Propofol for conscious sedation?

[EMTSNA]

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

[Looking4Seaglass]

We've used Versed ....no propofol yet.

[herring_RN, ASN, BSN]

I won't give propofol unless an anesthesia provider, Rt or other licensed person is present and available for advanced airway management.

Also have challenged an anesthesiologist wo started a drip and started to leave. This was a hospital where policy required only an MD to administer it.

The anesthesiologist stayed.

Patient is fine.

I think if you see questionable actions by any healthcare provider immediately notify the nursing management on duty, nurse manager or shift supervisor. Fill out an incident report.

Write letters up the chain of command at your facility and keep copies for yourself.

Report to the board of nursing and keep a copy. Include the datem time, location, medical record number of the patient, name of nurse, and any witnesses. Describe the facts only in detail.

Put the copy in a safe deposit box because you don't want any accidental HIPAA violations.

Do not gossip about it.

[MajorDomo]

The question in the ER is not really the drug given but the Doc. Is the "ER" doc a GP that hasn't intubated since before you were born? Do you know that this particular doc sucks at intubations (failed the last three out of four attempts)? Does this doc freak out in stressful situations?

Been there done that, requested (ei told) that a gas passer had to be at bedside since the doc couldn't do the procedure and push meds at same time since I wouldn't be giving any meds.

On the flip side, most docs I work with intubated in an emergent situation then some/most CRNAs and anesthsiologists so I don't mind pushing prop.

[MN BigJ]

We use the Milk of Amnesia all the time for CS. The key is to be trained as to proper doses, not only for the physician but RN as well, as long as you don't over sedate I don't see a problem. With the shorter half life I would rather use propophol than Versed/narc combo, even with Romazicon and Narcan at the bedside.

[knowurjoe]

Be sure to check your state board of nursing websites. In Texas RN's can not push Propofol , Ketamine , Etomidate or Brevital unless pt is getting intubated, already intubated or when a CRNA or anesth. is present.

Found in position statements on the boards website.

[PedsED-RN]

In our ED, I haven't ever seen propofol used, we use a lot of versed, and certain docs will use Ketamine (I think more should!). We do have a hospital policy restricting RN admin. of Ketamine though, must be given by the MD, or other provider who is able to manage airway if compromise arises. I wish more of our MDs and ortho residents/attendings would use Ketamine, especially for reduction sedations. The times I have done reductions with it, the pt is actually comfortable during the procedure, and they were awake and drinking within 10 min. of procedure being done. I hate the Versed/morpine (2mg/2mg) combo they usually use, it is not as effective, or they don't allow enough time for it to take full effect, so the pt is screaming in pain throughout, then totally asleep after when you want them awake for discharge. uugg!!!!

Funny time, once had one of our peds surgeons down to the ED, wanted to dilate a trach at the bedside in the dept, asked for ketamine, and looked at me like I was crazy when I handed it to him. "what, you want me to give it?!" Yup, sorry, I just follow policies, otherwise I would do it. =) hehehe

[mmutk, BSN, RN, EMT-I]

Rumor has it that RNs can't push it, but can maintain a drip here in our state. Although I remember pushing it more often early in my career.

[PedsED-RN]

Now that you mention it, I do recall RNs in our PICU (a Children's hospital) can maintain drips of Ketamine as well as paralytics (I know they use a lot of Roc/Vecuronium with vented kiddos), but still don't recall propofol used in the unit either. Funny to see slight procedural differences across the country, of what meds are typically used for some things. I guess to be expected when there are so many different drugs that have similar uses and new ones always being developed. Also, Interesting the difference b/w pushing or titrating drips of the same drugs. Then again, I know we push Roc or Vec during rapid sequence intubations.

One time I was in the PICU for a couple days, and had an 18-yo who was Autistic, and SEVERELY FOS. So bad, they had him on a Ketamine drip, as well as an NG drip of Go-Lytely to clean him out since he was a rather belligerent autistic . That was a fun day, once he had had a good 8 hrs of GI Dranno working, and his blockage started to "un-block". Let me just say WOW. Plus, he was a large 18 year old, so it would take 4-5 of us at a time to roll him back and forth to get him cleaned up each time. Kinda random and off-topic, but thought it was worth sharing for the laughs =)

[AMAH27]

I work in the ED of a children's hospital, and we regularly use Propofol and Ketamine for our conscious sedations. In our facility, an RN is authorized to push the drug with an MD (preferably and attending) in the room. We are required to complete additional training from the hospital in order to do this, though. Don't know if this helps or not.

[back2bRN]

Since I work in a small facility where the docs are GP's on call I am really cautious about ketamine and propofol is a big no-no (per P&P). If in doubt follow P&P, our region has the drug references online and up to date guidlines for administration, who is able to give it, rate, routes allowed, ect. I use that reference all the time.