propofol

Specialties Emergency

Published

do ya'll push it fo concious sedation?

So anyway, instead of just repeatedly telling us non-anesthesia people things like "you shouldn't be using this drug....it does things you aren't aware of....you don't even know what you don't know....you'll never get it.....read the package insert", why don't you instead try to have a little more respect for our capability to understand and educate us a little on what it is that we don't know?

In other words, why, specifically, shouldn't we be using the drug?

I know I'm beating a long dead horse, but it appeared that, even though this question had been answered in several different posts, it was never directly addressed. So, here is your answer:

1. Airway issues: ACLS is not the be all end all where airway is concerned. More than one nurse here has expressed the idea "so what if they stop breathing? I can always bag them!" OK, but what if you CAN'T ventilate the patient with a bag and mask? What do you do now? Hope the propofol wears off before the patient suffers an anoxic injury? Try to tube the patient, because after all it wasn't that hard on the dummy in ACLS? Rest assured, intubating a real patient bears only the slightest similarity to intubating a dummy. And yes, there are patients out there that, try as you might, even with an oral airway, you can not ventilate with a mask. In my practice, I have found those same patients can also be difficult intubations. So your ER doc, who does one whole intubation a night (at most) is out of his/her league. Bottom line is that this is NOT a conscious sedation drug, it is a general anesthetic. As such, you must be prepared for the airway issues caused by general anesthetics.

2. Cardiovascular issues: Propofol can have some pretty impressive cardiovascular effects. Therefore, before I ever push the drug to induce anesthesia, I make sure there are certain other drugs readily available (meaning within arms reach). Some of these drugs, like atropine, you probably have in the ED. Others, such as neosynepherine and ephedrine, you probably don't have, and even if you do, you don't know the appropriate doses to give IV push. You are giving a drug but are wholly unprepared to deal with the potential side effects. That alone should cause you a great deal of discomfort.

3. Legal/Liability issues: It doesn't really matter what your hospital policy says. Doesn't really matter what the BON has to say either. Consider the following situation: You give propofol to a 50 year old male with a shoulder dislocation. He stops breathing, so you grab the bag/valve/mask. Uh oh, you can't move any air! While all this has been going on, the monitor takes your patient's pressure, and it's 60/38, with a heart rate of 122. Now what? Your doc rushes to the head of the bed, all the while ordering epi to get the patient's pressure up. He gets out the scope, and can't see a thing. Now, you are in a can't ventilate, can't tube situation, and the tone from the sat monitor is about an octave lower than you started with and falling like a rock. Meanwhile, you have given the epi to get the pressure up, and it works. Unfortunately, the patient also had a previously unknown cardiac problem, and his ST segment is rising rapidly. The situation has rapidly spiraled out of your control, and the patient who came in with a dislocation now has had an MI and possible/probable anoxic brain injury. (Assuming, of course, the patient is still alive.) Guess where you are going? To court. Once there, the plaintiff's attorney provides the package insert to the jury, who are not medical professionals, and points out the paragraph concerning who should be giving the drug. He then points out that your ER doc, who ordered the drug, has no formal training in anesthetics. He also points out that you don't either. You counter "I am ACLS certified, that's good enough!" The attorney then asks you to find and point out in the package insert where it says the drug may be given by any medical professional who is ACLS certified. Of course, you can't. Do you know what your next action will be? The hospital, your ER Doc, and you will all get out your checkbooks, and each of you will sign a check, allowing the plaintiffs to fill in the amount. Its even possible that if you have independent of the hospital, they may tell you you are on your own, because you were administering a drug the manufacturer says you are not qualified to give.

4. In brief, do you think you could walk into an OR and administer general anesthesia? If not, why do you think you can do so in the less controlled, less well prepared ED?

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If not...let's look at changing that little piece of paper.....that if I am not mistaken was written in part by an anesthesiologist. Show me the proof.

