Nurses Pushing Propofol for Conscious Sedation -Your Thoughts?

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Specializes in Sedation.

I would be interested in getting feedback from GI nurses that are involved in propofol sedation in settings with and without anesthesia.

Your thoughts and experiences please.

Thank you,

Randy

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Specializes in Clinical Research, Outpt Women's Health.

Do a search. There is a very long thread from the past on this subject that will give you all the info you could ever want.

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Specializes in Sedation.

I will do that.

Thank you,

Randy

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Specializes in Sedation.

Most of the previous posts are from several years back.

"Times are changing" It would be interesting to see some current comments.

Thank you,

Randy

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Specializes in Anesthesia.
Most of the previous posts are from several years back.

"Times are changing" It would be interesting to see some current comments.

Thank you,

Randy

There are numerous studies on nurse administered propofol sedation/NAPS. My group actually did our Masters research project/literature review comparing different sedation strategies in the GI clinic with and without the use of propofol.

The last I knew there were about 22 states that allowed RNs(not CNRAs) to administer propofol for moderate sedation. The research is overwhelming in the consensus that NAPS is safe under the right conditions/dosages.

Is there something particular you are wanting to know?

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I asked a similar question in my post "lower endoscopy usual practice". I discussed conscious sedation practices for colonoscopy and I was surprized at the opinions that I got; I was mainly interested in unsedated exams but got a lotof info on propofol. The Chief GI doc said that patients overwhelmingly preferred propofol to the benzo/narcotic combination, but they didn't do many cases with propofol because it required a CRNA to push it and that added an unreasonable amout of money to the bill. He also said that it was often difficult to keep things on schedule because they were constantly waiting of the CRNA to show up to administer the drug. What surprized me was his opinion that a patient deeply sedated (ie with propofol) is more likely to get perforated that a lightly sedated or unsedated patient. Nurses are not permitted to push propofol in our hospital; a while back one of the CRNA's was telling me that the new drug fospropofol may be approved to be administered by non-CRNA's...which makes little sense to me since fospropofol is metabolized into propofol.

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Specializes in Anesthesia.
I asked a similar question in my post "lower endoscopy usual practice". I discussed conscious sedation practices for colonoscopy and I was surprized at the opinions that I got; I was mainly interested in unsedated exams but got a lotof info on propofol. The Chief GI doc said that patients overwhelmingly preferred propofol to the benzo/narcotic combination, but they didn't do many cases with propofol because it required a CRNA to push it and that added an unreasonable amout of money to the bill. He also said that it was often difficult to keep things on schedule because they were constantly waiting of the CRNA to show up to administer the drug. What surprized me was his opinion that a patient deeply sedated (ie with propofol) is more likely to get perforated that a lightly sedated or unsedated patient. Nurses are not permitted to push propofol in our hospital; a while back one of the CRNA's was telling me that the new drug fospropofol may be approved to be administered by non-CRNA's...which makes little sense to me since fospropofol is metabolized into propofol.

Fospropofol still has the same labeling that propofol has ie. not to be used for sedation by non anesthesia providers.

I have heard the same thing about higher potential for bowel perforation from another GI physician, but just because you give propofol doesn't mean it has to be deep sedation. You can titrate propofol to give any level of sedation you want. Most anesthesia providers are very comfortable with deep sedation, so we often choose deep sedation over moderate sedation. Deep sedation is often easier to deal with/obtain than moderate sedation.

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Specializes in Sedation.
There are numerous studies on nurse administered propofol sedation/NAPS. My group actually did our Masters research project/literature review comparing different sedation strategies in the GI clinic with and without the use of propofol.

The last I knew there were about 22 states that allowed RNs(not CNRAs) to administer propofol for moderate sedation. The research is overwhelming in the consensus that NAPS is safe under the right conditions/dosages.

Is there something particular you are wanting to know?

I would be very interested in seeing the results of your research project/literature review comparing different sedation strategies in GI clinics. My business partner is an anesthesiologist with a background in research, He started using propofol in a research setting at a major university hospital for computer controlled infusions back in 1991. He feels that in the proper hands it is a wonderfully effective drug and should be more widely used by GI Dr.s, as I am sure you are aware as a CRNA, we even get requests from dentists who want to examine its use in prolonged dental procedures that would require moderate sedation.

