Propofol

mwbeah · Feb 5, 2005

gi physicians endorse propofol use; asa to issue statement

in october 2003, the asa committee on ambulatory surgical care submitted an annual report to the asa house of delegates, examining an ongoing controversy about who should be allowed to administer propofol for medical and surgical procedures, including colonoscopies and endoscopies.

in the report (611-1), the committee on ambulatory surgical care summarized the level of concern as of august 2003:

"a growing issue in ambulatory surgery is the administration of propofol for sedation by nonanesthesia providers. typically this consists of drugs administered and monitored by a registered nurse under the supervision of the procedural physician. ..."

"whenever propofol is used, for general anesthesia or for sedation, it should be administered only by persons trained in the administration of general anesthesia. it is important that these persons are not simultaneously involved in the conduct of the surgical or diagnostic procedure. in addition, these persons must monitor patients continuously for oxygen saturation, respiration, heart rate and blood pressure. facilities must be immediately available for the maintenance of a patent airway, oxygen enrichment and artificial ventilation in addition to circulatory resuscitation."

"the location of service does not need to be limited, as long as the above criteria for qualified persons administering the drug, monitoring the patients and appropriate equipment are met."

"in addition, some states have prescriptive regulations concerning the administration of propofol. there are different considerations when propofol is given to intubated, ventilated patients in a critical care setting."

more recently, committee chair beverly k. philip, m.d., said her committee is close to finalizing a formal statement that addresses the issue, including the question of how to define "rescue." the committee's position statement will go to the asa board of directors for review and possible approval in august.

in addition, the american association for accreditation of ambulatory surgery facilities (aaaasf) has changed its standards and, as of march 1, 2004, requires that only anesthesiologists or nurse anesthetists administer propofol. this follows aaaasf's evaluation of reports of several patient deaths that occurred in facilities "without adequate resuscitation equipment and/or personnel airway management training." the aaaasf www.aaaasf.org> currently accredits approximately 1,100 facilities.

on march 8, three gi doctors' organizations put out a statement supporting nurse-administered propofol sedation (naps) by specially trained gastroenterology nurses. these nurses, however, are not trained in the administration of general anesthesia. the statement was the product of a six-member committee composed of representatives from each of the three societies: american college of gastroenterology, american gastroenterological association and american society of gastrointestinal endoscopy. it has been reported that the society for gastroenterology nurses and associates plans to release a similar statement in the next few months.

for additional information on asa's position on the subject of sedation by nonanesthesiologists, see the asa "practice guidelines for sedation and analgesia by nonanesthesiologist," http://www.asahq.org/publicationsandservices/sedation1017.pdf. this practice parameter, revised in 2001 and published in the journal anesthesiology (april 2002), was endorsed by the american society for gastrointestinal endoscopy (asge) as well as the american college of radiology and the american association of oral and maxillofacial surgeons. a related asa statement on continuum of depth of sedation is also available on the asa web site: http://www.asahq.org/publicationsandservices/standards/20.htm

to read the statement, go to:

www.gastro.org/media/newsrelease04/statement-sedationendoscopy.html

rn29306 · Feb 5, 2005

Thanks Mike, it seems that a showdown is on the horizon.

rn29306

mwbeah · Feb 5, 2005

Also,

The controversy is complex. "Different people will tell you that its basis lies in different things," continues Rex. "There are 12 states in the United States that have laws against administration of propofol by nurses.

originalred · Feb 8, 2005

The position statements are interesting. Will we ever see one that does not mention "billing issues"? That ruins the validity of the evidence for me. Is it safe or is it not or is it a turf war over who gets paid? Or some combination of all 3?

jwk · Feb 8, 2005

It's always a safety issue. Cases with the black snake aren't exactly a significant part of my practice.

yoga crna · Feb 12, 2005

I'll make a deal with all of you GI nurses who think they know enough to administer propofol. I won't do GI nursing, if you won't do anesthesia. Even though I am trainable, I have limited knowledge of your area of expertise, and I wouldn't attempt to practice in a GI lab. I do have extensive education and experience in anesthesia.

I continue to believe that those non-anesthetist RNs who administer propofol in the unintubated patient, DON'T KNOW WHAT THEY DON'T KNOW. Can you discuss the pharmacokinetics of propfol and relate it to the clinical situation, where the patient appears to require additional medication? Tell me how you would get an airway on a patient who is agitated or having a seizure while receiving propofol? How quickly can you intubate a patient who has massister spasm? These are just a few of the things we know how to handle. If you don't have the scientific foundation, education or experience to give anesthesia, don't do it.

Also, I agree with Stevie, why do it on a nurse's salary? CRNAS get reimbursed around $400 per GI procedure from insurance companies. That fee is based upon a number of things, including the relative risk of such procedures.