The rest of your anti-education post aside, I found this particularly funny. All the various manufacturers of propofol have included the restrictions on administration to satisfy one anesthesiologist who took part in writing it? Even to satisfy the entire ASA? As much as possible, the makers of drugs want as wide as possible use of their drugs. Why? Profits. If they could, they would want propofol to be available to ER's, GI doctor's offices, even family practitioners for short procedural sedation. So, why include such a prohibition? One reason and one reason only. When the situation I described above happens, and the plaintiff tries to sue the manufacturer of the drug as well as the hospital, the ER doc, and YOU, the attorney for the drug company will immediatly petition the judge to be released from liability in the case, and likely as not the petition will be summarily granted. Why? You did not follow the manufacturer's recommendation for safe administration of the drug.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

from institute of safe medication practices nursing newslette, echoes many of pasgasser's points:

ismp nurse advise-err september 2006

propofol sedation: who should administer?

make sure your personal is up to date.

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I know I'm beating a long dead horse, but it appeared that, even though this question had been answered in several different posts, it was never directly addressed. So, here is your answer:

1. Airway issues: ACLS is not the be all end all where airway is concerned. More than one nurse here has expressed the idea "so what if they stop breathing? I can always bag them!" OK, but what if you CAN'T ventilate the patient with a bag and mask? What do you do now? Hope the propofol wears off before the patient suffers an anoxic injury? Try to tube the patient, because after all it wasn't that hard on the dummy in ACLS? Rest assured, intubating a real patient bears only the slightest similarity to intubating a dummy. And yes, there are patients out there that, try as you might, even with an oral airway, you can not ventilate with a mask. In my practice, I have found those same patients can also be difficult intubations. So your ER doc, who does one whole intubation a night (at most) is out of his/her league. Bottom line is that this is NOT a conscious sedation drug, it is a general anesthetic. As such, you must be prepared for the airway issues caused by general anesthetics.

2. Cardiovascular issues: Propofol can have some pretty impressive cardiovascular effects. Therefore, before I ever push the drug to induce anesthesia, I make sure there are certain other drugs readily available (meaning within arms reach). Some of these drugs, like atropine, you probably have in the ED. Others, such as neosynepherine and ephedrine, you probably don't have, and even if you do, you don't know the appropriate doses to give IV push. You are giving a drug but are wholly unprepared to deal with the potential side effects. That alone should cause you a great deal of discomfort.

3. Legal/Liability issues: It doesn't really matter what your hospital policy says. Doesn't really matter what the BON has to say either. Consider the following situation: You give propofol to a 50 year old male with a shoulder dislocation. He stops breathing, so you grab the bag/valve/mask. Uh oh, you can't move any air! While all this has been going on, the monitor takes your patient's pressure, and it's 60/38, with a heart rate of 122. Now what? Your doc rushes to the head of the bed, all the while ordering epi to get the patient's pressure up. He gets out the scope, and can't see a thing. Now, you are in a can't ventilate, can't tube situation, and the tone from the sat monitor is about an octave lower than you started with and falling like a rock. Meanwhile, you have given the epi to get the pressure up, and it works. Unfortunately, the patient also had a previously unknown cardiac problem, and his ST segment is rising rapidly. The situation has rapidly spiraled out of your control, and the patient who came in with a dislocation now has had an MI and possible/probable anoxic brain injury. (Assuming, of course, the patient is still alive.) Guess where you are going? To court. Once there, the plaintiff's attorney provides the package insert to the jury, who are not medical professionals, and points out the paragraph concerning who should be giving the drug. He then points out that your ER doc, who ordered the drug, has no formal training in anesthetics. He also points out that you don't either. You counter "I am ACLS certified, that's good enough!" The attorney then asks you to find and point out in the package insert where it says the drug may be given by any medical professional who is ACLS certified. Of course, you can't. Do you know what your next action will be? The hospital, your ER Doc, and you will all get out your checkbooks, and each of you will sign a check, allowing the plaintiffs to fill in the amount. Its even possible that if you have malpractice insurance independent of the hospital, they may tell you you are on your own, because you were administering a drug the manufacturer says you are not qualified to give.

