Procedural Sedation in the ICU

How many of you are in a place where you (or some anesthesia provider) has to go to the ICU to perform procedural sedation. Here, RNs can't push Propofol, Ketamine etc, so often times the doc will push it with the nurse observing the patient and the doc ALSO performing the procedure. This doesn't seem like a remarkably good idea to me...

How is it done where you are?

Funny - I just posted our policy on another thread...

The hospital policy here is that no one but anesthesia providers (MDA, CRNA, or AA) may give Propofol, Ketamine, Amidate, Pentothal, or Brevital with the exception of propofol infusions for patients on vents in the ICU. Non-anesthesiologist physicians are not exempted from this policy, and it is strictly adhered to throughout the hospital.

Any intubation, cardioversion, GI or Radiology case that requires any of the above drugs for sedation must be attended by anesthesia.

When pt's are vented of course we push just about anything thats only if mech ventilated. If not mech ventilated we may push versed, ativan, any pain meds and have low dose propofol drip.

At our ICU the nurse can moderately sedate with versed/fentanyl, usually for endoscopy. The ASA and AANA have a position statement on propofol use and it makes sense--there is no reversal agent for propofol (time?) and you have to be prepared to intubate if you get carried away. Of course if you're already intubated... Here is the link: http://www.asahq.org/news/propofolstatement.htm

I have on three occasions in the last 4 months given very deep sedation versed/fentanyl/vec for bedside trach and peg jobs. I think this will only fly in a military hospital though.

I have on three occasions in the last 4 months given very deep sedation versed/fentanyl/vec for bedside trach and peg jobs. I think this will only fly in a military hospital though.

I'd call that a general anesthetic.

When I worked in the ICU I also gave versed/fentanyl for a PEG placement, and etomidate for cardioversion. Although I physically pushed the drug, it was also required that anesthesia was at the bedside.

In my area the competent critical care RN can administer MD ordered sedation (usually Versed and Diprivan) for procedures. Generally this would take place in special procedures, but the critical patients may need these procedures emergently, and to stay in ICU.Sometimes the docs will ask anesthesia to attend and frequently they CANNOT due to their own workload, etc.

Airway and vital signs are closely monitored continuously of course. I've never been asked to give a paralytic unless we were establishing an airway in the process.

I know a lot of anesthesia providers don't like the idea of critical care nurses giving Diprivan on unintubated patients but to me it seems a turf battle instigated by CRNA's. I read a lot of this on the BB. Until CRNA's staff the ICU I don't see this changing.

I have no problems with RNs giving propofol as long as they know how to manage an airway. Unfortunately, I don't think this is the norm. When I was working in the ICU, I thought I was moderate good at managing an airway... but it wasn't until anesthsia school that I realized I was wrong.

As the post on the joint statement from the ASA and AANA demonstrates, both anesthesia associations strongly believe that propofol should only be given by skilled anesthesia providers, so your comment on CRNAs perpetuating a turf battle is absurd.

99.7% of all CRNAs and SRNAs have at one time been critical care RNs in the units. Please trust those of us who have been on both sides of the fence that emergency management of unexpected complications is far better handled in the OR than in the units. We have an entire department at our immediate disposal, not to mention a pharmacy of drugs either already drawn up and on our tabletop or are two feet away in some sort of Omnicell or Pyxis. Anesthesia imparts on most all patients a condition upon induction that would qualify as all hell breaking loose in the units, which is not a pretty sight (I know from first hand experience). If a person does not have immediately, and I mean no more than 2 feet away, ephedrine, neosynephrine (and the knowledge / understanding of when to use each one), 4 different type of blades, 3 different types of tubes, bugies, and alternative airway methods AT MINIMUM then don't give anesthetic drugs.

I did alot as an RN (both in hospitals and esp pre-hospital) and would not change it for the world. With that said, RNs don't know a whole lot about airway management, unless you have some kind of EMS or flight training. Not trying to flame, but most of us know this is true.

MDs who ask that GA drugs to be given by an RN to an unintubated pt are asking a RN to do something that is against the drug mfg statements, is convenient on the physician's behalf, is outside most state-derived nurse practice laws, and is against what the two largest and most influential anesthesia organizations in this country have agreed upon. There is nothing to back you up but a plea of desperation...You are hanging yourself, and more importantly, your patient out to dry with no backup.

99.7% of all CRNAs and SRNAs have at one time been critical care RNs in the units. Please trust those of us who have been on both sides of the fence that emergency management of unexpected complications is far better handled in the OR than in the units. We have an entire department at our immediate disposal, not to mention a pharmacy of drugs either already drawn up and on our tabletop or are two feet away in some sort of Omnicell or Pyxis. Anesthesia imparts on most all patients a condition upon induction that would qualify as all hell breaking loose in the units, which is not a pretty sight (I know from first hand experience). If a person does not have immediately, and I mean no more than 2 feet away, ephedrine, neosynephrine (and the knowledge / understanding of when to use each one), 4 different type of blades, 3 different types of tubes, bugies, and alternative airway methods AT MINIMUM then don't give anesthetic drugs.

I did alot as an RN (both in hospitals and esp pre-hospital) and would not change it for the world. With that said, RNs don't know a whole lot about airway management, unless you have some kind of EMS or flight training. Not trying to flame, but most of us know this is true.

MDs who ask that GA drugs to be given by an RN to an unintubated pt are asking a RN to do something that is against the drug mfg statements, is convenient on the physician's behalf, is outside most state-derived nurse practice laws, and is against what the two largest and most influential anesthesia organizations in this country have agreed upon. There is nothing to back you up but a plea of desperation...You are hanging yourself, and more importantly, your patient out to dry with no backup.

That was very well said!

In my area the competent critical care RN can administer MD ordered sedation (usually Versed and Diprivan) for procedures. Generally this would take place in special procedures, but the critical patients may need these procedures emergently, and to stay in ICU.Sometimes the docs will ask anesthesia to attend and frequently they CANNOT due to their own workload, etc.

Airway and vital signs are closely monitored continuously of course. I've never been asked to give a paralytic unless we were establishing an airway in the process.

I know a lot of anesthesia providers don't like the idea of critical care nurses giving Diprivan on unintubated patients but to me it seems a turf battle instigated by CRNA's. I read a lot of this on the BB. Until CRNA's staff the ICU I don't see this changing.

If you have actually read these threads (you claim you have) then you would know it's not a turf battle.

It's a rare anesthesia department that can't EMERGENTLY attend to an ICU intubation. There's a difference between emergent and urgent. If it's emergent, they don't need sedation with propofol. What I often find is that I show up in the ICU for an "Emergency Intubation" only to find no ICU doc waiting on us - he's wandered off somewhere. That to me is NOT an emergency. If the patient was that critical, he wouldn't have wanderd off, and we will NOT wait on them while they get done chatting on the phone. If you want us, we'll come, do our thing, and leave. Be ready for us when we get there. We can almost always find someone to run to the ICU for the 5-10 minutes an emergency intubation will require. We don't have 20-30 minutes to waste.

mattsmom81 -

i am going to have to agree with the other posters - you are just wrong. i too was a nurse who considered myself good enough to give anything and usually did - i like brenna's dad - am now educated enough to know i should have never had a stick of propofol in my hand unless the pt was already on a ventilator. what you DON'T know will hurt you ...plus - you are placing yourself at a huge disadvantage - the AANA and ASA joint statement will fry you in court if there is a bad outcome - just not something a "competent" nurse would do.

Perhaps this link will explain some views held by posters:

http://www.allnurses.com/forums/showthread.php?t=91385