Non anesthesia provider providing anesthesia

jenniek · Apr 11, 2006

Jenniek
Thanks for the sarcasm.

You are welcome. It's one of my qualities, just not sure if it's a good or bad one.....

Enough banter from me. My books are calling.

I'm sure you will keep the discussions interesting, MmacFN.

And I'm curious to know how many states allow IV push on Propofol. I have not worked in any myself (I've worked in 4)........unless the patient is intubated.

jenniek · Apr 11, 2006

Uh
I did. In both discussions. with research and evidence.

http://www.diprivan.com

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

Check out the package insert.

I didn't read all the fine print....it's asking for a headache. But I see it's indications list for general anesthesia induction and maintenance and ICU sedation.

Don't get me wrong, I love to use the drug. But I'm not sure I'd use it without a protected airway. All you need is undiagnosed GERD with a nice dose of diprivan and the fun can begin.

For the nurse who is pushing the diprivan, is the airway their ONLY thing to do, or are they getting supplies, charting, ect? Just curious. It sounds like the patients are lucky to have you there, but what about some of the other nurses?

rayman · Apr 11, 2006

Seems like I am in the minority in regards to my RN colleagues but in full agreement with the anesthesia providers, threw that term in there just for you jwk. I have years in cvicu and trauma/sicu. I've INFUSED gallons of propofol. In fact had one patient, neuro, on propofol and pentothal drips. ALL of these patients were intubated and on a vent. I am starting na school in 9 months and hopefully I know where my little place in the world is at the moment. The only time I have EVER pushed a syringe of propofol is when there was a crna or mda at the end of the bed with a scope and ett in their hand. That is the only way I would do it at present. It is just asinine to have anyone other than an anesthesia pro giving prop to an unintubated patient. Any nurse that would do it, imho, has a very false sense of security and doesn't know the drug or their place in the world. If prop is the appropriate drug to be given in a given situation, you need someone who knows what they are doing giving it.

Ok, could someone please educate me. I have read all this stuff about GI clinics using prop for cs...where the hell and why the hell? Around here a couple of mg of versed is the standard. When I have had a patient getting scoped that's what I gave. People I know that have been scoped...that's what they got. Been with my wife on two colonoscopy occasions, sure I'm making her happy now, and a little versed and she was smiling, farting and calling me honey. Seems like it is just really overkill to me or are some people just that puckered up?

athomas91 · Apr 11, 2006

i am telling you ... that if your reasoning is..."if they crash the ED MD can intubate" then you shouldn't be giving propofol for sedation because you have just given it way wrong.

you spoke of a study... can you reference it so we can read it? was it random/double blind... internal and external validity are proven i assume... and what year was it done?

just because "things are done all the time" or "our hospital approved it" doesn't make it defend-worthy in court. ER physicians are trained to intubate patients - no assess airways... they also are not USUALLY overly familiar with anesthetic drugs - i have worked enough places to know that i pushed drugs for induction i was ordered to push that should have never been given to said patient ... but i didn't know then what i know now... and there is just no proving it to you until you walk the walk... and this is coming to you from a former die hard, nite shift, wkend working, know-it-all ED and trauma nurse...

i mean - who are reductions generally done on...kids and older people... those are usually who are breaking bones... and the two groups have vastly different reactions to anesthetics from what general knowledge is... you have to know all the age related changes in your body systems etc... to be able to give them the right way...

what ages require increase doses...decrease doses...why...the childs airway is vastly different from the adults...the elderly... what things do you have to think about during intubation.. why would rheumatoid arthritis be significant...

these are the fine tuning you will learn in anesthesia school and then you will truly come to appreciate why no one except those trained specifically in anesthesia should give anything classified as an anesthetic... there is a reason for the package insert recommendations. and BTW...i still stand by what i say...it goes bad - your facility and your doc will be the first ones to offer you up.

MmacFN · Apr 11, 2006

hey thomas

Sure, i referenced it in a previous post. It is one of many.

http://gidiv.ucsf.edu/course/things/propofolexp.pdf

Summary:

