Propofol

[czipp]

I wondered if anyone of you as RN's

use propofol? Only the anesthesia

people are using it. When anesthesia

is used they use propofol. We as Rn's are pushing the Demerol, Versed, Morpheine, Nubain,elc.for conscious sedation. We

are not "allowed " to push propofol or

really any Fentanyl. Is this typical?

Or are we as RN's being overruled or

not allowed to push such drugs..........???

We usually use Demerol and Versed.

but propofol requires a nurse anesthestist or an anesthesiologist.

Is this common????

[gwenith, BSN, RN]

Work in ICU but Aust. There is virtually nothing we cannot administer to a tubed patient and can give anaesthetic agents under medical supervision during intubation. But then our staff set up is completely different to American and the laws are also different.

[LibraSun]

I agree that propofol can cause hypotension, respiratory depression and loss of protective reflexes--as does demerol, fentanyl and versed given in quantities that some GI docs request for 'sedation'. We get unexpected responses from our 'sedation' too, like loss of inhibition when a pt decides he MUST get up off the stretcher during the procedure, or that he should strike out at the people that are 'tying' him down.

Like I said, so long as there are doctors available, RNs are not capable to provide the service, but as soon as there is no money/ reimbursement or no providers, we staff RNs are suddenly highly qualified to do what needs to be done. I expect that in 5 years when the demand by babyboomers overwhelms the supply of endoscopy suites and we need to 'speed up' the turn over, the staff RNs will suddenly be able to provide this service. Why wait?

[EndoRN]

I'd just as soon avoid it as long as possible. Yes, we can get adverse effects from normal IVCS, but those agents can be reversed. There is no reversal agent for propofol other than "tincture of time".

I am ACLS certified and have been in more codes than I cared to be in. But I still don't consider myself in the class of nurse anesthetists, especially when it comes to airway management.

Amy :)

[zambezi, BSN, RN]

The RNs are allowed to sedate with propofol in our CCU, the doc has to be there (this is usually during a bronch/cardoiversion, etc) and dictate how much to push. RT is also in the room managing the airway, crash cart on standby. It is a team effort. We have to pass the hospitals "test" before we are "certified". RNs job is to push, observe vitals and medication response. As a unit we also frequently run propofol gtts on intubated patients.

[Gardengal]

This thread concerns me from a legal and safety standpoint. Propofol is only indicated for intubated patients as an infusion. Bolus dosing may only be given with anesthesia. I do not as a nurse want to risk loss of respirations and an airway because I gave propofol to a non intubated patient-and will not do so despite pressure from some physicians who want to do a procedure. They'll say so and so- does it all the time and why can't i be like that nurse? My response is always -because I only work under my nurse practice act and do not choose to violate that-I then offer to call anesthesia to see when we can get the procedure scheduled appropriately. MDs back down. I then follow up with anyone the MD named and make sure that they understand the safety and legal ramifications of actions if what the MD is saying is true.

Intubated patients having a procedure typically are not considered concious sedation since they have a protected airway. In these patient I still do not bolus with propofo because these are anesthesia doses and not covered under my licensure and nurse practice act. Be careful.

[teeituptom, BSN, RN]

Hi

In the ER here the ED has to present for the administration of all concious sedation. Yes we use propofol great stuff. Yes they are on the monitor and pulse ox and all. Takes all the strain out of reducing dislocated sholders and hips. And they wake up so fast.

Ansthesiologists and CRNAs want to be involved just so they can charge for another patient fee.

[patsue53]

I would rather bag a pt for 1.8 minutes than give an 85 y/o 85 lb lady 125mcg of fent and 5 mg of versed!!!!!! Then have to reverse her!

I think you should review the definition of conscious sedation....or moderate sedation which I believe is the current preferred terminology. All the RN's in our department are required to be ACLS certified in case a patient has an adverse reaction to the medications or procedures. This does not give us license to administer deep sedation or general anesthesia.

Indeed, administration seems to find a loophole to allow RN's to perform tasks and administer medication that was previously prohibited in order to save money and ease budgets. But there state nurse practice acts that prevent them from crossing certain lines. Some states do allow RN's to push Propofol. I think it's a huge mistake. There are nurse anesthesists and anesthesiologists who have received more training and education, who make a heck of alot more money than I do and they should be administering these dangerous drugs, not I.

In 7 years in endoscopy I've only had to bag 2 patients as a result of their sedation......one was a 97 yo bronchoscopy patient who had had 2 of versed and the other was a 76 yo patient who had had 25 demerol and 3 of versed. Reversal agents brought them back in no time. Thank God I had reversal agents to give.

