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?

[Zachary2011]

Wow, Ouch, Sorry for the post........ No I dont know of LPNs pushing Diprivan, only RNs, heres a few examples of where I am coming from........ A friend of mine is a Gastro Doc and they used to use Fentanyl and Versed for colonoscopy procedures. Now they use only diprivan...........versed's duration is anywhere from 2-6 hrs., and diprivan's duration is 3-5 mins. so if complications where to occur ie: hypotension, apnea, bradycardia, the time from of managing these complications would be much shorter, Granted you can give romazicon for versed reversal. For example when we would do a reduction we used to give morphine and versed and monitor and sent the pts. home hours later. Now that we use diprivan we can send the pt. home 30 mins. post reduction. Recovery time for diprivan is 8 mins., 20 mins if given with an opiod. They pt. should be monitored equally the same with SpO2, Heart, BP, RR, and resp. equip. at bedside. Sorry if I dont see the diferences in monitoring and actions, and that I see the pros of diprivan related to the shorter half life. Please educate me on this, I have no problem being told why I am wrong and the reasons behind it. But please dont be rude and condenscending. Sorry I even expressed my opinion or view.... but really please let me know why my view is wrong, I would appreciate it.

[MmacFN]

Some good articles for you to read.

Essentially, the research on this topic is a mixed bag with no worse negative outcomes for diprivan use in the ER vs Versed. The worst identified outcome was hypotension with diprivan and and long term sedation with versed.

Now i totally understand the concerns of the list. However, the research is signifigant and does not seem to bear out all the negative outcomes suggested by the group.

I guess at the end of the day if we are to be fair in our assessment of the situation we have to ask a few questions;

1) Why is it if diprivan is designated for anesthesia trained individuals (for pt saftey) that the negative outcomes suggested are not occuring in a statistically signifigant way?

2) Where is all the research from the ASA and the AANA showing the difference in outcomes to prove its stance?

3) Certainly the majority of RNs are not trained to the degree of CRNAs in regards to the pharm of Diprivan. However, is this needed in such a limitied capacity with small doses to ensure pt saftey? If so where is the evidence?

4) All medical procedures and drug combos are utilized in a benefit vs risk stratification decision tree. If diprivan increases the success of, and decreases the risks of any given procedure based on evidence; yet the gold standard providers of anesthesia feel it is unsafe, where is the justification/evidence?

I did a pretty extensive search on pub med and found no articles suggesting the use of Diprivan in the ER was unsafe. Im not suggesting they dont exist, i just didnt find them.

This is NOT an inflammatory post or meant to heat turf debate. What im trying to do is cause discussion in regards to justifying a stance. Im sorry but "when your a CRNA you can come back and see what you think" and "the packet insert says only for anesthesia providers" isnt evidence of anysort whatsoever. Ive been doing research for sometime and standards of care are based of evidence based medicine, which comes from research, not opinion.

As for the liability due to what it says on the insert, i asked about that at my facility (for my own protection). There is none per the state nsg board and per the hospital lawyer. The ER physicians had to do a class setup by ACEP with MDAs in regards to propofol use in the ER in emergent situations. So its signed off by the MDAs, the ER Docs and the state medical board along with the hospital policy backing.

Im more than willing to see the otherside, but I think ive evidenced the ER side and now its incumbent upon the dissenting opinions on the list to evidence their side.

Let the evidence cometh!

http://www.caep.ca/004.cjem-jcmu/004-00.cjem/vol-3.2001/v34-311.htm

Propofol for emergency department procedural sedation--not yet ready for prime time.

Acad Emerg Med. 1999 Oct;6(10):975-8. No abstract available.

Coll-Vinent B, Sala X, Fernandez C, Bragulat E, Espinosa G, Miro O, Milla J, Sanchez M. Related Articles, Links Sedation for cardioversion in the emergency department: analysis of effectiveness in four protocols.

Ann Emerg Med. 2003 Dec;42(6):767-72.

Bassett KE, Anderson JL, Pribble CG, Guenther E. Related Articles, Links Propofol for procedural sedation in children in the emergency department.

