*traumaRN*

Still no certification.

The question to ask is who is that "certification" recognized by?

It is fairly common that sedation goes beyond "moderate" sedation. In fact in the ER for joint re location and cardioversion often these procedures cannot be completed without "deep" sedation. Another reason why propofol should be the drug of choice for these procedures, if they get to deep and stop breathing spontaneously you bag/mask for a couple of minutes and they wake up fine. Not the case with narcotics and benzos. Of course you have reversal agents but you open yourself to whole new set of problems if you go that path. For a list of state by state nursing regs click here (link censored by admin) If you are concerned about not being prepared to rescue the patient, then learn how. You have been a nurse for how long? Nurses expect the State Board to be on there side. State boards have one purpose - To protect the public, that's it. don't look to them to bail you out of anything. I do not understand why so few nurses take it upon themselves to be proactive in learning more. Airway courses are available, sedation training courses are available, propofol sedation training for nurses courses are available. If you Google any of these phrases you will find places that provide such training. It is through education and training that you gain the confidence and competence to provide proper patient safety.

Here is a link to a new study just released - As of March 1, 2010 done at Washington University in St. Louis MO. http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Safety-Efficacy-of-Propofol-During-Endoscopy-Evalu/ArticleNewsFeed/Article/detail/659316?contextCategoryId=40127

Here is Dr. Rex, the director of endoscopy at Indiana University, discussing propofol administration by non-anesthesia providers.

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

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.

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?

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

Unfortunately there is not currently a nationally recognized "Certification" in the administration of conscious sedation. Permissions and credentialing is done at a facility level. The Joint Commission for example, makes recommendations for the development of facility standards in sedation administration and uses phrases such as: 1) Qualified individuals 2) Appropriate equipment 3) Appropriate monitoring of the patient 4) Appropriate documentation 5) Appropriate monitoring of outcomes It is vague and leaves much to interpretation, this is intentional so as not to limit the scope of practice. Last July the state of New York passed a law that any procedures done in a physicians office with sedation more than local anesthetic, the facility must be accredited. Part of that accreditation process requires physicians and assisting staff to have continuing education on sedation administration. More states are following this example. Continuing education courses are available that will provide you with a certificate stating you have received CE in the administration of sedation. These will help document that you are staying current and will go towards satisfying most nursing boards scope of practice statements which say a nurse must have "Demonstrable Knowledge" before participating in an activity. One national sedation continuing education organization has a board certified anesthesiologist presenting the courses. Hope this helps. Randy

I will do that. Thank you, Randy

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

Back in the "good ole days" (early 90's) I was working 1900-0700 about 4 or 5 times a week in an ER. If it slowed down around 0300 or 0400 we could take turns hopping on a stretcher, pull the curtain and get a nap. Management was cool with it as long as we were all in the department and someone was monitoring the radio. My most recent night shift job when it slows down, you just sit around and comment on how tired everyone else looks. Best, Randy