By the way, I do not do GI procedures in my private anesthesia practice. I am simply a patient advocate and care deeply that the public receives the best there is. A non-CRNA administering propofol in a GI lab is substandard pracitice.

Yoga CRNA

squinkybear1 · Feb 12, 2005

I'll make a deal with all of you GI nurses who think they know enough to administer propofol. I won't do GI nursing, if you won't do anesthesia. Even though I am trainable, I have limited knowledge of your area of expertise, and I wouldn't attempt to practice in a GI lab. I do have extensive education and experience in anesthesia.
I continue to believe that those non-anesthetist RNs who administer propofol in the unintubated patient, DON'T KNOW WHAT THEY DON'T KNOW. Can you discuss the pharmacokinetics of propfol and relate it to the clinical situation, where the patient appears to require additional medication? Tell me how you would get an airway on a patient who is agitated or having a seizure while receiving propofol? How quickly can you intubate a patient who has massister spasm? These are just a few of the things we know how to handle. If you don't have the scientific foundation, education or experience to give anesthesia, don't do it.
Also, I agree with Stevie, why do it on a nurse's salary? CRNAS get reimbursed around $400 per GI procedure from insurance companies. That fee is based upon a number of things, including the relative risk of such procedures.
By the way, I do not do GI procedures in my private anesthesia practice. I am simply a patient advocate and care deeply that the public receives the best there is. A non-CRNA administering propofol in a GI lab is substandard pracitice.
Yoga CRNA

It's not a matter of pay or territorial rights. It's an ethical and quality of care issue. Nobody but the anesthesiologist assistants are going to be successful in invading CRNA territory. It's inevitable. I digress.

Nursing education is seriously lacking, as well as is the practice of standards of care in a facility that would give any RN, regardless of experience or training, the responsibility for the well-being of a patient who is anesthetized. Period. I don't believe that there exists a nurse practice law, within the USA, that gives this particular responsibility to the scope of practice of an RN with the basic, (and seriously deficient) NLN Accreditation Council-approved, two-year- devoid of clinical experience-education. When both lack of basic education in pharmacokinetics/dynamics and lack of clinical skill are joined with a careless management team that will risk the life of a patient in order to save a few bucks, nothing can be gained. It's pretty aggregious. (Did I spell that OK?).

A RN who takes on responsibilities for which she/he is neither trained nor prepared for academically or clinically, is jeopardizing her/his patients and her/his career, not to mention- enabling risky behavior and ensuring that dangerous practice continue and patient injury result.

Propofol has a reputation of being a benign agent. It's a great drug with a short duration of action, normally. However, I have had to bag patients and request re-intubation of patients in the PACU after they have undergone simple ortho procedures, when induced and intubated on Propofol, 2.0mg/kg, maintained on Propofol for a 45min-1hour procedure, & having had received no more than Fentanyl 50mcg & Versed 1mg at the beginning of the case. Redheads seem to need a bigger bolus for effect, but do not emerge well. And some people just have ideopathic responses to everything, no matter how "benign". THERE'S NO REVERSAL AGENT FOR THOSE WHO EXPERIENCE AN IDEOPATHIC RESPONSE: NEUROGENIC EXCITABILITY, POST-EXTUBATION APNEA OR HEMODYNAMIC INSTABILITY! Pediatric use of Propofol is not recommended these days because of resultant seizures, hemodynamic instability and apnea which have resulted in brain injury and death.

1. If you are a registered nurse, you should refuse to go beyond your scope of practice. You are not trained or certified to monitor and/or respond to the physiologic changes of a patient who is anesthetized. If you have to use your ACLS skills, (the only skills that you may actually need to use) it's too late for the patient.

2. You should possess the critical thinking skills and the professionalism to say, "NO" to physicians and managers who are willing to sacrifice standards and your license, for the sake of convenience. If you have any doubt, refer to your nurse practice laws and to the standards of care of the anesthetized patient. Care of the anesthetized patient requires specialized education and training far beyond that provided to pass the NCLEX.

What do you think?

jwk · Feb 12, 2005

It's not a matter of pay or territorial rights. It's an ethical and quality of care issue. Nobody but the anesthesiologist assistants are going to be successful in invading CRNA territory. It's inevitable. I digress.

Me? Invade? Nah............

stevierae · Mar 18, 2005

Oh, my goodness, do you guys believe this---I was turned down for an OR nurse job yesterday--and I only wanted to work one day a week, mind you--in a little 2 room free standing outpatient surgery clinic yesterday where the bulk of their cases consists of 3rd molar (wisdom teeth) extractions and other dental and maxillofacial cases, facial plastics, breast augs, tummy tucks, etc.