According to this article http://www.eurekalert.org/pub_releases/2009-12/asfg-gsr120209.php

over 600,000 cases by GI docs have been done safely.

The main points being proper training and patient selection are crucial to safe practice.

Proper training is pretty vague. The patient selection, pharmacology, pharmacokinetics, synergistic effects, plasma sensitive half times etc... all of that can be taught in a didactic setting.

What is the best way to provide advanced airway management training short of see one, do one, teach one which is the training I received in the military?

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Specializes in Anesthesia.
I would be very interested in seeing the results of your research project/literature review comparing different sedation strategies in GI clinics. My business partner is an anesthesiologist with a background in research, He started using propofol in a research setting at a major university hospital for computer controlled infusions back in 1991. He feels that in the proper hands it is a wonderfully effective drug and should be more widely used by GI Dr.s, as I am sure you are aware as a CRNA, we even get requests from dentists who want to examine its use in prolonged dental procedures that would require moderate sedation.

According to this article http://www.eurekalert.org/pub_releases/2009-12/asfg-gsr120209.php

over 600,000 cases by GI docs have been done safely.

The main points being proper training and patient selection are crucial to safe practice.

Proper training is pretty vague. The patient selection, pharmacology, pharmacokinetics, synergistic effects, plasma sensitive half times etc... all of that can be taught in a didactic setting.

What is the best way to provide advanced airway management training short of see one, do one, teach one which is the training I received in the military?

lol...I am military trained CRNA. Here is my reference list. Take a look at the meta-analysis by Qadeer and then there is another article by Walker et al. where an anesthesiologist set up sedation training for nurses and they did a 4yr prospective study on over 9K patients.

References

American Association of Nurse Anesthetists & American Society of Anesthesiologists (Producer). (2004). AANA & ASA Joint Statement on Nurse Administered Propofol Sedation [Video file]. Retrieved from http://www.aana.com/news.aspx?ucNavMenu_TSMenuTargetID=62&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=761&terms=aana+asa+propofol

American Association of Nurse Anesthetists (1996). Considerations for Policy Guidelines for Registered Nurses Engaged in the Administration of Sedation and Analgesia . Retrieved March 28, 2008, from http://www.aana.com/resources.aspx?ucNavMenu_TSMenuTargetID=51&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=706

Mackenzie, N., & Grant, I. (1987). Propofol for Intravenous Sedation. Anesthesia, 42(), 3-6.

Stoelting, R. K., & Hillier, S. C. (2006). Pharmacology & Physiology in Anesthetic Practice (4th ed.). Philadelphia: Lippincott Williams & Wilkins.

Aisenberg J, Cohen LB, Piorkowski JD, Jr. (2007). Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications. American Journal of Gastroenterology, . 102(4), 707-713.

Akin A, Guler G, Esmaoglu A, Bedirli N, A B. (2005) A comparison of fentanyl-propofol with a ketamine-propofol combination for sedation during endometrial biopsy. Journal of Clinical Anesthesia. (17), 187-190.

Bentley JB, Borel JD, Nenaad RE et al. (1982). Age and fentanyl pharmacokinetics. Anesthesia & Analgesia. 61: 968-971.

Brunton LB, Lazo JS, Parker KL. (2006). Goodman & Gilman's The Pharmacological Basis of Therapeutics (11th edition). New York: McGraw-Hill.

Cohen LB, Dubovsky AN, Aisenberg J, Miller KM. (2003). Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist. Gastrointestinal Endoscopy, 58(5), 725-732.

Cohen LB, Hightower CD, Wood DA, Miller KM, Aisenberg J. (2004). Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endoscopy, 59(7), 795-803.

Fanti L, Agostoni M, Arcidiacono PG, et al. (2007). Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomized controlled trial. Digestive and Liver Disease, 39(1), 81-86.

Fanti L, Agostoni M, Casati A, et al. (2004). Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP. Gastrointestinal Endoscopy, 60(3), 361-366.

