Propofol

I am all for pt safety. There are things that happen in every hospital in the country ( even those with Gonzo nurse consultants) that put the pt at risk. Nurses must decide with seconds to think about it, should I or shouldn't I. Sometimes we choose correctly sometimes we don't.

Personally I am undecided about diprivan, dream cream, milk of amnesia...What I do know is that are pts in Endo love it. I try to have an open mind about these things. The physician (who last time I checked has more training than nurse consultants and CRNAs) seem to think it is OK.

Last year we administered ~3000 doses of propofol and ~4000 of versed. Primarily in endo, some in cath lab, rad, er...

Would anyone like to guess what the complication rate was????

i just don't understand why you'd take on the extra headaches and liability--with no extra compensation. and, believe me, there is huge potential liability for you.

i am an operating room nurse and a legal nurse consultant. i, too, have very strong feelings on the issue of nurse administered propofol, and they are, in part, that propofol should not be given, by a nurse, to a non-intubated patient!!!!!!!! ever!!!!

there are nurses perfectly cabable of administering propofol, yes. they are called crnas.

i live in oregon. i will be waiting for the day when i see the medford facility called on the carpet for unsafe patient care practices, and i will be volunteering my services as a behind the scenes consultant--or as an or nurse expert--or assisting with expert location--to any attorney who wants to put a stop to this dangerous practice and shut your facility down.

in fact, maybe i can be the one to make a few calls and speed up the process.

i am really tired of "gonzo" nurses who don't know what they don't know, and think it makes them look important to do an anesthesia provider's job. if you are not capable of delivering one level higher than deep sedation--that is, general anesthesia; skilled intubation and all--then you should not be delivering deep sedation. i don't even think you should be delivering moderate sedation. that's an anesthesia provider's job.

i get tired, also, of hearing about your capability to "rescue." yeah, yeah, we're all (operating room nurses)acls certified; nothing special about that. but you guys in endo labs seem to think that as long as you can deliver--or think you can deliver; based on what you learned in classes-- acls, it almost makes it ok to take unnecessary risks.

why get a patient to a point where he needs to be "rescued?" the fact that he ends up there in the first place shows that you had no business doing what you did that got him there!!!!!!!

ususally "rescue" means that you have to call on someone--i.e., an er doc, who has to drop what he is doing and come to your "rescue" by intubating the patient for you and dealing with all the unnecessary problems that have been created--i.e., a period of anoxia or hypotension or both.

you've had no adverse effects to date? famous last words....many a nurse who gave propofol in a plastic surgery clinic has used that phrase--and maybe she didn't have any "adverse effects," by sheer luck or the grace of god--until the day she did, and her facelift patient died...

do you think the gonzo nurses are the ones ordering these meds? what i am sick and tired of are nurse consultants who think they know everything about medicine when you are just a nurse. why not let the crnas take care of propofol issues in court. why are qualified as an expert when you just stated no nurse should have anything to do with it?

try tackling the drs who order these things be given. and don't start with"the nurse always has the right to tefuse to carry out an order" crap. i understand that.

our endo lab has no gonzo nurses and no nurse consultants that think they hung the moon. i monitor all conscious sedation cases and have seen fewer rescue case in that dept that radiology that only uses versed, op surgery that will use versed...

get off your high horse, look at the numbers. is the drug really safe but you have a few idiots out there that don't know how to use it???

inapsine also caused quite a stir years ago. adjunct to general anesthesia...whoa...maybe crnas should give that.

i do not like your threat to make a few calls to speed the process along. if you want to respond privately to my e-mail i will be happy to give you our info. welcome the challenge. our chief of staff had the board of nursing change their stance on cs several years ago to include lpns. bring it on.

gonzo.

ummmm....i am an operating room nurse... with over 25 years of experience. i do travel assignments in operating rooms all over the west coast, in major teaching hospitals and trauma centers, and i scrub and circulate all specialties. i have a fair grasp of the way things are done elsewhere. you?

what you are doing is not conscious sedation--it is moderate or deep sedation--something only an anesthesia provider should be doing. i would only testify to nursing soc--that is, to what a reasonable and prudent nurse is allowed to do--and that does not include moderate or deep sedation.