4. In brief, do you think you could walk into an OR and administer general anesthesia? If not, why do you think you can do so in the less controlled, less well prepared ED?

although i understand your concern, your arguement is insulting to everyone you mention.

first off, if an er physician is not capable of intubation anything that walks in the door, he or she shouldn't be in the er. wouldn't it be a shame now if you took your family member to an er in respiratory distress and the doctor there couldn not intubate them. whether it's 1 a day or 4 a day, they, like you have to be 100% efficient at this skill AND able to handle any difficult airway as well.

it IS the er.

second, i take issue that you truly think er nurses don't know how to administer neo. here's a newsflash, not only do we have it, we have levo as well AND we know how to mix it and how to calculate mics per minute. we also know that no matter what pressors you need, volume is paramount and always the first intervention in hypotension. all the pressors in the world can't get the heart to squeeze output out of the ventricles, if there's none there because of fluid shifts causing leaking out into the ecf.

now take a break with the insults and get back to the point. the er physicians i work with took some kind of medical continuing ed class so that they could use propofol, as well as succs, etomidate etc when needed. they didn't just decide, nor did the hospital, to push it bc it was available. you are correct, it causes serious side effects and the person giving it needs to be properly educated. like anything in health care.

address your concerns with your group and hospitals in a committee that includes ER practitioners... because we use it. pts benefit, and all these drugs are so welcome when the sitation is right.

tridil... who remembers holding people down with security to be tubed.. before these meds.

ps.... with a heart rate of 122, epi is completely containdicated!

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ps.... with a heart rate of 122, epi is completely containdicated!

No, it isn't...consider anaphylaxis, where tachycardia and hypotension are paramount signs. Epi is your first choice drug.

I don't believe the post by passgasser was meant to be demeaning to you at all. Yes, ER physicians can intubate and a lot do, but there are so many out there that depend on the anesthesia departments in house to do this for them. If an ER MD is using Propofol and is not skilled at intubation, they should in no way use this medication without anesthesia backup. The use of pressors is a well known skill of ER nurses, however, how often do you have these "readily available" meaning right at hand when you give Propofol sedation? Anesthesia providers do have these meds "readily available" to treat these problems. Volume is a solution to hypotension, but ephedrine, neo and epi are sometimes necessary along with volume.

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although i understand your concern, your arguement is insulting to everyone you mention.

I apologize, I really don’t mean to be condescending or insulting. However, without even knowing it, your last post highlights exactly what I was trying to say. It also proves what I said in the thread on ketamine. You not only don’t know the drug, you don’t know that you don’t know, and your ego won’t allow you to listen to those with experience with the drug.

first off, if an er physician is not capable of intubation anything that walks in the door, he or she shouldn't be in the er. wouldn't it be a shame now if you took your family member to an er in respiratory distress and the doctor there couldn not intubate them. whether it's 1 a day or 4 a day, they, like you have to be 100% efficient at this skill AND able to handle any difficult airway as well.

it IS the er

There is NO ER physician capable of intubating anything that walks in the door, end of statement. Why? Because there are people out there who cannot be intubated with a laryngoscope. I know, I’ve seen them. And I’ve intubated them, using the bronchoscope, intubating LMA, awake fiberoptic intubation, and retrograde intubation. (How many of those items are readily available on your unit. And do you know how to use them?) And I hate to tell you this, but as a rule I have never found an ER physician as adept at intubation as even a new CRNA graduate or a second year anesthesia resident. Again, that’s not meant as an insult. The discriminator is experience. Earlier in the thread, someone bragged about how good their ER docs were at intubation, they intubated as many as four people a night in their level 1 ER. Four for the whole unit. Guess what? Most anesthesia providers do that many or more intubations every day. Airway management is only part of the problem. Again, since you are one of the strongest advocates of RN administration of propofol, what do YOU do when you get into the "can’t ventilate, can’t intubate" situation. I’ve been there, and been able to solve the problem with no harm to the patient. I can only assume that your overactive self assuredness means you've never been there.

second, i take issue that you truly think er nurses don't know how to administer neo. here's a newsflash, not only do we have it, we have levo as well AND we know how to mix it and how to calculate mics per minute. we also know that no matter what pressors you need, volume is paramount and always the first intervention in hypotension. all the pressors in the world can't get the heart to squeeze output out of the ventricles, if there's none there because of fluid shifts causing leaking out into the ecf.

