shift off orientation in my current place of employment. This nurse that pushed the medication thought she was in her boundry to do so. This situation did upset me to the point of migraine because of not only of the risk of harm to the patient, but the attitudes of my peers. I feel the action I have taken by the documentation I presented to my mananger will have an impact. I have begun to see evidence of this.

As I stated, as just being off orientation, I made it my business to make sure all of my competencies were completed, including the one my facility offers on moderate sedation for 4 ceu's, which I also referenced in my documentation to my new manager. As it stands, it seems I opened up a pandora's box. I really need some respect and support regarding this matter.

Thanks.

MmacFN · Apr 19, 2006

hey 2lungsg

You rock.

Im not a CRNA im just an RN. However, i applaude you for standing up for what you believe in and taking the initiative to make change. It sounds like you have people there who may make changes based on your concerns. I wasen't as lucky but I think you just have to keep hammering away.

Good luck!

Hey Mike,
I appreciate the feedback in response to my posting. I was feeling a little "out numbered" for having the opinion I have at my place of employment. I did mention that I have worked in other ICU's where the practice was that anesthesia is responsible for sedation during intubation in the ICU. What I failed to mention in my senario was that this event occurred during my second shift off orientation in my current place of employment. This nurse that pushed the medication thought she was in her boundry to do so. This situation did upset me to the point of migraine because of not only of the risk of harm to the patient, but the attitudes of my peers. I feel the action I have taken by the documentation I presented to my mananger will have an impact. I have begun to see evidence of this.
As I stated, as just being off orientation, I made it my business to make sure all of my competencies were completed, including the one my facility offers on moderate sedation for 4 ceu's, which I also referenced in my documentation to my new manager. As it stands, it seems I opened up a pandora's box. I really need some respect and support regarding this matter.
Thanks.

Sheri257 · Apr 21, 2006

This is my first posting to this site. I would like to add that the "we do this all the time" attitude exists in just about all the ICU's I've worked.
My story with Propofol is that while re- intubating a cardiothorasic surgical intensive care patient, a nurse pushed 100mg instead of 10mg as ordered by the Physician's assistant at the bedside prior to intubation. The Patient cardiorespiratory arrested. Not to worry, CPR, fluids, pressors helped this patient out. I confronted this nurse and the charge nurse and got the "we do this all the time" thingo. In this new setting where I'm working, my manager was responsive to my written suggestions I provided with citations from the literature. My past experience in other settings was that anesthesia managed the airway.
It seems for this population, this drug is too risky. Also, and in the wrong hands near fatal.
As far as I am aware of, Propofol may be taken out of this setting. Don't get me wrong, I respect the wonder of this drug and have managed many patients on propofol drips safely. The above senario may have even occurred even if the patient recieved the proper dosage as these types of patients are in tenuous states.

I was wondering about the same thing ...

Apologies if I happened to miss any posts that may have already explained this but ... I am totally confused on the ICU situation. After reading this and other threads on Propofol, many people seem to indicate that it is ok for ICU nurses to administer propofol as long as the patient is intubated. But is it?

As deepz pointed out, the AANA states ...

*This statement is not intended to apply when propofol is given to intubated, ventilated patients in a critical care setting."

However, since people keep hammering on the package insert, what does it say ... if anything ... on this question. Unfortunately the earlier link to the package insert was illegible, and all I've seen is people posting that it has to be given by a qualified anesthesia provider.

So ... is it ok, or not, for ICU nurses who are not anesthetists to give propofol to intubated patients?

:confused:

heartICU · Apr 21, 2006

So ... is it ok, or not, for ICU nurses who are not anesthetists to give propofol to intubated patients?

Yes. Check this out on page 17.

http://www.baxter.com/products/anesthesia/anesthetic_pharmaceuticals/downloads/propofol.pdf

MmacFN · Apr 21, 2006

hey

Its common and accepted practice for ER and ICU RNs to manage intubated patients on a propofol drip. The ASA and AANA are OK with that.

It is when pts are getting any amount of propofol without an ET tube that would violate the statement by ASA/AANA. While there are not any RNs who are approved anywhere (to my knowledge) to administer a bolus, ER docs and GI docs do it alot.

That is the concern of the associations and the group here.

I was wondering about the same thing ...
Apologies if I happened to miss any posts that may have already explained this but ... I am totally confused on the ICU situation. After reading this and other threads on Propofol, many people seem to indicate that it is ok for ICU nurses to administer propofol as long as the patient is intubated. But is it?
As deepz pointed out, the AANA states ...
However, since people keep hammering on the package insert, what does it say ... if anything ... on this question. Unfortunately the earlier link to the package insert was illegible, and all I've seen is people posting that it has to be given by a qualified anesthesia provider.
So ... is it ok, or not, for ICU nurses who are not anesthetists to give propofol to intubated patients?

klj836 · Apr 22, 2006

I overheard an ED attending discussing a policy regarding the administration of propofol w/ an RN at work today. Apparently the policy states that propofol or any other medication may be administered to a non-intubated pt if an attending ED/Pulmonary physician is in the room. This would be done for a procedure ie: reduction of a fx....etc. I asked him why anesthesia personnel would not provide the anesthesia. He responded that the ED/Pulmonary physician is able to provide all services that anesthesia could. What do you guys think about this?