and, oh, trust me--any crna or anesthesiologist would be more than willing to testify that what you are doing does not constitute safe patient care--that only an anesthesia provider should be administering propofol.

and, i know more than one gastroenterologist expert who does not feel that propofol is even the appropriate sedation of choice for colonoscopy. most people go with fentanyl and versed, and truly conscious sedation. they want their patient to be alert enough to let them know if--and where--and the nature of--any pain or discomfort, so that they can intervene accordingly. in other words, they want the patient to be an active participant in the procedure.

this is what i feel perfectly comfortable testifying to in court--the fact that you are overstepping your bounds. you are stepping outside the parameters of what is permitted of a registered nurse. if you are from the southern oregon facility, read the oregon nurse practice act!!! if you are from somewhere else, read your own state's nurse practice act!

does the joint statement put out by the american association of nurse anesthetists and the american society of anesthesiologists denouncing your practice mean nothing to you? what about the one put out by aaaafs? how do you think a jury would react to both those statements, blown up about 500x?

argue about semantics and terminology to call it whatever you want, but the bottom line is, no rn should be administering propofol to a non-intubated patient. ever.

in fact, i won't even give conscious sedation---not even "just fentanyl and versed." they don't pay me enough to do an anesthesia provider's job, and, truthfully, i think every patient deserves an anesthesia provider gving his anesthesia. i know my limits--i am only an operating room nurse. i know what i don't know.

you have lpns giving conscious sedation? lpns are not even allowed to carry out patient assessment!! how can they give conscious sedation, if they cannot continually assess the patient?

you still have not told me why you choose to do an anesthesia provider's job for a nurse's salary. is it the "prestige" you enjoy, that makes it all worthwhile?

oh, and inapsine? most reasonable and prudent practitioners across the country have all but abandoned its use. zofran and even decadron are being utilized to combat post-op nausea--and in some places compazine is making a comeback. there are those diehards who insist on using iv phenergan, but more and more reasonable and prudent nurses are reluctant to give that particular drug iv, due to the effect of its ph on peripheral veins, and just saying "no" to giving it via peripheral iv. i absolutely will not give phenergan through anything but a picc, ej, or ij--regardless of who says it's "ok" or who orders it.

there are many of us out there that don't do things simply because a doctor or a nurse supervisor tells us to. we think for ourselves, and we function, always, in our primary role--that of patient advocate.

In the Endoscopy center I now work in RN's cannot push propofol or fentanyl. However when I work in the ED. I do it all the time. We give it for pt's placed on vents and use it for conscious sedation. I've given fentanyl to assist with placing chest tubes. These drugs are just that drugs, all have risks and benefits and side effects. If you are familiar and comfortable in giving the drug there's no problem. I love our CRNA's that work with us. But I didn't need another two years to learn conscious sedation. Having said that, I wouldn't step into an OR and do the same thing because I don't have experience using the drugs over a long period of time, greater than 4 hours or so that I might have to hold a vented pt in the ED while they scramble to make room for them in unit.

In the Endoscopy center I now work in RN's cannot push propofol or fentanyl. However when I work in the ED. I do it all the time. We give it for pt's placed on vents and use it for conscious sedation. I've given fentanyl to assist with placing chest tubes. These drugs are just that drugs, all have risks and benefits and side effects. If you are familiar and comfortable in giving the drug there's no problem. I love our CRNA's that work with us. But I didn't need another two years to learn conscious sedation. Having said that, I wouldn't step into an OR and do the same thing because I don't have experience using the drugs over a long period of time, greater than 4 hours or so that I might have to hold a vented pt in the ED while they scramble to make room for them in unit.

I'll say it again--there is a HUGE difference in giving Propofol to an airway protected (trach'd or vented) patient than to one with an unprotected airway.

In an ICU setting or an ER or OR setting where the patient is on a ventilator, and anesthesia and RT immediately available, and the proper syringe pump--MADE for giving Diprivan-- available--that's appropriate. The patients' airways are protected.

In a gastroenterology lab in patients with unprotected airways and giving Propofol IV push, it's inappropriate.

Simple as that. They can rationalize it all they want. It's dangerous patient care.