Here's a newsflash. I wasn't talking about starting a neo gtt. The patient I described doesn’t have time for you to go get the neo drip, prime the IV tubing, hang it and wait for it to work. He needs intervention, right now. Neither does he have time (nor does he really need) for you to compensate for the vascular dilation with a fluid bolus. He needs appropriate intervention, right now. As a CRNA, I am used to giving propofol, and used to what it can do. Therefore, before I give it, I have neosynepherine, in a syringe, at the right concentration to be able to give as an IV push dose. I am ready to intervene, before a problem becomes a crisis. It’s not in the next room, not out on the crash cart, not in the form of a drip. And a drop in BP like I described is not due to fluid shifts. It is simply a reflection of a loss of vascular tone. Immediate intervention, with the right pressor, and fluid shifts don’t even come into play. Of course, if the patient can’t tolerate that BP for long owing to a previously unidentified cardiac condition, and has a big MI waiting for the neo gtt, then that might become a whole different issue.

now take a break with the insults and get back to the point. the er physicians i work with took some kind of medical continuing ed class so that they could use propofol, as well as succs, etomidate etc when needed. they didn't just decide, nor did the hospital, to push it bc it was available. you are correct, it causes serious side effects and the person giving it needs to be properly educated. like anything in health care.

Again, no insults intended. But really. A whole continuing ed class, huh? I have a master’s degree in the specialty, and I have more humility before these drugs than what you describe. I’m not afraid of them, I just think I have more respect for them and what they can do than you do. That probably is a function of experience.

ps.... with a heart rate of 122, epi is completely containdicated!

Um, yeah I know that (generally). That was my point. But what else do you have on your crash cart or in your unit that you can give, IV push, to immediately solve this patient’s hypotension? I have the drug in my kit, ready to go, that will do that and will most likely concurrently solve his tachycardia.

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One other point needs to be made. When you administer an anesthetic agent, such as etomidate, propofol, brevital, or ketamine, you are performing anesthesia. In court, your actions will be judged on whether or not you met the standard of care. But not the standard of care as an RN. If you choose to administer anesthesia, you will be expected to meet the same standard of care that any CRNA, AA, or MDA must meet. Are you prepared to say you can meet that standard of care?

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No, it isn't...consider anaphylaxis, where tachycardia and hypotension are paramount signs. Epi is your first choice drug.

I don't believe the post by passgasser was meant to be demeaning to you at all. Yes, ER physicians can intubate and a lot do, but there are so many out there that depend on the anesthesia departments in house to do this for them. If an ER MD is using Propofol and is not skilled at intubation, they should in no way use this medication without anesthesia backup. The use of pressors is a well known skill of ER nurses, however, how often do you have these "readily available" meaning right at hand when you give Propofol sedation? Anesthesia providers do have these meds "readily available" to treat these problems. Volume is a solution to hypotension, but ephedrine, neo and epi are sometimes necessary along with volume.

in anaphylaxis, antihitamines, steroids and fluids, as well as inhaled bronchodilators, are used.

if epi is administered, it is given subq and in the 1:1,000 concentration to aid in bronchodialation early on....mostly in the form of an epi pen, or by the medics. it is the last thing you want to use for hypotension iv. additionaly, we keep an eye on the mean bp and try not to overeact to the systolic going down.

it's nothing to throw 5 liters of saline in a pt with anaphylaxis. there's a lot of concern with throwing vasopressors at anaphylaxis and stressing out the heart more than it already is. induced tachyarrythmias are hard to resolve once brought on in these such cases.