Nurse-Administered Propofol Sedation Without

Anesthesia Specialists in 9152 Endoscopic Cases in

an Ambulatory Surgery Center

CONCLUSION: Nurse-administered propofol sedation in an

ambulatory surgery center was safe and resulted in high

levels of patient satisfaction and rapid postprocedure recovery

and discharge. (Am J Gastroenterol 2003;98:

i am telling you ... that if your reasoning is..."if they crash the ED MD can intubate" then you shouldn't be giving propofol for sedation because you have just given it way wrong.
you spoke of a study... can you reference it so we can read it? was it random/double blind... internal and external validity are proven i assume... and what year was it done?
just because "things are done all the time" or "our hospital approved it" doesn't make it defend-worthy in court. ER physicians are trained to intubate patients - no assess airways... they also are not USUALLY overly familiar with anesthetic drugs - i have worked enough places to know that i pushed drugs for induction i was ordered to push that should have never been given to said patient ... but i didn't know then what i know now... and there is just no proving it to you until you walk the walk... and this is coming to you from a former die hard, nite shift, wkend working, know-it-all ED and trauma nurse...
i mean - who are reductions generally done on...kids and older people... those are usually who are breaking bones... and the two groups have vastly different reactions to anesthetics from what general knowledge is... you have to know all the age related changes in your body systems etc... to be able to give them the right way...
what ages require increase doses...decrease doses...why...the childs airway is vastly different from the adults...the elderly... what things do you have to think about during intubation.. why would rheumatoid arthritis be significant...
these are the fine tuning you will learn in anesthesia school and then you will truly come to appreciate why no one except those trained specifically in anesthesia should give anything classified as an anesthetic... there is a reason for the package insert recommendations. and BTW...i still stand by what i say...it goes bad - your facility and your doc will be the first ones to offer you up.

athomas91 · Apr 11, 2006

so - from what i am reading...this study was primarily looking at cost effectiveness and patient/doctor satisfaction..the study clearly has validity issues which the author themselves refer to...

no capnography in a study to test if RN's can safely push propofol... respiratory effort nor acceptable PO equal ventilation and alveolar gas exchange... their po2 may have been great even though their co2 was 75....

it wasn't random - there is no control group to compare it to... the level of complications may be huge compared to a study with a control group of patients where the anesthesia was given by anesthesia providers...they also refer to the ASA/AANA guidelines which would make a study like this nearly impossible now... and they specifically excluded patients who would present a problem based on airway assessment...and if RN's are going to push propofol in such a setting -one would logically assume they will do it for all the patients in that setting...this exclusion really skews the number of "difficulties" encountered...

so...

MMac.. you do know you can find a study to support just about anything you want to support..that doesn't make it a good study.

yoga crna · Apr 11, 2006

cross posted from another site.

from out-patient eweekly magazine;

pa. patient safety authority reports propofol mishaps

(link:

http://www.psa.state.pa.us/psa/lib/psa/advisories/mar_2006_advisory_v3_n1.pdf)

pennsylvania's patient safety authority says it has received reports of more than 100 medication errors involving propofol, according to the march 2006 issue of its patient safety advisory. sixteen percent of these cases could be classified as "serious events," says the agency, including four patient deaths in which propofol may have played a role. the cases are evidence of the confusion over who may administer the fast-acting sedative, how much should be administered and how its use should be monitored, the psa notes.

the cases, which were reported through the pennsylvania patient safety reporting system, included the following:

a 40-year old patient was admitted with injuries to the face and subarachnoid hemorrhaging. the patient received propofol but was not intubated. while in radiology getting a ct scan, the patient became bradycardic and went into cardiac arrest. the patient was resuscitated but died two days later.

a gastroenterologist who thought propofol was used all the time in the intensive care unit asked a nurse to get a "10 ml" dose for him. the nurse took a 10-mg/ml dose from an automated dispensing cabinet using the override function. another nurse, trained in the use of moderate sedation, but not deep sedation or anesthesia, questioned the gastroenterologist about the dose, but still administered it via infusion pump. the patient experienced respiratory arrest, though the icu staff was able to intubate and ventilate the patient.

a physician performing breast augmentation surgery thought he could administer propofol himself while performing the procedure. neither he nor his surgical assistant was able or qualified to monitor patients under deep sedation or anesthesia. they failed to recognize the patient's rapidly deteriorating respiratory status and the young woman died of hypoxic encephalopathy.

at one facility, nurses were told to administer a little more propofol if the patient moved after the anesthesiologist left the room. the propofol syringe would be left attached to the iv port and nurses would monitor the patient.

the authority's report concludes that the safest strategy is to limit propofol use to healthcare professionals with specialized training to administer, monitor and treat its "untoward effects."

