Non anesthesia provider providing anesthesia

susswood · Apr 13, 2006

Okay sedation nurses... here you go.

A 70 kg 54 year old female with a history of asthma and parkinsons arrives in the ER with a dislocated shoulder after a ground level fall. Her vital signs are stable and she has no history of cardiovascular disease. Her mentation is normal. She has no drug allergies but is allergic to eggs and shellfish. The only thing she has had to eat today is a glass of orange juice 2 hours ago. Her pain is 10/10 and she is complaining of nausea. A 22 g IV is started in her left arm. The ER doc orders 5mg morphine and 10 mg reglan IV and asks you to prepare for sedation for reduction of the shoulder. The meds are given and the patient states her pain is now 5/10. After applying the monitors and establishing stable vital signs you administer 140 mg of propofol IV push as ordered. After several minutes, her saturation drops to 84% and the ER doc begins to manually ventilate while asking you to hold criciod pressure. The ER doc notes that there is a lot of tension on the ambu bag and is having a hard time ventilating. Her sat is now 74%. Suddenly, bright orange stomach contents start blowing forcefully from her mouth. WHAT SHOULD YOU DO? You have .5 seconds to decide. (multiple choice)

a. let go of the cricoid pressure

b. ensure you are at the cricoid ring and apply more pressure

for a bonus.... do you see anything wrong in the above scenario? What is happening? CRNA/SRNA's are NOT welcome to answer.

p.s. be prepared to defend your answer in court

versatile_kat · Apr 13, 2006

Suss! Don't go givin' the incredible edible egg a bad name!

Mountain CRNA · Apr 13, 2006

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?

Thank you! Thank you for your answer. I have been teaching sedation workshops to RNs for over 10 years and much of what you have said is exactly what I try to get RNs to understand about the use of propofol. The difference between propofol and sedative agents such as versed was pointed out so well in an analogy offered by a physician malpractice case reviewer evaluating the intraoperative death of a woman in Florida. He stated that givng propofol versus other sedative agents was the difference between flying an F-14 jet(propofol) or a piper cub(sedatives/narcotics)---you can get into trouble faster and make a bigger hole with the F-14. Also remember that there are lies, damn lies, and then there are statistics. Somewhere around 30 million anesthetics are given each year in this country with only about 2000 or so untoward events---statistically that is far from significant, but you'd have a hard time making those 2000 think their experience or the death of their family member wasn't significant. Research is extremely important and well done research should form the basis of good practice--but in the end you can never lose sight of the fact that every patient we care for is unique--as a friend who is one of the most outstanding CRNAs inthe country always says "you're only as good as the last anesthetic(sedation) you did. "In other words, it can seem routine, but you only need one bad event to erase all the other "routine" sedations you've ever done.

louloubell1 · Apr 13, 2006

Thank you! Thank you for your answer. I have been teaching sedation workshops to RNs for over 10 years and much of what you have said is exactly what I try to get RNs to understand about the use of propofol. The difference between propofol and sedative agents such as versed was pointed out so well in an analogy offered by a physician malpractice case reviewer evaluating the intraoperative death of a woman in Florida. He stated that givng propofol versus other sedative agents was the difference between flying an F-14 jet(propofol) or a piper cub(sedatives/narcotics)---you can get into trouble faster and make a bigger hole with the F-14. Also remember that there are lies, damn lies, and then there are statistics. Somewhere around 30 million anesthetics are given each year in this country with only about 2000 or so untoward events---statistically that is far from significant, but you'd have a hard time making those 2000 think their experience or the death of their family member wasn't significant. Research is extremely important and well done research should form the basis of good practice--but in the end you can never lose sight of the fact that every patient we care for is unique--as a friend who is one of the most outstanding CRNAs inthe country always says "you're only as good as the last anesthetic(sedation) you did. "In other words, it can seem routine, but you only need one bad event to erase all the other "routine" sedations you've ever done.

