Non anesthesia provider providing anesthesia

MmacFN · Apr 11, 2006

thomas

I appreciate you advice and experience. I will be glad to just get on with it and goto school at this point. Reading this board is exciting and, while some of my posts are contraversial, I enjoy reading the in depth discussion that they elicit.

Now, as to if i think diprivan should be pushed at all? The answer is no. My opinion wasent what i was wanting to argue about though, just the research which seems to have guided some practices.

I do know a bit about research and stats, ive done some grad classes and a few of my own publications. It is absolutely true that you can make a research study say whatever you want. What i was hoping to see was evidence to refute it from everyone here.

Yoga got some good stuff

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

Thanks yoga!

There must be some studies related to those comments. I will see if i can find them.

Cross posted from another site.
From Out-Patient eweekly magazine;
Pa. Patient Safety Authority Reports Propofol Mishaps
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

susswood · Apr 11, 2006

In addition to all of the above affirming that non-anesthesia providers SHOULD NOT push propofol...... The package insert is pretty clear about who can administer the drug. You may have some MD tell you to go ahead and push... but in a court of law it's you against the package insert. Guess who would win that one?

rn29306 · Apr 11, 2006

Actually, it isnt a concern to me.
Not only are there inservices for new RNs in the ER who are pushing diprivan (i often teach them), but it is backed by hospital policy and state nsg board regulations. There isnt anything to be concerned about. Secondly, there is an ER doc in the room or just outside of it (if its a GI doc in the rm) 100% of the time. There isnt any need for an anesthesia person at all.
Third, the fact of the matter is that Versed and Morphine combo we have typically used in the past are signifigantly more dangerous due to the prolonged effects they have on the patient (most studies citing versed as lasting up to 120 minutes). I dont see where the evidence is for your ascertions at all. Please post the research which proves this.
Please find my research at the bottom of the page proving my point.
Please elighten me as to the reasons you seem to think its so dangerous. Diprivan wears off in minutes and post bolus we bag them, It isnt anymore of a risk for me than it is for a CRNA. I would have absolutely no problem defending myself in court.
As for the legal consulting, i think your friend missed an important piece of information which a RN/JD (lawyer) friend of mine enlightened me to. When a law suit begins, lawyers identify the parties who are negligent. In the case of an RN pushing diprivan in an ER, with a hospital policy and nsg board policy, the order of a physican who is in the room with the RN, the RN would not be negligent and therefore not liable. As for your contention to get 2nd party insurance, he also informed me not to. When an investigation begins the parties whom money can be extracted are identified. The two parties which are prime targets are institutions and physicians due to their large income and large insurance policies. RNs are rarely named or sued (which you can see if you do a search on lawsuits) unless they HAVE insurance as there is little to gain monetairily from them (read: low income).
Research:
This is a study done in a surgery center NOT an ER where a recognized airway expert (ER physician) is always present yet the research clearly shows no issues. There are a number of other studies as well but they dont have the n value (9152) this one does.
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:
1744-1750. © 2003 by Am. Coll. of Gastroenterology)

Then I wonder why the Georgia BON aligns itself with the AANA and ASA's Joint Statement on NAP? Hospitals across Georgia are now restructuring how labs, esp the GI suites, function. Either CS it on your own or call anesthesia for propofol.

MmacFN · Apr 11, 2006

for whomever asked

13 states prohibit RN admin of diprivan. All the rest allow it apparently.

maturner · 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.

Look man, I just read it right from the source in Barash. Morgan and Mickhail shows the same thing. Nagelhout is brilliant, has a PhD. in pharmacology, and I have heard it repeatedly right from his mouth.

Mike you are clearly very intelligent and have nearly single handedly revived this web site, now chill out. Keep posting the controversal stuff, I love it, just strap your muzzle on a little tighter before you respond.

Like you and many others I was on the top of my game before school, in retrospect I had no idea how much I simply didn't know and you will find the same to be true.

rn29306 · Apr 11, 2006

RN
We usually agree on everything. Do you or have you worked in the ER? Of course ER RNs are taught to assess airways. Are they as competant as a CRNA, of course not. That wasent the point. Also, the response was that the ER doc made the final assessment. Do you contend that an ER physician (whom have similar rates of success as MDAs in studies) cannot assess airways and manage them?