Ann Emerg Med. 2003 Dec;42(6):773-82.

PMID: 14634602 [PubMed - indexed for MEDLINE]

Guenther E, Pribble CG, Junkins EP Jr, Kadish HA, Bassett KE, Nelson DS. Related Articles, Links

Propofol sedation by emergency physicians for elective pediatric outpatient procedures.

Ann Emerg Med. 2003 Dec;42(6):783-91.

Holger JS, Satterlee PA, Haugen S. Related Articles, Links Nursing use between 2 methods of procedural sedation: midazolam versus propofol.

Am J Emerg Med. 2005 May;23(3):248-52.

[rn29306]

As for the liability due to what it says on the insert, i asked about that at my facility (for my own protection). There is none per the state nsg board and per the hospital lawyer. The ER physicians had to do a class setup by ACEP with MDAs in regards to propofol use in the ER in emergent situations. So its signed off by the MDAs, the ER Docs and the state medical board along with the hospital policy backing.

Since when does doing a totally elective reduction of a fracture or shoulder with propofol in the ER become an 'emergent situation'? I'll tell you: It is when some idiot ER physician does this elective case to a patient of unkown NPO status and that patient aspirates all down his trachea.

The emergent paragraph above has no application to CS in the ER.

[MmacFN]

Hye RN

Yer back to opinion and no evidence. The definition of "emergent" as defined in the hospital policy signed off by the MDAs ER Docs and hospital, is "anything entering the ER with an acute condition". Certainly the dislocation of a shoulder or hip can be an emergent situation directly related to the nerve and arterial damage that is possible in dislocation.

You said this:

some idiot ER physician does this elective case to a patient of unkown NPO status and that patient aspirates all down his trachea.

Hey, I agree! It could be dangerous. Show me the evidence of this. Secondly, the pt sedated deep enough with versed and morphine is at the same risk.

If you are going to make dissenting statements, show me the evidence of your opinion.

Since when does doing a totally elective reduction of a fracture or shoulder with propofol in the ER become an 'emergent situation'? I'll tell you: It is when some idiot ER physician does this elective case to a patient of unkown NPO status and that patient aspirates all down his trachea.

The emergent paragraph above has no application to CS in the ER.

[Nitecap]

Hye RN

Yer back to opinion and no evidence. The definition of "emergent" as defined in the hospital policy signed off by the MDAs ER Docs and hospital, is "anything entering the ER with an acute condition". Certainly the dislocation of a shoulder or hip can be an emergent situation directly related to the nerve and arterial damage that is possible in dislocation.

You said this:

some idiot ER physician does this elective case to a patient of unkown NPO status and that patient aspirates all down his trachea.

Hey, I agree! It could be dangerous. Show me the evidence of this. Secondly, the pt sedated deep enough with versed and morphine is at the same risk.

If you are going to make dissenting statements, show me the evidence of your opinion.

Yeah but the difference is that the ER doc will push the drugs, reduce the arm and walk away leaving the RN to protect, monitor, assess and manage the airway and pt's sedation level. The RN will be charting and what not and running around tending the other pts. The anesthesia provider will be at the head of the bed continually assessing and be there to intervene if shiat goes bad. IF indeed the pt starts vomiting ect the RN will have to scream for the ER doc if they are even present in the room. I have worked some ER as a nure and know how it goes. The ER doc and RN are not with the pt the entire time, esp when the pt is awake but sedated. Yes a pt sedated deep enough with Morphine and midaz can have a compromised airway but both those drugs for one can be antagonized with narcan or rimazacon, propofol can be. Also profofol has more cardio depressant effects and blunts baro receptor reflexes so their are issues there. Also many time the ER doc doesnt select the drug he wants to used based on all the confounding variables. Propofol though shorter acting isnt the best drug for some pts will certain coexisting issues.

[London88]

Nitecap:

i totally agree with your comments. The issue definetly comes down to the different level of monitoring.Anesthesia is always 1:1. That being said I must confess that i have no desire to have to go to the ER everytime they have to reduce a fracture etc.

