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?

[MmacFN]

Ah.. the hated thread revives!!!

Well let me tell you, I have changed my views in some ways.

I still believe that diprivan can safely be given in the ER by ER physicians. However, they MUST have training in the drug designed by CRNAs or MDAs. This mitigates the education issues, and apparently this is quite common. I didnt know it, but apparently in the ER where i worked all physicians have to take a competency test for diprivan designed by the ASA FOR ER physicians administering it in the ER setting. Once they pass they are certified to use it as they see fit.

An anesthesiologist friend of mine said it best when he said "The reason people want to use diprivan for everything is because an experienced provider makes it look easy". He suggested that an ER physicians could certainly fit in this role with the extra training but that no GI lab shoudl EVER be using it at all. I agree.

I also believe RNs should not be pushing diprivan in any case.

[JiffyGriff]

Only time any of us do it in my ICU is to sedate a patient prior to intubation.....I don't know what they do in the ER.

[paindoc]

If I might interject, I am a MD pain physician now in AA (anesthesiologists anonymous) that has had RNs inject propofol for over 12,000 cases in the prone position with an unprotected airway. Used in small doses for conscious sedation, or even deep sedation, airway obstruction in the prone position is much less common than the supine position due to airway mechanics, but one must remain vigilant regarding the airway and exchange of air. There have been zero incidences of patient awareness, zero incidences of intubation, 4 incidences that required the patient to be turned to the supine position for further airway management, zero admissions to the hospital, zero aspirations, and zero other complications.

I am not suggesting this as a modus operandi but am saying there is a proven track record here for very short cases (most

For us, the procedure has become so safe that we now use an office procedure room (fully equipped of course) for these procedures. The key is not to use any other IV or inhalational agent...pure propofol only. The purpose of this post is not to make claims the technique may be used safely in all situations, but that under controlled conditions, propofol has a remarkable safety record when administered by non-MDs.

[rn29306]

If I might interject, I am a MD pain physician now in AA (anesthesiologists anonymous) that has had RNs inject propofol for over 12,000 cases in the prone position with an unprotected airway. Used in small doses for conscious sedation, or even deep sedation, airway obstruction in the prone position is much less common than the supine position due to airway mechanics, but one must remain vigilant regarding the airway and exchange of air. There have been zero incidences of patient awareness, zero incidences of intubation, 4 incidences that required the patient to be turned to the supine position for further airway management, zero admissions to the hospital, zero aspirations, and zero other complications.

I am not suggesting this as a modus operandi but am saying there is a proven track record here for very short cases (most

For us, the procedure has become so safe that we now use an office procedure room (fully equipped of course) for these procedures. The key is not to use any other IV or inhalational agent...pure propofol only. The purpose of this post is not to make claims the technique may be used safely in all situations, but that under controlled conditions, propofol has a remarkable safety record when administered by non-MDs.

Do you dictate the adminstration of propofol?

How are you administering the drug, ie: bolus to titration of effect or via pump at a specific mcg/kg/min?

[paindoc]

Usually 1-2 boluses for short cases, and for longer cases continuous infusion based on their response.

[jwk]

Usually 1-2 boluses for short cases, and for longer cases continuous infusion based on their response.

No thanks - I'll pass on your pain clinic. Even if you're an anesthesiologist, you're using non-anesthesia personnel to administer the drugs and monitor your patient while your attention is focused elsewhere. It's the same argument for GI docs, although the fact that you're an anesthesiologist has more than likely kept you out of trouble far more than most GI docs. Personally though, I think you've just been lucky. I know oral surgeons who do things the same way you do, and they've been burned BAD!

I'm not sure how much versed and fentanyl you used in the past, but using those drugs and propofol, my GI patients are awake and talking before they arrive in recovery, and are out the door before I'm in there again with my next patient, usually in less than 20 minutes.

[paindoc]

The technique is not meant as an endorsement- it is one of many ways in which to practice safe anesthesia. At some point what would be considered "luck" by those that are detractors of a particular proven technique, becomes a statistic. And the statistics in this particular situation argue that the technique as applied in this situation is indeed safe. What anesthesiologists, CRNAs, and AAs must realize is that there are other important realities in providing care, and one of them is cost effectiveness. Insurers are increasingly not paying for a anesthesia provider to administer anesthesia for interventional pain cases, and the patient must pay your bill out of their own pocket. My experience is that if patients can save a $1500 ASC fee and another $225 anesthesia fee to have a 5 minute procedure performed in an office, then they will elect to do this 99.9% of the time. The realities of health care finance, aside from safety, may marginalize the need for your services to the extent patients will receive neurology or physiatry ordered versed/fentanyl in their office for procedures or no sedation at all.