It is conscious sedation and there are rules and regulations about this procedure and JCAHO has their eye on this and will ask for training for nurses and docs.

rn29306 · Apr 22, 2006

It is conscious sedation..

Hey klj836, follow this link, read the post #133 and tell me what you think.

https://allnurses.com/forums/f16/non-anesthesia-provider-providing-anesthesia-152639-14.html

Conscious sedation with propofol is a play on semantics. In reality and how your patients respond, there is no such thing as conscious sedation with propofol.

We all know (or should know) that propofol has no analgesic properties. If non-anesthesia personnel indeed gave propofol dosages that corresponded to true CS guidelines, then these patients would be screaming in pain during bone reductions. But no one does that. Who wants a screaming patient? No me, and probably not anyone else. So we give more to the point of unsciousness hopefully with spontaneous respirations. Now do you think these patients will responnd to "light tactile or verbal stimuli?

The answer is NO.

Your intentions for a comfortable patient are at least in the right direction, but you are entering into an unknown realm of anesthesia that you are not prepared to manage.

Zachary2011 · Apr 22, 2006

Hi again, I just want to say I have learned a lot from this discussion, and myself will no longer give diprivan personally, however I am sure it will remain the drug of choice for reductions in the ERs I work at.............. My only question is, we are all talking about aspiration, apnea, etc. other s/s , these same complications occur with versed, in fact just lucky Im sure but the only time I have had to bag a pt. post reduction was on versed.... we always consider last meal and fluids...... then the part about calling anesthesia........ oh my..... that wont happen..... at least where I work it takes an act of God to get them to do a blood patch........I understand they are busy........ but our ER docs in my opinion def. have the skills to manage these pts. , of course now I say if you want the diprivan pushed...... you push it.......... anyway I guess the real question was ,dont these same complications occur with versed......... are they just more likely with diprivan? How much more likely? If you worked in the ER what would you rather give for reductions and why? Thank you for all your help!!

deepz · Apr 23, 2006

...... the real question was ,dont these same complications occur with versed......... are they just more likely with diprivan? How much more likely?......

Again, as someone has pointed out already on this thread, the difference is like flying a Cessna compared to an F-14. Versed will be subtle and gradual usually, depending on individual response; propofol will slam-dunk a patient before you realize. Then you (and they, the patient is in) are in deeeep pooooo.

.

gaspassah · Apr 23, 2006

i'm sure it has been stated before but i will do so again for completeness.

if the ed/gi doc is pushing the propofol, who is in charge of the airway while they are doing the procedure, ie setting bone or doing the colonoscopy. the point of propofol administration by anesthesia personel is that we are responsible for airway control and maintenance and not involved in the procedure.

rn29306 · Apr 23, 2006

Hi again, I just want to say I have learned a lot from this discussion, and myself will no longer give diprivan personally, however I am sure it will remain the drug of choice for reductions in the ERs I work at.............. My only question is, we are all talking about aspiration, apnea, etc. other s/s , these same complications occur with versed, in fact just lucky Im sure but the only time I have had to bag a pt. post reduction was on versed.... we always consider last meal and fluids...... then the part about calling anesthesia........ oh my..... that wont happen..... at least where I work it takes an act of God to get them to do a blood patch........I understand they are busy........ but our ER docs in my opinion def. have the skills to manage these pts. , of course now I say if you want the diprivan pushed...... you push it.......... anyway I guess the real question was ,dont these same complications occur with versed......... are they just more likely with diprivan? How much more likely? If you worked in the ER what would you rather give for reductions and why? Thank you for all your help!!

Imagine your best Bevis and Butthead impersonation:

......Uh..huhuhuhuhuhu..Dude how much versed are we talking about here?

Zachary2011 · Apr 23, 2006

Most the docs I know differ the versed dose for each individual pt., the usual things as in weight, age, extent and type of injury...... many times they will give 2-4mg, monitor the pt and if needed give more.........also I completey understand the diprivan being the big gun as compared to versed being a little 22. I was just curious as to which you would prefer to administer for reductions. As I mentioned on earlier posts, I have learned a lot from these posts and will never personally give diprivan to a pt. not intubated. Is there even a better drug of choice then versed........ at times if the docs think they can do the reduction with just valium and morphine or demerol they do that...... I prefer that for pt. safety also ,if at all possible. If this question is for a whole different post I apologize,,,, I just thought who better to ask then the people whoms post Ive been reading. All seem like they could give me some helpful info. on this subject. Thanx again