[NRSKarenRN, BSN, RN]

[color=#212120]

[color=#212120]from pa patient safety authority

vol. 3, no. 1 march 2006

who administers propofol in your organization?

medication errors

the pennsylvania patient safety reporting system

(pa-psrs) has received over 100 medical and

medication error reports in which the use of propofol

has been cited. sixteen percent (16%) of these

reports have been classified as serious events,

including four patient deaths in which propofol may

have played a role.

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

no reversal agent

unlike other agents used for sedation (e.g., midazolam, morphine), propofol has no reversal agent.

state board

more than a dozen states specifically consider

nurse-administered propofol beyond the scope of

nursing practice according to their nurse practice

acts.

8 pennsylvania does not have an official advisory

opinion or declaratory statement regarding the

administration of propofol by nurses.

the pennsylvania code stipulates that the administration

of anesthesia is a proper function of a registered

nurse who has successfully completed an

accredited education program for nurse anesthetists

and who works in cooperation with a surgeon

or dentist.

15 the code also specifies that a registered

nurse who is not a certified registered nurse

anesthetist may administer intravenous conscious

sedation medications during minor therapeutic and

diagnostic procedures.

16

safe practice strategies

unfortunately, there is no easy answer to the question

of who to allow to administer propofol in your

organization. the process requires input from many

parties. a good first step may be to convene a multidisciplinary

team consisting of administration,

nurses, pharmacists, and physicians (including representatives

from anesthesia, gastroenterology,

radiology, surgery, and other physicians from areas

that may administer or monitor propofol) to:

* review state regulations to ascertain which

practitioners may or may not be able to administer

propofol within their respective scope of

practice.

* evaluate the literature and various position

statements available from professional societies

such as the asa, american association of

nurse anesthetists, and others. see the resources

section below for selected societies

and web addresses.

* establish policies and practice guidelines for

the administration of propofol (or other agents

such as thiopental, methohexital, or etomidate)

to non-ventilator-assisted patients undergoing

minor surgical or diagnostic procedures.

* define qualifications of professionals who can

administer propofol to non-ventilator-assisted

patients during procedures.

* if nurse-administered propofol is agreed upon

as acceptable, specify the circumstances and

required education and mentorship to be accomplished

beforehand and competencies to

be evaluated and met periodically. keep in

mind that acls certification alone may not be

sufficient for this purpose.8

* evaluate locations where propofol administration

is appropriate, and ensure that those areas

are able to follow the developed criteria for

administration, including expertise and availability

of equipment to intubate patients.

* define and document the intended level of

sedation that patients should receive. ensure

that all patients, even if moderate sedation is

intended, are able to be monitored and rescued

from deep sedation.

*establish a continuous monitoring process and

assessment criteria (e.g., vital signs, oxygen

saturation, capnography) for non-ventilatorassisted

patients who are receiving propofnol.

* ensure that equipment is readily accessible at

the point of care to maintain a patent airway,

provide oxygen, intubate, ventilate, and offer

circulatory resuscitation.

conclusion

propofol, an injectable emulsion, is a high-alert

medication according to ismp.17,18

based on theaction and nature of the medication

and the numberof error reports submitted to pa-psrs and other

organizations, the safest strategy is to limit propofol

use to healthcare professionals with specialized

training in administering, monitoring, and treating its

untoward effects. however, errors can still occur

despite the presence of a trained healthcare professional.

thelargest number of events involving propofol

received by pa-psrs occurred in the icu

and or--practice settings designed with constant

supervision in place.

many articles listed at end above report. karen

[yoga crna]

When there is a professional negligence lawsuit, the plaintiff must show that the practice leading to the incident was below the standard of care. This is done by evidence being being presented to the judge or jury (finder of fact), Evidence presented include package inserts, learned treatises (such as journal articles, textbooks), institutional policies, standards and guidelines from professional organizations and other pertinent writings. Each side, plaintiff and defendant then have expert witnesses testify to as the practice being within or below the standard of care. The judge or jury will then determine which side has presented the most credible evidence in making their final judgment.