MountainCRNA,

You make the best point about this whole argument. Statistics, shmatistics. They are patients we are talking about. Real people. One avoidable death, whether "statistically" significant or not, is certainly significant.

I love this topic!

Mike,

I would suggest that you carefully read the articles you have listed, keeping in mind MountainCRNA's post. I have read each of the articles you posted, and many, many more on this subject because this is the topic of my thesis. I really don't have the energy right now to delve deeply into the details of what I have found upon dissecting these studies, but I can sum it up in two short phrases: 1) You can twist statistics to support whatever you want to, and 2) If you want to give anesthetic agents, go to anesthesia school. Until such time, protect your patients with the level of advocacy they deserve from you & leave the administration of anesthesia to those trained to provide it. If you provide propofol to 10,000 patients without incident, & then on case #10,001 cause the death of a patient because you could not rescue them from the state of general anesthesia you induced, that avoidable death is significant. It doesn't matter that the numbers wouldn't have crunched to show a "statistical" significance. That one single person out of 10,001 will matter to the family, will matter to the jury, and should matter to you.

Lou

yoga crna · Apr 13, 2006

Mountain,

You are a breath of fresh air on this forum. We need someone who is not afraid to put statistics and research in a clinical perspective. We hope to hear more from you.

Yoga

MmacFN · Apr 13, 2006

Hye Night

Good post

Im not saying you guys are right or wrong. What im saying is that in order to make claims about saftey in the name of patients one must do research to back up those claims.

I see alot of good point here, i agree with them. The problem is that this wont simply continue but it will proliferate unless there is evidence to the contrary done by CRNA/MDA showing it is unsafe. All the evidence being done is by ER and GI physicians showing large numbers of cases successful.

Why hasent any been done to back up the assoc. statement? Or is there and i didnt find it?

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.

MmacFN · Apr 13, 2006

Good post yoga.

I agree with you. However, the problem is there is a deep well of research done showing it to be safe. Really, there is very little to suggest that the packet insert is standard. After all, there are MANY drugs which have off label uses that are commonly used.

However, probably most importantly is the fact that the insert does not say CRNA or MDA. It says "trained in the administration of anesthesia". All ER docs have some experience, particularily the ER residency trained ones. Then an MDA group puts on an inservice for them and Poof, they fit the packet insert.

Now what? See, there is only one way to counteract this practice and its by research proving it is unsafe, and there is little.

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.

MmacFN · Apr 13, 2006

Hey Lou

Im not suggesting they are right or wrong, good or bad. All stats can be twisted anyway you like them and you then could say that is true of the CRNA vs MDA study and safety.

Peer reviewed, independantly confirmed studies, no matter what you may feel about them, are WHERE standard of care comes from. People can pontificate all day how they believe it is unsafe to give propofol (btw propofol and diprivan are the same thing to the poster who asked that question), however, as long as the research says its safe, it will not only continue but it will evolve.

The reason CRNAs conttinue to exist is the careful research done by people in the profession to prove competance and saftey vs MDAs. If the Modus operandi of CRNAs was to say "well i think and i saw and when i was there this.." CRNAs would have ceased to exist in the face of MDAs onslaught years ago.

Real medicine is decided by research. That is how things change. A good example is the common practice of giving 3:1 n/s:unit of blood loss in blunt and penetrating trauma. There have been many patients who died because of this unfounded "opinion". Clearly, N/S dosent carry hemoglobin and therefore dosent carry O2. It also hemodilutes causing coag issues as well as pops a clot at a pressure of 80 systolic. The research about this topic (of which i have been published on) is clear. However, people still are popping off how they have to give fluids to hypotensive trauma patients. The standard has changed in both ATLS, BTLS, TNCC and FNATC yet people get stuck on their opinion and "we always did it this way before because Dr X said so" that they are killing patients with ignorance.