Medic,

Your lack of knowledge of pharmacology is frightening. A drug is not just a drug. I studied pharmacology at a medical school as part of my anesthesia degree. Until you understand pharmacokinetics, metabolic pathways of drug elimination, drug interactions, synergistic and additive effects, you should not feel that you know everything there is to know about a drug.

You are correct, you don't need two years of education to do conscious sedation; but you do for administering UNCONSCIOUS sedation. There is a very narrow margin between the two.

In my opinion, the best professionals know their limitations. It's the "cowboys" who get into trouble.

Yoga CRNA

It never ceases to amaze me what 2 more years of education does for some people. Yoga needs to realize setting in class is not the only way to learn good pt care. I know some MDs that spent more than 2 years in class that I wouldn't take my neighbors dog to.

Sometimes it is the "cowboys" that are out there saving lives while others discuss who has the best education.

Did it ever occur to you that the best clinicians are the ones who use "book education" as a basis for clinical practice. Not only do I know how to do things, I know WHY and the scientific basis for what I do. The two are not inconsistent--they are the ideal.

The internationally renown plastic surgeon with whom I work, does not do one thing to the patient without a rationale based on anatomy, physiology and pathology. On top of that he is a supurb technician. Today we did a facelift on the father of a plastic surgeon. His son would only send him to my surgeon. By the way, I wouldn't be working there if I wasn't both good and knowledgable. For example, this patient also has a history of atypical pseudocholinesterase; a real anesthesia nightmare. My "book" training helped me know what to do.

What you fail to understand is the difference between a professional and a technician. I am proud to call myself a professional.

Yoga

Kudos to you Yoga for being the only person in the medical profession intelligent enough to do anything. I also work with RNs who think the LPN should only do bedbaths and bedpans. I think it has something to do with job security.

My, my, why all of the hostility? Could it be that I have hit a few raw nerves? I don't need job security, I am doing well. I also promote very vigorously the nursing profession and have great respect for my nursing friends. I am simply looking at what is best for the patient. What are your motives?

Yoga CRNA

No hostility here (I don't think). I have seen situations in ER where we have several RN,CCEMT-P working. A patient comes, difficult intubation, facial trauma...anesthesia is called, can't get the tube in. Critical care paramedic is mentioned. People who have lived and breathed this sort of thing and told they were not "qualified" and if a Dr couldn't do it, what made them think they could. I have been in the same ER with a different DR in charge that would allow help. Things went very well.

I saw an LPN under a DR direct supervision make an incision for a PEG tube. I hit the roof. Stupidest thing I had ever seen, certainly not in her scope of practice. The DR told her exactly where, when, how... she had seen it done hundreds of times. Dr was holding the scope...Guess what, the patient did fine.

No I don't want an LPN cutting on me but if the DR is there, guiding every move, much like they are when the RN pushes Diprivan, it will be OK.

Do I want the RN in a rural clinic with a PA pushing Diprivan. No.

I just hate to see people with such a closed view. When I started in ICU the only person to even touch a Swan Ganz was the DR. He did COs, wedges...never dreamed a nurse would be able to DC one. After a couple of years...call a DR to do one of thise procedures and see the *** chewing...

When I started in ICU the only person to even touch a Swan Ganz was the DR. He did COs, wedges...never dreamed a nurse would be able to DC one. After a couple of years...call a DR to do one of thise procedures and see the *** chewing...

When and where in heaven's name did you work ICU that only an MD could wedge a PA line or get a cardiac output from one? Even in the very early '80s, when I was a new RN, that was a NURSING function. I can remember obtaining cardiac outputs using iced NS; it's been that long...

Sounds like the ICU where you worked either did not TRUST the nusing staff or you did not have much autonomy....or both...

first of all, conscious sedation is a term of the past. moderate sedation is the politically correct term.

fentanyl chest rigidity occurs usually when the doses aren't spaced out or too large of a dose is given. when our gastroenterologist first started using fentanyl, they wanted the relaxation to take place as fast as it did with the use of demerol. having worked in the operating room for 10 1/2 years before coming to endoscopy, i knew this. the docs would push for me to give more, he's not relaxed, etc. but i would say give it time. after several nurses caved under pressure and had to bag with no help (chest rigidity) and then reverse the patients with thank god, nothing horrible having happened to the patient, the docs now listen. it's all about education and being a patient advocate. i space my fentanyl doses about 3-5 minutes a part and never push more than 50mcg at a time. after i reach 150mcg, i go to 25mcg. the use of fentanyl in combination with versed makes the drug even more dangerous. i rarely give more than 5 mg of versed total for an endoscopy. i am thankful for the knowledge i gained from the anesthesiologist in the o.r. and i have respect for all narcotics, benzos, and anesthetic drugs.