As for my attention being directed elsewhere, I don't think it is reasonable to make such statements unless one knows the setup. We have nurses trained in airway management at the head of the bed, I am at the side watching both the patient and monitors that are immediately under my fluoroscopy monitors. GI physicians are clearly different in that they have few skills in airway management, are often in dark rooms, for colonoscopies are at the wrong end of the patient to adequately monitor airway or immediately assist in management, frequently do not have direct line of sight of monitors, and some use archaic medicine combinations such as demerol/valium in massive doses.

I am happy your patients are out the door in 20 minutes after versed/fentanyl, but in my experience based on patients that have had that combination vs propofol alone is that the after effects of the versed and fentanyl linger for hours, and are associated with a much higher incidence of nausea, and airway obstruction (when combined with propofol). But one of the joys of anesthesia is that there are many ways to skin a cat. What works in one situation for one provider fails miserably in another for technical reasons beyond the providers control. I offer but one view on a cost effective safe anesthetic monitored by me when administered by others.

[jwk]

As for my attention being directed elsewhere, I don't think it is reasonable to make such statements unless one knows the setup. We have nurses trained in airway management at the head of the bed, I am at the side watching both the patient and monitors that are immediately under my fluoroscopy monitors.

Thanks for proving my point. "Nurses trained in airway management". Same argument the GI docs use. And you're watching the patient, and the monitors, and doing your procedure? Nah, don't think so. Again, you've proved my point.

I'm curious - how much do you charge for sedation? Surely you're not doing it for free. What about the use of your own facility - monitors, equipment, drugs, etc. Is all that free too?

[paindoc]

Obviously, you do not practice pain management, so I can forgive your ignorance.

As for sedation, we do charge for it CPT 99144. We are not reimbursed by medicare for this code, and we are reimbursed an average of about $27 from insurance. We write off any balance not paid. Yes, the monitors, fluoro suite, IVs, and drugs are free to the patient since it is not possible to charge a facility fee in an office procedure room.

So, lets turn the tables....do you write off any balance not paid by insurance when you are giving anesthesia to pain patients? Does the facility you work in not charge for the equipment or supplies?

When it comes down to hard dollars, your situation is simply not competitive and as there continues to be a proliferation of office based pain management, you will find less and less need for your services. A small chunk of your business, I am sure, but business is business....

[HyperTension]

As an ICU / ED RN, I have used Diprivan in both settings. Interestingly enough (and a bit older / wiser), I'm more hesitant to use diprivan in the ED setting, but with training / exposure / COMMON SENSE, I find that those ideals minimize the possiblity of adverse events (not saying that **** doesn't happen regardless of what your plans are).

Some of our ED Providers are asking for Brevital. After being in the room with it being pushed by an RN with about 1 year of experience, I'm a bit more hesitant on using that medication vs. propofol. The statement that I hear the most is "Well, it wears off quick enough......" as justification in using these medications in the ED. My response is generally: "And just how long does it take for hypoxia to set in?" It absolutly has a place in the sedation of the mechanical vent. patient, as well as induction, but A LOT of nurses / and some providers feel very cavalier because of a percieved safety net in its short half-life.

[deepz]

This thread IS two years old, but ... once again:

Compare a person perfectly competent to administer Versed and to monitor and intervene with a sedation ... to a pilot perfectly competent in a Cessna light aircraft.

Then drop that pilot into the cockpit of an F-14.

That's the difference between Versed and propofol, and that's just how fast a person will get themselves -- actually get the PATIENT, of course -- in trouble.

!

[RRTNeuroRN]

Propofol is most definitely a drug that needs to be respected and only used by trained providers. I remember having an intubated pt that was very agitated and trying to extubate herself....long story short I got a little happy and generous with the propofol and my BP went up while my pt's pressure plumeted!!!! Luckily it wore off quickly and all was well, but ever since then I have had a new respect for the drug.

One of our new Neurosurgeons likes for us to use propofol when he is inserting EVD's and camino's on our non-intubated pt's and I was very nervous the first time I did it because I was always told RN's were not allowed to bolus or infuse propofol on a pt with a non-secured airway. We spoke with pharmacy and administration and they said as long as an RRT was at bedside we could do it (respiratory intubates all of our pt's outside of OR).

I think people underestimate the drug because of its quick action, but I won't ever make my mistake again!! I will start CRNA school this fall and I am already gun shy because of my mistake, and I know they give a lot more propofol in the OR than I did....but I will be better trained and equipped with the knowledge to correct any hypotension and respiratory distress that I cause from anesthesia.