Non anesthesia provider providing anesthesia

[EMS/ICU/SRNA]

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?

[rn29306]

Patient variability keeps our lives in anesthesia interesting to say the least. Titration to effect and tincture of time are our friends due to the above-mentioned variability. You never know how someone is going to respond to medications, especially something as foreign (hopefully) to that individual as versed, fentanyl, or propofol.

The lovely thing about versed is usually the people that profess to not taking much medication, narcotic, or using meth (although looking like meth-head) is that the truth comes out eventually, usually on the 4th-5th milligram.

I had this one young male patient that stated he was as clean as a straight laced Christian. Something about him just threw up a giant red flag of BS. He was going for a 4 hour clavicle repair, so I got 5mg of versed and 20 mls of fentanyl. Out in pre-op he got 2 of versed. No response. I chased that with 1 ml fentanyl. No change. 3 mg chaser of versed with adequate circulation time. He gets this goofy grin on his face. I'm thinking, "here we go." Into the room, monitors placed, drugs in line, preoxygenation started. BIS monitor reading 96. Page MD. I start working in the fentanyl. Now he starts telling perverted jokes to the scrub nurses. They give me a look as if "snow this guy". Long story short this guy has 5mg of versed and 10mls fentanyl prior to induction and is not slurring a word. MD to room. BIS at this point is 93. 200 mg propofol actually takes about 1 minute to lose eyelid reflexes. BIS only dropped to 40 on induction. Needless to say, his P450 was one mean mofo. Ran extremely high forane during case and went through multiple vials of norcuron.

At end of case, he awakens with a start despite having .25 ET forane and starts talking like nothing happened.

Now he tells me that he:

1. Smokes weed like a couple times per day.

2. Takes Xanax just for fun.

3. Steals his neighbor's Darvocet like candy.

Really.

[rayman]

:beer:

LOL. Remember all those people that come in and say oh I just have one beer a day....yeah right, one twelve pack per day.

[jwk]

:beer:

LOL. Remember all those people that come in and say oh I just have one beer a day....yeah right, one twelve pack per day.

From Happy Days...

Richie Cunningham - "But dad - all I had were little itty bitty glasses of beer."

Howard Cunningham - "How many glasses did you have Rich?"

Richie - "42"

[athomas91]

sounds like last thursday...

[apaisRN, RN, CRNA]

From an ICU pt with varices:

I drink a few bottles - I mean glasses - of wine a day.

[deepz]

This is how alcoholics are like surgeons:

When they report they drink a six-pack a day, DOUBLE that for the true amount.

When a surgeon says that little incarcerated hernia will take only one hour ... yeah, you get the point: twice as long as they say.

.

[jenniek]

This is how alcoholics are like surgeons:

When they report they drink a six-pack a day, DOUBLE that for the true amount.

When a surgeon says that little incarcerated hernia will take only one hour ... yeah, you get the point: twice as long as they say.

.

I would always double the alcohol intake, too. So true about surgeons....

[BANN45]

Don't Do It ! ! ! ! Scope Of Practice, If You Are Going To Give The Anestesia Why Don't You Just Set The Fx. Or Try Gastric Bypass. Get It. If You Aint Anestesia Trained Don't Give Do It.

[rn29306]

Don't Do It ! ! ! ! Scope Of Practice, If You Are Going To Give The Anestesia Why Don't You Just Set The Fx. Or Try Gastric Bypass. Get It. If You Aint Anestesia Trained Don't Give Do It.

i bEt yOuR tEaCHerS haD a FIelD dAY on youR pAPerS iN SChOoL.

[NYCRN16]

hey there

I actually live in Arizona and it is common practice to use diprivan here in the ER both for closed reductions, cardioversions and some docs like to use it to intubate. The state nsg board clearly says that we (RNs) may titrate diprivan on our own but that in order to push it there must be a direct order from a physician who should be standing in the room for some procedure.

Ive also used it when the GI docs come up to sedate patients. I have never had a problem with diprivan as i is a drug im very farmiliar with. The half life alone and how quickly patients come back to baseline makes it much safer than giving massive doses of versed and morphine, as we did in the past.

I totally agree with this. We use it in the ER all the time for the same things, and they always wake up faster when they get this then with fentanyl or versed. The main risk is resp depression, and when you have all intubation equipment and a code cart on hand at the bedside, I dont think there is any increased risk to the patient. Just to add, the nurses push the propofol not the MD's, but we only do it when the MD is right at the bedside already, the patient is on the monitor and all intubation equipment is on hand.

[dayplay]

My hospital does limit our ability to inject propofol to intubated patients only. Our hospital policy dictates that the patient has to be on a mechanical ventilator before or airway is already secured for propofol infusion or injection.

[rlbl50]

I think RN's with proven competencies are very capable of administering Diprivan. We gave it in our Endoscopy suite with the physician at the bedside. Of course we were very aware of problems which could arise and we read everything we could to remain safe. Again just my opinion but the half life makes it so much more patient friendly.