Gasparovic S, Rustemovic N, Opacic M, et al. (2006). Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: a three year prospective study. World Journal of Gastroenterology, 12(2), 327-330.

Harrington L. (2006). Nurse-administered propofol sedation: a review of current evidence. Gastroenterology Nursing, 29(5), 371-383; quiz 384-375.

Heuss LT, Inauen W. (2004). The dawning of a new sedative: propofol in gastrointestinal endoscopy. Digestion, 69(1), 20-26.

Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. (2003). Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases. Gastrointestinal Endoscopy., 57(6), 664-671.

Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. (2003). Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients-a prospective, controlled study. American Journal of Gastroenterology, 98(8), 1751-1757.

Langley, M.S. & Heel, R.C. ((1998). Propofol. A Review of its pharmacodynamic and pharmacokinetic properties and use as an intravenous anesthetic. Drugs., 35, 334-372.

Leffler TM. (2004). Propofol for sedation in the endoscopy setting: nursing considerations for patient care. Gastroenterology Nursing, 27(4), 176-180; quiz 180-171.

Levitzky BE & Vargo JJ. (2008) Fospropofol disodium injection for the sedation of patients undergoing colonoscopy. Therapeutics and Clinical Risk Management, 4(4), 733-738.

Lubarsky DA, Candiotti K, Harris E. (2007). Understanding modes of moderate sedation during gastrointestinal procedures: a current review of the literature. Journal of Clinical Anesthesia, 19(5), 397-404.

Meining A, Semmler V, Kassem AM, et al. (2007). The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam. Endoscopy, 39(4), 345-349.

Moos DD. (2006). Propofol. Gastroenterology Nursing, 29(2), 176-178.

Qadeer MA, Vargo JJ, Khandwala F, Lopez R, Zuccaro G. (2005). Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis. Clinical Gastroenterology & Hepatology, 3(11), 1049-1056.

Rex DK. (2006). Review article: moderate sedation for endoscopy: sedation regimens for non-anesthesiologists. Alimentary Pharmacology & Therapeutics, 24(2), 163-171.

Rex DK, Heuss LT, Walker JA, Qi R. (2005). Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology, 129(5):1384-1391.

Riphaus A, Wehrmann T. (2007). Sedation, surveillance and preparation. Endoscopy, 39(1), 2-6.

Rudner R, Przemyslaw J, Plotr K, et al. (2003). Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy. Gastrointestinal Endoscopy, vol. 57. No. 6, 657-663.

Saenz-Lopez S, Rodriguez Munoz S, Rodriguez-Alcalde D, et al. (2006). Endoscopist controlled administration of propofol: an effective and safe method of sedation in endoscopic procedures. Rev Esp Enferm Dig, 98(1), 25-35.

Sieg A. (2007). Propofol sedation in outpatient colonoscopy by trained practice nurses supervised by the gastroenterologist: a prospective evaluation of over 3000 cases. Z Gastroenterology, 45(8), 697-701.

Ulmer BJ, Hansen JJ, Overley CA, et al. (2003). Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists. Clinical Gastroenterology & Hepatology, 1(6), 425-432.

Vargo JJ, Holub JL, Faigel DO, Lieberman DA, Eisen GM. (2006). Risk factors for cardiopulmonary events during propofol-mediated upper endoscopy and colonoscopy. Alimentary Pharmacology & Therapeutics, 24(6), 955-963.

Vargo JJ, Zuccaro G, Jr., Dumot JA, et al. (2002). Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology, 123(1), 8-16.

Walker JA, McIntyre RD, Schleinitz PF, et al. (2003). Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center. American Journal of Gastroenterology, 98(8), 1744-1750.

Waring JP, Baron TH, Hirota WK, et al. (2003). Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointestinal Endoscopy, 58(3), 317-322.

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Specializes in Sedation.

Thats Awesome! Thanks,

I love the paragraph from the Douglas K Rex article which poses the same questions I was trying to ask.

"The major remaining issue is how training of nurses

and endoscopists should be accomplished."