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There is NO ER physician capable of intubating anything that walks in the door, end of statement. Why? Because there are people out there who cannot be intubated with a laryngoscope. I know, I’ve seen them. And I’ve intubated them, using the bronchoscope, intubating LMA, awake fiberoptic intubation, and retrograde intubation. (How many of those items are readily available on your unit. And do you know how to use them?) And I hate to tell you this, but as a rule I have never found an ER physician as adept at intubation as even a new CRNA graduate or a second year anesthesia resident. Again, that’s not meant as an insult. The discriminator is experience. Earlier in the thread, someone bragged about how good their ER docs were at intubation, they intubated as many as four people a night in their level 1 ER. Four for the whole unit. Guess what? Most anesthesia providers do that many or more intubations every day. Airway management is only part of the problem. Again, since you are one of the strongest advocates of RN administration of propofol, what do YOU do when you get into the "can’t ventilate, can’t intubate" situation. I’ve been there, and been able to solve the problem with no harm to the patient. I can only assume that your overactive self assuredness means you've never been there.

you really think that in the er we haven't had to use lmas etc??? do you think that now medics should also just move over bc they too aren't as able to intubate as well as you? if you haven't seen an er doc who can tube better than a new crna, then i am not sure what kind of ers you have in your area?!! the most difficult airways are traumas!!!!

Here's a newsflash. I wasn't talking about starting a neo gtt. The patient I described doesn’t have time for you to go get the neo drip, prime the IV tubing, hang it and wait for it to work. He needs intervention, right now. Neither does he have time (nor does he really need) for you to compensate for the vascular dilation with a fluid bolus. He needs appropriate intervention, right now. As a CRNA, I am used to giving propofol, and used to what it can do. Therefore, before I give it, I have neosynepherine, in a syringe, at the right concentration to be able to give as an IV push dose. I am ready to intervene, before a problem becomes a crisis. It’s not in the next room, not out on the crash cart, not in the form of a drip. And a drop in BP like I described is not due to fluid shifts. It is simply a reflection of a loss of vascular tone. Immediate intervention, with the right pressor, and fluid shifts don’t even come into play. Of course, if the patient can’t tolerate that BP for long owing to a previously unidentified cardiac condition, and has a big MI waiting for the neo gtt, then that might become a whole different issue.

what if the pt iwas allergic to eggs and you didn't know that? do you have solumedrol and and benadryl also drawn up every time you use propofol? don't you waste a ton of meds, having them all drawn up out of their vials etc every time you give something?

Again, no insults intended. But really. A whole continuing ed class, huh? I have a master’s degree in the specialty, and I have more humility before these drugs than what you describe. I’m not afraid of them, I just think I have more respect for them and what they can do than you do. That probably is a function of experience.

and these board cert er docs went to medical school! to do er they also had to do 4 years of residency. i am not sure of the certification course they attended a few years back, but like anything else, they took the time to make sure they learned about these meds.

Um, yeah I know that (generally). That was my point. But what else do you have on your crash cart or in your unit that you can give, IV push, to immediately solve this patient’s hypotension? I have the drug in my kit, ready to go, that will do that and will most likely concurrently solve his tachycardia.

we have a kit too. and i have never seen a board certified er doc or an intensivist in 20 years put pressors before fluids. see my post above about tachyarrythmias etc. you would really do that? push neo directly for a sbp in the 60s and a heart rate of 122? do you worry about throwing the pt into svt of 160 or so? do you have adenosine ready in 3 syringes? 6/6/12? do you wonder about inducing v tach? do you compare the mean to your baseline?? now you've got bigger problems!!!

i expect my docs to know their stuff and if they don't i let them know about it!

i am soooo pronursing that i can't believe i am defending them in this post. but please don't put other professions down so that us nurses can get ahead. it's pointless and only causes friction. every practitioner brings something to the table.

