Propofol

I just don't understand the debate. Ventilated ICU pt - go for it RN. Anyone else, have an anesthesia provider give it. Why any nurse would want to take the risk I just don't know - it seems like common sense. That said - to each his own & Viva la difference!

We use Propofol ALL the time in our MCCU and SICU! We hang it as an IV drip I have never given it IVP though.

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????

We use Propofol ALL the time in our MCCU and SICU! We hang it as an IV drip I have never given it IVP though.

That's different--you have a patient with a protected airway, and RT, intensivists, pulmonologists and anesthesia immediately available. We are talking apples and oranges here.

The subject of this thread surrounds gastroenterology RNs who think it's in their scope of practice to give Diprivan during colonoscopies and gastroscopies in free standing endo labs. They don't have the resources you do, and their patients don't have protected airways. Somehow, they think because they take ACLS every two years, it's OK, because theoretically they can "Rescue" the patient. They also think because they have a doc there--that is a gastoenterologist--he will magically take over.

This logic is flawed, because, first of all, if a nurse takes a patient to a place from which he needs to be "Rescued" then she does not know what she is doing in the first place. I will say it again--this is a drug that has no business being given by ANYONE but an anesthesia provider in any setting in which the patient does not have a protected airway.

Second, do you really believe that most gastroenterologists are capable of running a code? I've worked with surgeons who just stay sterile and step away--if called upon to do CPR, they do it wrong. In an operating room setting, anesthesia runs the code, the circulator is his right hand, giving drugs, starting IVs, defibrillating etc--and the scrub delivers CPR. It's a well choreographed ballet--we have all done it before.

Most importantly, we generally already have a protected airway when a problem occurs. If not, we soon will have a protected airway. That's why we have skilled anesthesia professionals.

In an endo lab, do you think they have those skills? Doubtful. In reality, they will end up calling 911, and pointing fingers. Do you think these gastroenterologists are going to take the blame for a patient with laryngeal edema and cerebral anoxia? Think again.

Second, do you really believe that most gastroenterologists are capable of running a code? I've worked with surgeons who just stay sterile and step away--if called upon to do CPR, they do it wrong. In an operating room setting, anesthesia runs the code, the circulator is his right hand, giving drugs, starting IVs, defibrillating etc--and the scrub delivers CPR. It's a well choreographed ballet--we have all done it before.

Most importantly, we generally already have a protected airway when a problem occurs. If not, we soon will have a protected airway. That's why we have skilled anesthesia professionals.

So now it is not only nurses that shouldn't give prpofol but any Dr other than an anesthesia provider...

How many codes do you guys have in OR??? And why are the anesthesia providers better versed in ACLS? We have a few anesthesia Drs that are the best in the world at codes. We have a couple that will come in and stop everything until they get the pt intubated...even if the pt is in vfib...and then leave.

And you continue to downplay the weekend every 2 year ACLS class. How long have your anesthesia providers been out of school??? Did they take an ACLS course 2 years ago??

The REAL learning starts after class, after graduation...you have to be exposed to these situations on a frequent basis or continue to study or anyone will lose their skills.

I still think there is an underlying cause for all the debate that no one will admit. Turf war, reimbursement, ego, pt safety??? I have seen very little proof from either side that would say it is OK to give or not.

While the package insert is a heavy hitter, stop and read every package insert on every device or drug we give. We might all want to reconsider what we do.

So now it is not only nurses that shouldn't give prpofol but any Dr other than an anesthesia provider...

ABSOLUTELY CORRECT IF THEY CAN'T MANAGE THE AIRWAY - and trust me, most of them can't.

How many codes do you guys have in OR??? And why are the anesthesia providers better versed in ACLS? We have a few anesthesia Drs that are the best in the world at codes. We have a couple that will come in and stop everything until they get the pt intubated...even if the pt is in vfib...and then leave.

And you continue to downplay the weekend every 2 year ACLS class. How long have your anesthesia providers been out of school??? Did they take an ACLS course 2 years ago??

You're not serious are you? We deal with critically ill patients every day. We use the skills and physiology and pharmacology that ACLS only touches on on a DAILY basis.

And guess what? Anesthesia recertifies in ACLS every two years, mainly to keep up with changes in accepted protocols. We do it in a very brief session that lasts less than a couple of hours, testing included. Why? Because the rest of it, we do every day. Duh.

I still think there is an underlying cause for all the debate that no one will admit. Turf war, reimbursement, ego, pt safety??? I have seen very little proof from either side that would say it is OK to give or not.

While the package insert is a heavy hitter, stop and read every package insert on every device or drug we give. We might all want to reconsider what we do.

It's not a turf war. I can't tell you how many gastroenterologists butts I've saved multiple times when they've OD'd their patients on any number of drugs. Propofol is perhaps the most dangerous, because it's too easy to give too much, and too easy to become impatient when it doesn't work as quickly as you think it should. There is no anti-propofol drug. Romazicon and Narcan don't work. If you've OD'd with the propofol and your patient is apneic, and you can't manage the airway, you're screwed.

And yes - you better read the package insert. The attorneys certainly have.

I know that ER and critical care docs all over the world will be glad to hear this. DUH.

I know that ER and critical care docs all over the world will be glad to hear this. DUH.

Puhleeeeeeeeeze.....

I was referring to the GI docs, most of whom CANNOT handle an airway. ER and critical care docs (many of whom are anesthesiologists) certainly can.

God Bless anesthesiologists. Without whom, the world would no longer turn. It does sound like we have gone past pt safety and entered into some sort of turf/ego thing. Sound off any way you need to on the board but stop and take a good look deep inside and make sure pt safety, pt satisfaction and ego are all in their place.

And I travel quite a bit...not met an ER doc yet that was anesthesiologist.

Interesting comment though. A glimpse into certain thought processes that help define your believes.

God Bless anesthesiologists. Without whom, the world would no longer turn. It does sound like we have gone past pt safety and entered into some sort of turf/ego thing. Sound off any way you need to on the board but stop and take a good look deep inside and make sure pt safety, pt satisfaction and ego are all in their place.

And I travel quite a bit...not met an ER doc yet that was anesthesiologist.

Interesting comment though. A glimpse into certain thought processes that help define your believes.

Note that the (many of whom are anesthesiologists) came after the critical care doc reference, not the ER doc.

I'll invite you do the the same - make sure your ego doesn't get in the way of patient safety.

Same reply. NONE of the critical care docs I know have been anesthesia providers.

I wonder if the ISMP or anyone has numbers of deaths r/t all drugs given...Anesthesia may need to give all sedating drugs. I am pretty sure we have needed airway control after versed, mso4, fentanyl...

And we all know that a weekend ACLS class doesn't help anyone at any time.

I'm still waiting on Tbird's response to this forum.........

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