˜ connie o'kane

maturner · Apr 11, 2006

Please do not insinuate I dont know anything about induction. While many RNs probably couldnt pronounce some of those drugs, im not them.
What intravenous induction agent (propofol, pentothol, ketamine, etc.) given in equipotent doses has the greatest cardiac and respiratory depressive effects?
Thiopental is absolutely the worst. Thiopental causes a significant decrease in cardiac output, systemic arterial pressure and peripheral vascular resistance. The depression of cardiac output is due to a decrease in venous return caused by peripheral venous pooling, as well as by direct myocardial depression.
Ketamine actually does the opposite and increases BP by up to 25%. It causes minor respiratory depression due to its signifigant bronchodilatory effetcs. In fact, ketamine has been the induction agent of choice in the military for a long time due to its miminam effects on cardiac and respiratory systems.
Diprivan decrease bp by up to 30% in most patients and has no place in trauma care where the patient is hypotensive based on all of the avlaible studies
Priority number one is not absence of personal liability but the presence of patient safety.
Which i clearly proved with the citation of a 9000+ patient study.
Please evidence your opinions.

WRONG!

PROPOFOL has the most cardiac and respiratory depressant effects of any of the induction agents.

Per BARASH, NAGELHOUT, and no doubtedly any other text comparing induction agents.

I am not trying to insult you. I am simply pointing out your sophemoric attitude and the fact that you have much to learn.

Y O U D O N O T K N O W, W H A T Y O U DO N O T K N O W !

MmacFN · Apr 11, 2006

hey thomas

Yes, i do realise there are many studies which refure each other. However, the research done on RNs pushing diprivan has all been positive in that there we no negative outcomes for patients, ergo safe. What was weird is that alot of these studies were done in regards to GI procedures OUT of hospital. If it is safe in that environment (noone would suggest an n value of 9000 is a weak study), it is easy to extrapolate that it would be safe in the ER setting with proper monitoring and a physician trained in intubation.

Put aside associations and personal feelings and just look at the data, is my conclusion not reasonable?

so - from what i am reading...this study was primarily looking at cost effectiveness and patient/doctor satisfaction..the study clearly has validity issues which the author themselves refer to...
no capnography in a study to test if RN's can safely push propofol... respiratory effort nor acceptable PO equal ventilation and alveolar gas exchange... their po2 may have been great even though their co2 was 75....
it wasn't random - there is no control group to compare it to... the level of complications may be huge compared to a study with a control group of patients where the anesthesia was given by anesthesia providers...they also refer to the ASA/AANA guidelines which would make a study like this nearly impossible now... and they specifically excluded patients who would present a problem based on airway assessment...and if RN's are going to push propofol in such a setting -one would logically assume they will do it for all the patients in that setting...this exclusion really skews the number of "difficulties" encountered...
so...
MMac.. you do know you can find a study to support just about anything you want to support..that doesn't make it a good study.

rayman · Apr 11, 2006

WRONG!
I am simply pointing out your sophemoric attitude and the fact that you have much to learn.
Y O U D O N O T K N O W, W H A T Y O U DO N O T K N O W !

LMAO....Thank you for using one of my favorite words, sophomoric. Great word when used appropriately! :lol2:

athomas91 · Apr 11, 2006

no it is not. and i will only give you two other pearls... you never know who is on this board...be careful what you say and how you say it... and all my luck to you in school... you will need it...not because you aren't smart enough - because i am sure you are...but because that is only 3/4 the battle.

talk to me in a few years and let me know what you think about non-anesthesia providers giving anesthesia.

your study wasn't well supported... large numbers do not ensure internal nor external validity - and when those are lacking in a study - the study is no good... but you will too learn all about that in graduate school and EBP.

good luck..and godspeed

MmacFN · Apr 11, 2006

wow

Well thats interesting since I took that quote directly out of these 2 studies

Barash PG, Cullen BF, Stoelting RK: Clinical Anesthesia. Philadelphia JB lippincott,2001;327-343
Hartmannsgruber MW, Gabrielli A, Layon AJ, Rosenbaum SH. The traumatic airway: the anesthesiologist's role in the emergency room. Int Anesthesiol Clin . 2000 38(4):87-104

I do see in the nurse anesthesia secrets book on page 88 it suggest that diprivan ca a slightly greater effect on MAP but identicle on respiratory.

Since you are in CRNA school ill defer to your education. However, my knowedge of anesthesia wasent what the discussion was about, i have already said i know nothing outside of crash rapid sequence intubation.

WRONG!
PROPOFOL has the most cardiac and respiratory depressant effects of any of the induction agents.
Per BARASH, NAGELHOUT, and no doubtedly any other text comparing induction agents.
I am not trying to insult you. I am simply pointing out your sophemoric attitude and the fact that you have much to learn.
Y O U D O N O T K N O W, W H A T Y O U DO N O T K N O W !