Why was I, an RN with nearly 30 years of OR experience, turned down? Because I told the person who interviewed me (a PACU nurse who also occasionally circulates and gives IV sedation) that I would not give Propofol, and that I thought it belonged only in the hands of an anesthesia provider (just as I have said many, many times on this BB.)

She said that their practice "as the IV nurse" was to give the usual IV sedation drugs, (Fentanyl, Versed) and occasionally IV Brevital or "a little Propofol." I did not want to appear argumentative on a job interview, so I simply stated that giving Propofol was not within an RN's scope of practice (I am not even certain that Brevital is; last time I saw Brevital used by anesthesia was in the late '80s, and it was used rectally.) She disagreed, politely, with me, but conceded that there was "a fine line" (whatever THAT means.) I told her I would do IV sedation with Fentanyl/Versed but I would not administer Propofol, under any circumstances.

To their credit, they had a really good, up to date, well-stocked crash cart there, and they also have an anesthesiologist who, presumably, would be in the other room doing a general anesthetic while you, "the IV nurse" would be doing the local with sedation case. (Oh, and did I mention that for the "little cases" like blephs and wisdom teeth the "IV nurse" was also the circulator?)

But, still, I'm sorry--I am not going to mess around with a drug that I have no business using, with the idea that it's somehow OK because there is an anesthesiologist doing his own case across the hall. I think their other rationale was that their docs (at least some of them) are double boarded in dentistry and medicine, and that we as ACLS certified RNs are capable (well, I agree with this, but why get to this point?) of slipping in an oral airway and hyperextending the head and/or doing a chin thrust to mask (or bag and mask) a patient should they need oxygenation and airway support. The person interviewing me also mentioned that "the fire department was right around the corner" should a patient arrest and need to be transported to the hospital (which was just a few blocks away.) I don't know if they've had to actually call EMS to respond in a crisis before--I didn't ask. I left there with a really uneasy feeling.

Not only that, but they wanted to offer me only $25 an hour to take on this additional responsibility! I never understand why people think that nurses who work in free standing surgery centers somehow deserve less money than those who work in hospital operating rooms, since we are all held to the same standard of care.

So, a headhunter had referred me to this job--I wasn't actively looking for a job; he found my name somewhere and kept calling me, so I went to check it out, just out of curiosity.) I was going to tell him if they offered it to me that I could not work that cheaply, particularly if IV sedation was part of the job description.

Today the headhunter called me and told me that they thought I "wasn't a good match" because I said I was not comfortable giving IV sedation. I told him that what I had SAID was that I would not give IV Propofol. I guess they use Propofol enough as part of their "IV sedation" that any nurse who is hired there is expected to be comfortable giving it. I'm not.

Sorry for the length of this. Just have to vent a bit--I am actually feeling like I am the one who did something wrong--"not a good match," indeed!! I am going to email the headhunter some literature on Propofol, the AAAAFS statement, and the joint statement issued by anesthesiologists and CRNAs (I am so upset--literally shaking-- right now the initials for your organizations escape me) and the recommendations for using it in free standing surgery centers.

What say you all?

rn29306 · Mar 18, 2005

I say congratulations for standing up for what you believe, regardless of the subject matter, althought we CERTAINLY agree on this. How stupid do they think people are? I'm sure someone will fill this slot, it seems that they want just a number instead of a critically thinking RN who has questionable backup (hey the FD is just around the corner!)

Sometimes you gotta do what you gotta do and I say cheers to you for having the ____________ fortitude for doing what you believe is right.

spaniel · Mar 19, 2005

I know what you mean. Even though you used your "instincts" as well as your sense of ethics, and knowledge, you feel as if you are the one "turned down." Make no mistake about it, you are right. I personally would not have even minor surgery in a surgical "storefront" .

ERCJA · Mar 31, 2005

WE don't use Propofol either.
We use mostly versed, sublimaze, and occasionally (for 1 doc) demerol.

This is a new subject for our ER. We have recently added new ER physicians that are use to giving propofol in their residency program. I have been told by our OR Director that RNs in the State of Indiana are not covered to push Propofol under the Indiana state practice act. Current literature also indicates this is a hot topic among GI Labs/endoscopy centers in different states because some states require nurse anethetists or anethesiology only to administer this med which can also affect reimbursment from insurers. I have been looking for the information in the 40 page Health Professions Bureau for Indiana and have yet to find it and again, most of the articles out there are controversial depending on the state. Does anyone have any links that you are aware of specifically outlining RN requirements/liability for giving this drug? Or any information on how your facility supported the use of propofol administered by RNs in the ED or ICU, especially related to JCAHO standards, which approve conscious sedation in the ED but not deep sedation. Any info would be greatly appreciated.