Or how about patients who are paralyzed that never got sedation or pain control in the past? Changed by research. How about avoiding simply giving a sedative for intubation for a pt with extremis, paralytics became the standard because of research.

Without research there is no evidence based medicine, without EBM then everything we do is no more than witch doctor magic.

Susswood, your questions are easy work for anyone who actually is professional enough to know a med before they give it. This is not evidence, simply a what if that could easily be applied to any number of procedures done within the hospital.

MountainCRNA,
You make the best point about this whole argument. Statistics, shmatistics. They are patients we are talking about. Real people. One avoidable death, whether "statistically" significant or not, is certainly significant.
I love this topic!
Mike,
I would suggest that you carefully read the articles you have listed, keeping in mind MountainCRNA's post. I have read each of the articles you posted, and many, many more on this subject because this is the topic of my thesis. I really don't have the energy right now to delve deeply into the details of what I have found upon dissecting these studies, but I can sum it up in two short phrases: 1) You can twist statistics to support whatever you want to, and 2) If you want to give anesthetic agents, go to anesthesia school. Until such time, protect your patients with the level of advocacy they deserve from you & leave the administration of anesthesia to those trained to provide it. If you provide propofol to 10,000 patients without incident, & then on case #10,001 cause the death of a patient because you could not rescue them from the state of general anesthesia you induced, that avoidable death is significant. It doesn't matter that the numbers wouldn't have crunched to show a "statistical" significance. That one single person out of 10,001 will matter to the family, will matter to the jury, and should matter to you.
Lou

MmacFN · Apr 14, 2006

As an aside, here is what ACEP and ENA say about propofol in the ER:

First, from ACEP:

ACEP Policy #400344, Approved October 2004

ACEP believes that:

Emergency physicians and nurses under their supervision are qualified to provide procedural sedation/analgesia in the emergency department, and
ACEP is the authoritative body for the establishment of guidelines for procedural sedation and analgesia by emergency physicians.

Then, jointly from ACEP and ENA:

Approved by the ACEP Board of Directors April 2005 and the Emergency Nurses Association (ENA) Board March 2005

Published simultaneously, October 2005, in Journal of Emergency Nursing and Annals of Emergency Medicine

ACEP Policy #400347, Approved April 2005

The Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) support the delivery of medications used for procedural sedation and analgesia by credentialed emergency nurses working under the direct supervision of an emergency physician. These agents include but are not limited to etomidate, propofol, ketamine, fentanyl, and midazolam.

Here is the section from ACEP entitled Clinical Policy on "Procedural Sedation & Analgesia in the Emergency Department" that deals with this question. The Clinical Policy can be found at the following URL:

http://www.acep.org/NR/rdonlyres/6FF6A276-E14E-4C00-B9C7-083FDDDDDE3E/0/cpSedAnalg2Feb05.pdf

susswood · Apr 14, 2006

propofol (btw propofol and diprivan are the same thing to the poster who asked that question)
Susswood, your questions are easy work for anyone who actually is professional enough to know a med before they give it. [/size]

First off- propofol and Diprivan have important differences in preparation which may have significant impact for certain groups of patients. Actually, I won't go on... not only have I illustrated my point, I think you may have as well. Thanks.

p.s. My questions may be easy work, so how come I haven't gotten any responses from "sedation nurses"? Come on..... anyone.... wanna discuss context senstive half-time of propofol? Come on.... It's easy work for professionals.

heartICU · Apr 14, 2006

Hey Lou
...(btw propofol and diprivan are the same thing to the poster who asked that question)...

Incorrect. Better check on that.

rn29306 · Apr 14, 2006

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.

Let me try this again. From the above statement, I understand that your ER docs had to have an inservice on how to use propofol in "emergent situations." So how does having the green light to use propofol in "emergent situations" allow the ED docs to use it for totally elective procedures such as reductions? I fail to see that aspect.

The ED is being given an inch and running with it.