You can't ignore package inserts because they don't say what you want them to say. I can assure you that the plaintiffs' bar is very familiar with what is in them. As a courtroom observer in a very important legal action where a patient died after surgery, I saw the surgeon incriminate himself when he admitted he never read the package insert of a medication used. His lawyer and insurance company recommended a large out of court settlement to avoid an even larger jury verdict. His testimony and lack knowledge about the medication led to this final outcome. But the real final outcome is a dead patient because of the arrogance and carelessness of the surgeon.

[austin heart, BSN, RN]

Do you give versed as an RN, well if so, diprivan is no different, Has pretty much same effects with a much shorter half life. And as with versed you need to have an Ambu bag, and Resp Box at hand for possible BVM and intubation if unable to BVM effectively. We give Diprivan all the time in our ER also for reductions and such and use the gtts for post intubation sedation. Just need your ER doc there for airway managment. I guess I dont understand the big deal w/ diprivan and some nurses not thinking it should be in there job description. Nothing to be too concerned about, so easily titrated even by IV push, onset is like 30 sec.s and pt. is back to baseline LOC in 15 min.s Its a wonderful med and so much safer then Versed .

I see Zachary2011 that you are still an LVN. Do you push Propofol in your ER?

[Zachary2011]

I am not an LVN anymore, graduated ADN and now working on BSN, Sorry I just never updated my profile. I was also unaware that this was strictly a CRNA post, my bad.

[austin heart, BSN, RN]

I think that there are alot or RNs (non CRNA) posting in this thread though like myself.

I would really like to take an experience, title and length of time as a nurse poll. I wonder how long these people saying "it's not any big deal, we do it everyday" have been nurses and what kind of experience they have. I would almost be willing to bet the farm that most of them have been nurses less than 5 years and have experience limited to one or two specialties with very little critical care.

Just my opinion , I have 10 years experience as an RN 8, of those in CCU/ICU and the last two in ER. I think of myself as a pretty well rounded critical care nurse but I still try and learn something new every time I punch the clock. I would never push propofol on a non-intubated patient!

If we as regular RNs can do anesthesia then why do we have CRNA schools?

And again, like I said in the other thread, If I am expected to push propofol then they aren'y paying me enough!

[susswood]

It takes a lot of guts to refuse to push a drug that is ordered by an MD. I got a lot of flack one night in the ER from a doc when I refused to push propofol as an RN. Another nurse even laughed at me. I held my ground, and I'm glad I did, especially now that I am in CRNA school.

Any nurses out there reading this who routinely push propofol should ask themselves what kind of patient advocate they are. If you choose to push propofol ask yourself: (you must know all of this off the top of your head-no cheating allowed when your patient is coding)

Do you know the difference between propofol and Diprivan?

Do you know the contraindications for propofol administration?

Do you know the appropriate dose of propofol for anesthesia, sedation etc.?

What does redistribution mean?

What is the context sensitive half-time for propofol?

What is functional reserve capacity?

Is a decrease in 02 sat an early or late sign of hypoxia?

Are you prepared to deal with cardiovascular collapse?

When was the last time you mixed up and used levophed?

What is the ACLS dose for epi?

Do you know what laryngospasm is and how to treat it?

Is your wall suction ready to go?

Your patient is a full stomach-do you understand the implications of that?

Your patient is obese-do you know what that does to gastric emptying time?

Do you know if your patient had GERD?

Whaere is the cricoid ring located?

What are the ASA fasting guidelines?

How do you repond to and treat acute aspiration?

Do you know what qualities of stomach aspirate make it more or less lethal?

Do you believe the MD you are pushing these drugs for knows all the answers to these questions?

Are you prepared to defend yourself in court?

Do you think any doc will stand behind you in a court of law?

How much money do you have?

Do you want to keep your house?

It only takes one bad day. It could be your family member in some ER.... wouldn't you rather have someone take care of them who knows the answers to the above questions?