Yes, I've worked the ER and I have never seen or heard of a RN receiving any kind of airway assessement skills. Never heard them talk about it either. ER docs can probably hold their own. But on the other hand we can do better than that and probably would not get in some situations that ER docs get themselves into in the first place.

Is it really true that the majority of CRNAs and MDAs throughout the country respond to hospital codes, rush to the ER and intubate for the ER doc and work in the trauma room as the anesthesia provider?

Yes. CRNA carries code pager everyday at our facility. Have personally gone up and bumped a resident from mucking up the airway. In fact, several times. This is not a brag at all, but RT or RN has usually inflated the stomach at that point to pressures resembling a blimp, the patient is certainly a full-stomach with air and food at this point and the person with the most experience should be tubing this individual. We as seniors go up for intubations in the unit / floor. Sometimes a CRNA goes with us, sometimes not. Talk about a life lesson in being conservative and not burning any bridges...Lessons learned 'away from home' will stick with me for a long time. For the most part, the ER handles their own, but they do call for difficult airways or diagnosing something wrong with the tube. They handle their own as far as trauma rooms, but I have seen CRNAs on the Discovery Channel in the trauma rooms.

Much of this is location specific.

MmacFN · Apr 11, 2006

Wow

http://scholar.google.com/scholar?q=propofol+registered+nurse&hl=en&lr=&safe=off&start=10&sa=N

It is clear that the majority of these studies are done by GI guys looking to avoid anesthesia costs

jenniek · Apr 11, 2006

Wow
http://scholar.google.com/scholar?q=propofol+registered+nurse&hl=en&lr=&safe=off&start=10&sa=N
It is clear that the majority of these studies are done by GI guys looking to avoid anesthesia costs

I haven't checked your link....but I think you are seeing the light. Atta' boy!

MmacFN · Apr 11, 2006

Hey!

I appreciate you comments and your right. However, sometimes the fingers get engaged before the brain gets in gear

Ah well!

Look man, I just read it right from the source in Barash. Morgan and Mickhail shows the same thing. Nagelhout is brilliant, has a PhD. in pharmacology, and I have heard it repeatedly right from his mouth.
Mike you are clearly very intelligent and have nearly single handedly revived this web site, now chill out. Keep posting the controversal stuff, I love it, just strap your muzzle on a little tighter before you respond.
Like you and many others I was on the top of my game before school, in retrospect I had no idea how much I simply didn't know and you will find the same to be true.

MmacFN · Apr 11, 2006

cool

I want to work in that kind of location!

Yes, I've worked the ER and I have never seen or heard of a RN receiving any kind of airway assessement skills. Never heard them talk about it either. ER docs can probably hold their own. But on the other hand we can do better than that and probably would not get in some situations that ER docs get themselves into in the first place.
Yes. CRNA carries code pager everyday at our facility. Have personally gone up and bumped a resident from mucking up the airway. In fact, several times. This is not a brag at all, but RT or RN has usually inflated the stomach at that point to pressures resembling a blimp, the patient is certainly a full-stomach with air and food at this point and the person with the most experience should be tubing this individual. We as seniors go up for intubations in the unit / floor. Sometimes a CRNA goes with us, sometimes not. Talk about a life lesson in being conservative and not burning any bridges...Lessons learned 'away from home' will stick with me for a long time. For the most part, the ER handles their own, but they do call for difficult airways or diagnosing something wrong with the tube. They handle their own as far as trauma rooms, but I have seen CRNAs on the Discovery Channel in the trauma rooms.
Much of this is location specific.

rn29306 · Apr 11, 2006

I work at a large teaching hospital. When there is code the code team that responds along with so many residents that you are lucky to be able to get a enough room in there to have a nurse to push drugs. Usually a respiratory terrorist handle the airway after it has been established. At the private hospitals in town a crna does ALL the intubations except maybe for an especially emergent ER case. CRNA=all intubations.

This seems to be a regional thing rayman. Ours just supports us doing things here in TN. Our docs will back us up if needed ANY day and have done so, even to the med, trauma MDs.

Assess the situation. Walk in, see what the deal is, and if you need to get to the HOB, then inform (don't ask) that you are coming through the mental masturbation crowd, and then do so. Sometimes a gentle nudge with the tackle box does the trick. Or just whack them up side the noggin with a Mil 3. :lol2: Tell the resident to move. Take over the stomach insulflattion technique and do it yourself. Assign someone to hold crich. Blah, blah, blah.

Not that this is used often cause you will come across as a punk. But sometimes you have to.