i now work with the veteran population and anybody in healthcare knows that veteran patient's are walking train wrecks for the most part. they take tons of antidepressants, antipsychotics, narcotics, benzos, seizure meds. we have to be extremely careful about avoiding reversal. we have less than 1 reversal a month due to the docs having respect for the nurses and the nurses having respect for the drugs. i am the ultimate patient advocate and a great thing about working in the vamc is that the docs are employees too. we have atropine, ephedrine, neosynepherine, epinephrine readily available. there are oral airways, laryngoscopes w/blades, nasal airways, an ambu bag on our cart. fortunately, our physicians are trained well in intubation and (knock on wood), we haven't had to intubate anybody ever. bottom line: there are those who know their limits and those that push them which is the fine line between moderate sedation and general anesthesia.

bringing the use of diprivan to our unit would be suicide for the staff and the patients. not to mention the immediate side effects that occur, the lipid content itself would be contraindicated in most of our patients.

if we are unable to achieve adequate safe sedation to perform the test, our docs recommend a colonoscopy with general anesthesia in the operating room.

and some nurses want to give propofol just so they can prove what "nursing studs" they are, regardless the risk they are taking with their patients. this is a stupid argument. if this poster had half as much knowledge as he has bravado (and that bravado is at the expense of patient safety), he'd never give anesthetic medications.

the truth is that i am paid a salary, and i work for the hospital. we have no anesthesiologists. we do anywhere from 10 to 30 endoscopies a week, and the sedation for them is administered either by myself or the other crna at the hospital. i get paid the same amount whether anesthesia does the "conscious" sedation or not. at our hospital, anesthesia providers exclusively administer the propofol, as well as fentanyl, ketamine, and a number of other anesthetic agents. not because we get paid more, not because we can bill more for the service, but because we put patient safety first.

i was frankly shocked at some of you who said "i can give propofol safely, because i am acls certified." guess what? i give propofol daily, several times a day, and my justification isn't that i'm safe because i know acls. in fact, if i need acls after administering propofol, then i made a big mistake.

are you all aware that propofol can cause a dangerous drop in blood pressure? if you are, what medications do you have available that can treat that side effect? because there are patients for whom a drop in bp can be lethal in a matter of minutes. or that it can induce apnea? what will you do when you cause a patient to be apnic, and you can't ventilate them? yes, that happens, and you better be ready to intubate them. the catch is that if you cannot ventilate someone with a bag/mask, they will probably be a difficult intubation. and i don't care how many dummies you have intubated at acls class, intubating a living human being is a completely different experience.

what are you going to do when you give someone 100 mcg of fentanyl, and induce chest rigidity? look it up, it happens. the chest becomes so rigid that no amount of force on a bag will put air into the patient's lungs. when it happens, about your only option is to paralyze the patient and intubate them. when you give fentanyl, do you have a paralytic handy?

i really am not trying to belittle anyone. i simply want to get across that these drugs, for all the talk of short half lives and rapid emergence, have the ability to bite you, and bite you hard when you least expect it. and if you aren't prepared for this eventuality, the patient is likely going to die, notwithstanding your expertise in acls. crna's and anesthesiologists face these effects every day, and we are prepared for them. how many of you have atropine, ephedrine, neosynepherine, and succinylcholine readily available (i.e. drawn up and on the cart) when you administer these drugs? i do, every time. it isn't cheaper, but it's safer for the patient. if you have these drugs, do you know the appropriate dose for your patient?

the point is that when an anesthesia provider says that only people trained in anesthesia should administer anesthetic medications, it isn't out of a desire to enrich ourselves. it's out of a desire to see that patients are cared for safely. and if the endoscopist wants to proceed, having an rn, who is very good but not trained in anesthesia, administer deep sedation, who is really trying to make as much money as possible?

kevin mchugh, crna