Propofol for conscious sedation?

Specialties Emergency

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Specializes in ER.

Hello Everyone, I was hoping I could get your thoughts on this issue

I have been under the impression that the use of propofol was limited to anesthesia providers when used with non-intubated patients, and as such I have refused to administer it as an agent for conscious sedation. I was backed up by our pharmacist in my decision not to administer the medication.

However in casual reading of the october 2007 journal of emergency nursing, I found an article where they specifically state that propofol is acceptable for administration by a registered nurse for procedural sedation when an board-certified emergency physician is present to manage airway. For that matter ketamine is also listed as acceptable in the ena article, I believe there has been some debate concerning this medication as well.

I was hoping that the board would help me reconcile these views.

Thanks

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We have to pass a yearly proficiency in order to give conscious sedation (this includes propofol but I work in a MICU and we have MDs at the bedside also.

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Specializes in Critical Care.

The use of propofol and ketamine is governed by the Board of Nursing for each state. Here in Wisconsin, an RN can administer as long as there are personel present who can insert and manage advanced airways.

Look at your state's guidelines for nursing to see how is is in your state.

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Specializes in CRNA.
Hello Everyone, I was hoping I could get your thoughts on this issue

I have been under the impression that the use of propofol was limited to anesthesia providers when used with non-intubated patients, and as such I have refused to administer it as an agent for conscious sedation. I was backed up by our pharmacist in my decision not to administer the medication.

However in casual reading of the october 2007 journal of emergency nursing, I found an article where they specifically state that propofol is acceptable for administration by a registered nurse for procedural sedation when an board-certified emergency physician is present to manage airway. For that matter ketamine is also listed as acceptable in the ena article, I believe there has been some debate concerning this medication as well.

I was hoping that the board would help me reconcile these views.

Thanks

I think you should refer to the package insert when questioning whether or not an RN can push the white stuff. It clearly states only those trained in general anesthesia should be administering propofol. This statement to me trumps what any state nursing board approves or disapproves of. After your obese patient with the anterior airway and small mouth opening crumps, the nurse and/or RRT can't BVM the dude, the ER doc and/or GI doc fumbles around and misses the airway and the patient now drools in bed for a living, the scumbag trial lawyer only has to ask one question.....What does the package insert say regarding the administration of this drug?

Besides, I think when considering conscious sedation, the nurse should understand what that statement really means. The patient is supposed to remain conscious, answer questions, and cooperate with the procedure. There is a thin line between consciousness and being completely obtunded or apnec when playing with propofol.

Aquavan (a prodrug of propofol) when it is approved by the FDA will probably solve most of these current conflicts in nursing/medicine.

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In my state, it's not a big issue. It's given by nurses abs in the unit. however, the floor nurses are not allowed to administer it, only unit and special procedure nurses for conscious sedation.

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Specializes in ER,ICU,L+D,OR.

We dont use it in our ER for C.S.. We do use ketamine which is so keen. Do I see an issue with propofol, no not really as long as the MD and airway supplies are at bedside. It is a tool. nothing else. Hospital Anesthesia committee and the ER docs are always going around about something. This is their area of contention currently. Im glad I stay out of meetings.

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Specializes in OB, ER.

We are using it more and more in our ER and I'm really starting to like it.

It is great for a quick concious sedation because it works quickly and doesn't last long. As far as airway issues the drug only lasts a couple of minutes if pushed. If you do an infusion the patient arouses almost immediatly with discontinuing so you should be able to BVM the pt for that short time if needed. We used it on a poor girl with lockjaw the other day. She was out, jaw released, and back awake within 5 min. It was beautiful. No waiting hours for them to fully wake up like with a lot of the concious sedation drugs.

We also use it on trauma pts to keep them sedated and I love that you can easily titrate the dose to effect.

We do always have an MD in the room for the initial sedation and often they push the drug themselves but as nurses we bolus and titrate ourselves. We often have respiratory present as well if the pt isn't already intubated.

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Specializes in ER,ICU,L+D,OR.

Brevitol is neat also

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Specializes in Family Nurse Practitioner.

I like to call it milk,

we use it for bedside procedures and administer it to effect

They are already on a monitor, sats etcs anyway in the ICU

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Specializes in Anesthesia.

If you do a search on Nurse Administered Propofol Sedation/NAPS you can find there is actually a lot of information on RNs safely administering propofol for moderate sedation. Somewhere in the neighborhood of over 100K+ randomized trials haved showed no statistical significance in safety profile of RNs administering propofol and anesthesia providers giving propofol. About 20 or so states allow RNs to give propofol for moderate sedation.

Now saying that since I am currently in anesthesia school I can see how you can easily get yourself in trouble trying to titrate propofol for moderate sedation. Propofol can cause on almost immediate loss of respiratory drive and protective airway reflexes in as little as 0.5mg/kg, and not everyone can be effectively bagged until their respiratory drive returns. As an anesthesia provider it is not that big of deal to lose the respiratory drive/airway reflexes. As an anesthesia provider we can, usually, easily manipulate the airway, bag the patient, and/or place LMA or ETT.

In my personal opinion after doing a lot of research on the subject NAPS has the potential to be very safe when the total amount of propofol is tightly controlled by institutional policy (10-40mg boluses every 2-5mins until desired effect is achieved). One of the biggest issues with NAPS is money. There are many CRNAs/MDAs that make their living basically doing moderate sedation with propofol. It is much more cost effective for RNs to provide NAPS than a CRNAs.

By the way ketamine and propofol is a great combination with the right training. Ketamine provides intense pain relief while maintaining respiratory drive and the propofol tends to ease the ketamaine dysphoria/delirium.

One other thing fospropol (a prodrug of propofol) was recently approved and has the same safety labeling as propofol. http://news.prnewswire.com/ViewContent.aspx?ACCT=109&STORY=/www/story/12-14-2008/0004941657&EDATE=

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Specializes in CRNA.

What were the ASA classifications of the patients involved in these randomized trials wtbcrna? I do agree that Aquavan will do a lot to end this current argument.

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Specializes in Anesthesia.
What were the ASA classifications of the patients involved in these randomized trials wtbcrna? I do agree that Aquavan will do a lot to end this current argument.

ASA I-IV patients with some studies specifically looking at ASA III and IVs patients.

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