Propofol administration by ER RN

Editorial Team / Moderator · Sep 8, 2019

Regarding your first question, did you search the California Nurse Practice Act? https://www.rn.ca.gov/practice/npa.shtml

A simple search on "sedation" will answer your question.

In regards to restraints, I have used them in ERs (not in California but elsewhere) where there are no hospital beds in the first place; however, we stopped using hard restraints (leathers) a long time ago. What is your facility policy? It is usually more important to have a valid order with the proper checks.

NurseVoldemort, BSN, RN · Sep 12, 2019

I've worked in Washington, NY and Oregon. Never in Cali, but we have never had a regular hospital bed to even think about using locking/hard restraints on. We only have every used them on the stretchers. The biggest thing is to ensure you have proper charting and orders for said restraints.

I've been legally allowed to give propofol IV push for sedation in every state I work with in the prescence of the MD for moderate sedation procedures. The hospital I currently work in only allows ED RN's to perform this and when our house float comes to help (from the ICU) they can't do it since it is against hospital policy; only ED nurses can do it and only when the MD is present.

For sedation for intubated patients though we also can do boluses in prescence of MD and then titrate drips without MD being in the room once the pt is tubed.

Guest219794 · Sep 13, 2019

Propofol- a quick Google search indicates it is legal. The idea that it is illegal is one of those persistent nursing myths. (Though maybe it is illegal in some states.) Nurses will tell you with absolute authority that it is legal to maintain a drip and titrate, but illegal to bolus. I curious where this is actually true.

As far as 4 points on an ER cot- common practice.

Guest219794 · Sep 13, 2019

Propofol- a quick Google search indicates it is legal. The idea that it is illegal is one of those persistent nursing myths. (Though maybe it is illegal in some states.) Nurses will tell you with absolute authority that it is legal to maintain a drip and titrate, but illegal to bolus. I curious where this is actually true.

As far as 4 points on an ER cot- common practice.

Also- check with the Cali BON.

Have you ever heard of a nurse losing a license for applying 4 points on an ER cot as ordered, or administering a drug as ordered?

Curious- what kind of nursing do you do? Are you a new hire in an ER?

diane e · Sep 13, 2019

Hi. I have been an ER nurse for 33 years.( yikes that seems like a life time). I used to work in a big county hospital in Los Angeles for 19 years in a level 1 trauma centerThen in 2002 moved to Kodiak Alaska. Still in Er. But went from 44 beds to 6 beds. My daughter is a new grad and got hired here in Southern California. I was actually inquiring for her. The ER she got hired at, hires new grads, but the orientation they gave was all about speed, and getting patients in and out fast. So she had those questions for me. I honestly appreciate the replies. Nursing has changed over the years. So much I used to know, and now not sure what I know,, Thank you for the information

JKL33 · Sep 14, 2019

On 9/13/2019 at 12:00 AM, diane e said:
The ER she got hired at, hires new grads, but the orientation they gave was all about speed, and getting patients in and out fast. So she had those questions for me. I honestly appreciate the replies.

Kudos to you on your long ED career. ?

Unfortunately I would say your daughter's take on the orientation is probably spot on.

Good nursing judgment might be more important than ever. You can help her learn how best to verify what she is being taught, through policies, regulatory agency websites, information from professional bodies, etc., etc. A good ED reference manual can help fill in the gaps of knowledge about actual patient care. I think a close review of the ESI triage manual can help new people too, because it helps lay out a good foundation and sequence for deciding who is sick/high risk and who isn't. She needs to try to get up to speed about patient conditions and who is at risk for what ASAP so she can use good judgment despite all the competing foci.

Take care ~

ExperiencedCRNA · Oct 4, 2019

Propofol can be administered ONLY by a person specially training in anesthesia: including anesthesiologists, anesthesia residents, dentists that completed an anesthesia residency, nurse anesthetists and student registered nurse anesthetists.

You can find this information in the manufacturer's package insert for propofol.

The only exception is when a patient is intubated and has a secure airway. ICU nurses can titrate an infusion in this scenario and I believe they can bolus through the pump. I'm not sure if ED nurses can administer it by infusion with a secure airway but I am certain that an ED nurse, or any other nurse not trainied in anesthesia, SHOULD not administer freehand propofol.

I don't know where you would find this information in the nurse practice act or if it specifically stated. Conscious and moderate sedation refers to midazolam and fentanyl only. Propofol provides deep sedation.

If your hospital is asking you to bolus propofol freehand I would immediately consult your supervisor to determine that this is in fact the policy and ask where you can review it in writing. Also, if it is true that this is the hospital policy I would urge you to go to administration and ask that they review the policy.

I can tell you from personal experience that propofol is extremely unpredictable. I have seen people go completely apneic and require bag-mask ventilation from 1-2cc boluses. I have seen extreme hypotension and bradycardia from "normal" amounts.

The ASA strongly recommends that the person giving propofol be a trained anesthesia professional not involved in the procedure. I know an ED physician should be able to rescue an airway but sometimes the effects of propofol happen so quickly that IMMEDIATE intervention is necessary to prevent cardiac or respiratory arrest; including specialized airway maneuvers and boluses of heavy duty vasopressors.

Regardless of whether or not it is legal/illegal, or written in hospital policy, I would not recommend doing it from a patient safety standpoint.

Editorial Team / Moderator · Oct 4, 2019

As a long-time ED RN, I was only ever allowed to hang propofol as an infusion on a patient whose airway was secured with an ETT. No ED RN boluses where I worked (Afghanistan was sorta the wild west, I will say), but the ED physicians could bolus if desired. If propofol was indicated for some kind of procedure requiring sedation without an airway adjunct in place, we had to have a second physician in the room for the duration, or a CRNA. So if it was a closed reduction of a fracture or dislocation, for example, sometimes we'd have ortho and the ED physician, or the ED physician and one of the in-house CRNAs (they were usually in L&D and would come to help if able).

Stella_Blue · Oct 15, 2019

I'm my ER (Indiana) nurses are not allowed to bolus propofol for sedation. It must be pushed by a physician. We can push any other sedation med but propofol. We can manage and start drips, just no bolus.