I was at a GI nurses conference on Saturday where this issue was addressed by one of the speakers who happened to be Jo Wheeler-Harbaugh, the current president of the SGNA. She is very much against having RN's in the GI lab push propofol. Our lab follows SGNA guidelines.

Propofol is a great drug. When the anesthesiologists adminsiters it I appreciate its properties.

[robrn]

Librasun, Thanks for your support in the use of

propofol for sedation. I am a nurse that works at the

GI lab you described in southern Oregon. With proper

monitoring (EKG, SAO2, NIBP and ETCO2) Propofol is not

only safe but also very effective. For instance

narcotic using patients (we never see them) need large

amounts of narcotics and benzos just to control the

patient. If we are into an ERCP for 30 to 40 min

nothing is more frustrating then having a patient

twist and turn dislodging the cannula the MD just got

into the duct.

Our administration of propofol is small incremental

doses in which the patient's airway is not compromised

and total comfort is achieved. I can't say that

patients don't desaturate but I haven't noticed a

discernable difference in patients receiving propofol

as compared to Fentynl and Versed. Here we don't just

use propofol, as the MD's that do, must be

credentialed in deep sedation. Some of our MD's are

not, and don't use propofol so I have a pretty good

grasp on the use of both.

If we give our patient instructions prior to the

procedure with Versed there is a retrograde amnesia.

With propofol there is no retrograde amnesia, and as a

bonus the patient is wide-awake about 15 min. after

the last dose of propofol.

In conclusion propofol is safe and effective in the GI

lab setting when used by properly trained RN's, MD's

and well monitored here in southern Oregon we have

administered propofol to about 25,000 patients without

any adverse effects.

I encourage you to visit http://drnaps.org for more

Information about training and Nurse Administered

Propofol Sedation. Thanks again for your support.

sorry I first placed this as a new thread and it isn't.

[Kyli]

We absolutely DO NOT give propofol. Nor do the Gastroenterologists. Only the anaesthetists are supposed to according to our policies.

[athomas91]

i have a unique point of view here...formally an ER nurse who believed anything could be done and be done well by an ER nurse...anything could be handled...

after being in school for only 2 months i can tell you adamantly and 100% that i was wrong...for those of you saying "i will just bag a pt" - that is the absolute hardest thing to do properly! if you have mastered that - you have succeeded to surpass many years of study by others...(i think not)

propofol is a wonderful drug...but it is a dangerous drug as well - and i agree infusion in an already intubated pt is ok...but as a bolus..forget it. it is right up there w/ ketamine and other drugs that nurses feel they can use just because they have once or twice w/o an adverse effect...well...when your patient dies..and as yoga stated- the insert says that it can only be given by an anesthesia provider...then you are screwed.

as for teeituptom who thinks MDA's and CRNA's only want to bill for extra services....you are clueless...it didn't go into this to bill...i went into this field for the learning...and quit being jealous and go yourself if it is too hard for you to understand that.

[athomas91]

what allergies contraindicate administration?

which preparation of this drug will you give based on what ingredients it has?

--there are two preparations you know

what med are you going to give when you see profound hypotension??

what if they are hypotensive and tachycardic?

what if they are hypotensive and bradycardic?

what do you do when the sat drops to 70%?

what if you cannot efficiently bag the pt to maintain sats?

who is going to intubate that pt?

when was the last time they actually intubated? probably in ACLS class

what do you do when they wake up w/ a tube in their throat?

what do you give if they laryngospasm?

if you cannot answer these questions correctly w/o looking it up...you have no business giving this med. i have seen ALL of the above happen in only two months........

[OC_An Khe]

Interesting discussion, wouldn't want to use propofol as described in the preceding posts. It doesn''t provide conscious sedation but rather unconscious sedation or more properly close to TIVA (total intravenous anesthesia) when combined with opoids and the benzo's. Just bagging the patient may not be enough. Respiratory side effects, although the obvious, are not the only potential dangerous side effects of these combination of drugs.

Interesting how pushing the scope of RN practise is OK with the Docs / Hosp Admins when it saves them money and increases their profits; but when it increases the RN/CRNA's income it all of a sudden it moves to its outside the scope of practise for a nurse.

This practise is nothing more than a cost cutting tactic at the expense of the RN giving conscious sedation. If they want the patient unconscioous, no matter how short the duration of the drug, they should have an anesthesia provider do it for patient safety. Are we not advocates for patient safety?