FUTURE TRENDS AND ISSUES

The evidence base for nurse/endoscopist-administered propofol

is now sufficiently strong to support its expansion in appropriately

selected patients. Patients with higher ASA risk class, difficult

airways, or at increased risk of aspiration have often been

excluded from clinical reports of nurse/endoscopist-administered

propofol. The major remaining issue is how training of nurses

and endoscopists should be accomplished. Although guidelines

for developing and training programs in propofol have appeared,

additional and more specific recommendations from

the gastrointestinal specialist societies regarding training in

propofol would help extend the safe use of the drug. The model

of targeting propofol to moderate sedation seems particularly

attractive to achieving widespread use.

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I'm gathering from these comments that more research needs to be done. The article from 'eureka' has some odd study designs, so I question it. I think it's also interesting that less than half the states allow non-anesthesiology trained nurses to administer propofol...there should be a unanimous decision if you ask me.

I just read an issue brief from Preventing Colorectal Cancer.Org http://www.preventingcolorectalcancer.org/sites/images/pcc/files/PCC_PR_Propofol_Issue_Brief_Final.pdf

and am convinced that propofol is the best option for sedation during CRC screenings, but the administration by trained personnel is crucial. It's insane that gastroenterologists can go to a weekend course in Vegas and come home certified in anesthesia. A rigorous training program or sticking to certified CRNA's/Anesthesiologists seems like the only responsible choice.

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Specializes in Sedation.
I'm gathering from these comments that more research needs to be done. The article from 'eureka' has some odd study designs, so I question it. I think it's also interesting that less than half the states allow non-anesthesiology trained nurses to administer propofol...there should be a unanimous decision if you ask me.

I just read an issue brief from Preventing Colorectal Cancer.Org http://www.preventingcolorectalcancer.org/sites/images/pcc/files/PCC_PR_Propofol_Issue_Brief_Final.pdf

and am convinced that propofol is the best option for sedation during CRC screenings, but the administration by trained personnel is crucial. It's insane that gastroenterologists can go to a weekend course in Vegas and come home certified in anesthesia. A rigorous training program or sticking to certified CRNA's/Anesthesiologists seems like the only responsible choice.

Anne,

I agree with the majority of your post. More research does need to be done. Propofol does facilitate the procedure and should be more widely used in CRC screenings. We are talking about a practice that should only be attempted by highly trained practitioners.

I think it is erroneous to draw the conclusion that if a state nursing board does or does not allow a practice, it is an indicator of what should be happening. As part of my job as an anesthesia consultant, providing training and CE for physicians, nurses, dentist etc... and assisting with the development of sedation programs for facilities, I communicate with state dental, medical and nursing boards across the country on a daily basis. Their job is to protect the public - that's it, and that is all they want to do. It is up to the practitioners to reach a consensus as to what the policy should be, not the state boards, you will never get a unanimous decision from 50 states on anything, nor should you.

I'm not familiar with any "weekend Vegas courses" that certify gastroenterologists in anesthesia, but the main thing would be for them to have sufficient training and skill in airway management, better yet it makes more sense for the nurse to have the airway management skills.

The propofol package insert clearly states:

WARNINGS

For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trained

in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Patients should be continuously

monitored, and facilities for maintenance of a patent airway, artificial ventilation, and oxygen enrichment and circulatory resuscitation must be immediately

available.

For sedation of intubated, mechanically ventilated adult patients in the Intensive Care Unit (ICU), DIPRIVAN Injectable Emulsion should be administered

only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management.

If the Dr. is doing the procedure, it is up to the nurse to monitor the patient (see underlined above)

Now one would probably point out the first part of that statement that says " should be administered only by persons trained in the admin of GA" but upon closer look that is for general anesthesia and mac sedation. For a colonoscopy we are talking about conscious sedation (remember the continuum) Not to mention the fact that if you look up how many anesthesia providers there are in this country and divide that by the number of procedures done using propofol each year, you will have a better understanding of the problem.

We need more nurses who are competent enough to administer this drug safely, that is done through training and continuing education.

That's my soapbox opinion.

Thank you,

Randy

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