I'm not a CRNA, but I couldn't think of a better forum to ask this question. I work in a Neuro ICU and of course, we use lots of propofol on INTUBATED patients. We got into a discussion last night about propofol and whether it could be used on non-intubated patients as well. Some people seemed to think that in small doses it would work because of how quickly it works and how quickly it wears off. But I say no. I've seen how fast people can go out w/ propofol and would not feel comfortable giving it to a non-intubated patient (actually I would be terrified!). And no, no one has done it, nor are there plans to do so, we were just having a lively conversation.
That being said, IS propofol ever used on non-intubated patients? If so, is it only anesthetists and nurse anesthetists that would administer it? Am I asking a really dumb question? I've looked online and can't find anything that answers my question either way.
Yes, propofol can be used in the unintubated person. It can be a scary thing however. You know how quickly it works and the apnea can be a scary thing. It has been used for sedation during spinal anesthesia, Monitored anesthesia care, and I know that it has also been used in oral surgeons office for surgeries without intubation. There is of course someone holding the head and maintaining the airway the entire time. Sounds like your group sparks some good discussions during your shift.
Propofol is labeled as an anesthetic for a reason, if given enough of a dose it causes apnea. Those of us in anesthesia use propofol all the time, not only as induction agents to put people to sleep, but also as continuous infusions for various stages of sedation, as continuous infusions for a general anesthetic, and as bolus doses to get patients through very stimulating parts of procedures. We know the doses necessary for all situations, but herein lies the problem, sometimes a small dose causes apnea. But because we are able to manage the airway, we can get through bolus doses without having to intubate. So for a drug that can have such an effect on a patient, it should not be given by providers not trained in it's use. In addition, propofol is very cardiac depressing and has also been shown to cause metabolic acidosis in some patients, especially pediatric, if the infusion exists beyond a day. We are very cautious to use this in cardiac patients and often experience the effects of the drug for 10-15 minutes after induction in these patients especially. I always hear of these procedures being done in the ER, why isn't anesthesia called to help with these situations? We have gone to the ER on occasions to provide sedation for dislocations and such. It may seem like we do little more than push the drug, but there's a lot of preparation and knowledge behind it.
Thanks for the great info... How about etomidate.... or midazolam and fentanyl? Where is the line between "conscious sedation" and "anesthesia?" Curiouser and curiouser
Thanks for the great info... How about etomidate.... or midazolam and fentanyl? Where is the line between "conscious sedation" and "anesthesia?" Curiouser and curiouser
Conscious it the key word. If your patient doesn't respond to verbal stimulation, you've passed conscious sedation and gone to deep sedation. If they don't respond to a painful stimulus (which is exactly what these damn GI docs want their non-anesthesia RN's to do) and/or lose their protective airway reflexes, it is then a general anesthetic, even if you're "just using propofol".
Thanks for the great info... How about etomidate.... or midazolam and fentanyl? Where is the line between "conscious sedation" and "anesthesia?" Curiouser and curiouser
etomidate is a general anesthetic, midazolam is a sedative, fentanyl is a narcotic, combine them together and you have a general anesthetic.
You are not going to like this--but if you have to ask the question, you shouldn't be giving the drugs under any circumatances.
Read the preceding answer about the definition of conscious sedation. He is right on.
You are not going to like this--but if you have to ask the question, you shouldn't be giving the drugs under any circumatances.
Yoga,
If I didn't like it, I wouldn't have engaged myself in the discussion. Your insight is always appreciated and frankness unequaled.
So far as if I "have to ask the question"- I appreciate your recap of basic nursing care... before giving any pharmacologic, it is expected practice, CRNA or RN, to understand the medication.
It has been pointed out in this thread that if anesthetic is to be administered, anesthesia [specified] staff must be present. Point well taken...
Versed and fentanyl, even in "small" doses, can tank narcotic naive patients, pushing them uncomfortably close, if not into anesthesia. How often have we attended codes in Endo or TEE where a little was obviously too much? This is when we, the RNs who have not yet achieved ultimate wisdom in anesthesia (like Master Yoga :wink2: ), must keep our cool and remember that airway is always number one.
"For general anesthesia or monitored anesthesia care (MAC) sedation, propofol 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 (emphasis added) adult patients in the Intensive Care Unit, propofol should be administered only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management."
Anytime you give propofol to a patient, you have departed the world of conscious sedation and entered the realm of deep sedation, aka monitored anesthesia care. The package inserts for all manufacturers of propofol in some way state that only qualified anesthesia providers should be giving this drug to non-intubated patients.
Whether you were aware of this information or not, a plaintiff's attorney will be aware of it. I don't care what your hospital policy states. I don't care what the physician in the room told you to do. The attorney will simply provide this insert to the court, then ask you what training you have had in the provision of anesthesia. If your answer is not that you are a CRNA, MD anesthesiologist, or AA, the attorney will state that according to the instructions of the manufacturer, you are not qualified to give the drug. Period. Get out your checkbook, sign a check and hand it over.
Yes, small doses of versed & fentanyl (& especially propofol) can be dangerous. Too often, it is taken for granted that "I've given it 100 times before and so far nothing has happened." Well, I have an example: How many times have we given a pt 50-75mcg of fentanyl? I did just that and the patient went into respiratory arrest. She was very difficult to ventilate via mask and jaw thrust was not working. Luckily, we had just entered the recovery room and had a nasal airway at the bedside. We were able to get that in and ventilate her much better. Some narcan and we were doing well again. However, what if that had been somewhere less prepared? No dose is "just a small dose."
As for the propofol, if you check the nurse practice act, the manufacturers warnings, and the protocol in your institution, it is likely that as a non-anesthesia provider, you are NOT to be utilizing it for non-intubated patients and you are not to be giving it IV push. I believe that it must be on ICU, intubated pts, and on an infusion pump. Know your risks and know your laws.
I have learned my lesson and I will NEVER ask a question here again unless I first do a search! I appreciate all the responses I received, and I can see there has already been much debate even before I posted this particular thread.
Maybe the mods can close this thread? I don't know that anything more can be gained by continuing this discussion.
I appreciate all the responses I received, and I can see there has already been much debate even before I posted this particular thread. 
PattyD404
6 Posts
Yes, propofol can be used in the unintubated person. It can be a scary thing however. You know how quickly it works and the apnea can be a scary thing. It has been used for sedation during spinal anesthesia, Monitored anesthesia care, and I know that it has also been used in oral surgeons office for surgeries without intubation. There is of course someone holding the head and maintaining the airway the entire time. Sounds like your group sparks some good discussions during your shift.