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in anaphylaxis, antihitamines, steroids and fluids, as well as inhaled bronchodilators, are used.

if epi is administered, it is given subq and in the 1:1,000 concentration to aid in bronchodialation early on....mostly in the form of an epi pen, or by the medics. it is the last thing you want to use for hypotension iv. additionaly, we keep an eye on the mean bp and try not to overeact to the systolic going down.

it's nothing to throw 5 liters of saline in a pt with anaphylaxis. there's a lot of concern with throwing vasopressors at anaphylaxis and stressing out the heart more than it already is. induced tachyarrythmias are hard to resolve once brought on in these such cases.

When I treat true anaphylaxis(with shock)...Epinephrine is the first drug that should be given. Above and beyond the anti-histamines/steroids etc... and it is given IVP with a start dose of at least 100mcg of a 1:10,000 solution titrating to effect, thereby avoiding the "induced tachyarrythmias that are hard to resolve." It is not the "last thing you want to use for hypotension iv" it's the first thing in the above scenerio. You can also administer it IM ususally starting at 500mcg of a 1:1,000 solution. Epi, fluids, antihystamines, steroids is the best order to treat anaphylaxis and if you've got a lot of hands...this can be done at the same time. Epi pens can be of questionable effect especially if your MAP is very low and you've shunted blood from your periphery to your central circ thereby not allowing the epi to be distributed. Early on, Epi-pens are of great use.

respectfully

skipaway

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When I treat true anaphylaxis(with shock)...Epinephrine is the first drug that should be given. Above and beyond the anti-histamines/steroids etc... and it is given IVP with a start dose of at least 100mcg of a 1:10,000 solution titrating to effect, thereby avoiding the "induced tachyarrythmias that are hard to resolve." It is not the "last thing you want to use for hypotension iv" it's the first thing in the above scenerio. You can also administer it IM ususally starting at 500mcg of a 1:1,000 solution. Epi, fluids, antihystamines, steroids is the best order to treat anaphylaxis and if you've got a lot of hands...this can be done at the same time. Epi pens can be of questionable effect especially if your MAP is very low and you've shunted blood from your periphery to your central circ thereby not allowing the epi to be distributed. Early on, Epi-pens are of great use.

respectfully

skipaway

you give iv epi first? for what exact reason, hypotension or brochospasm? is there any reference i could use to bring to my practice/education department? i have always known epi iv to be reserved for cardiovascular collapse.

subq and im yes. but in the er the pts usually present after this has been given by medics oframily.

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Specializes in ER.
So your ER doc, who does one whole intubation a night (at most) is out of his/her league. Bottom line is that this is NOT a conscious sedation drug, it is a general anesthetic.

See this is where I get stuck. The ER docs are expected to intubate, and consider themselves competent to do so- and so does the hospital. I agree with you that an ER doc that is in the middle of some procedure is not going to be timely in putting down a tube, they,and the hospital, feel that solong as someone is in the room who could intubate, then the patient is safe.

Unfortunately I get stuck with a doc who chafes at the time it takes for me to set up bag/mask/suction/ reversing agents at the bedside and attach pt to moniters. Some don't even want to move out of the small examining rooms, feeling that they are the best judge of safety- not me. They certainly have more letters behind their names, but I really feel sometimes that I might be better prepared than the doc for complications. And that is REALLY putting the patient at risk.

Please keep answering these questions, because for every RN that is countering your arguments their is one like me who is listening and mentally making a list so I can defend my decision not to give propofol/etomidate when we are not doing a crash intubation.

Another question for CRNAs;

My ER docs choose to intubate someone emergently and only sedate without paralyzing in case they can't get the tube in and then the pt will still breathe if they are unsuccessful. I notice the patient still has lots of muscle tension that interferes with successful visualization of cords, and we have only about a 10% success rate with intubations based on the ones I have observed. In previous hospitals we would sedate AND paralyze, and got about a 90% success rate.

I conclude that 1) our docs are not dependable at intubations if we need one fast, so I should keep that in mind during concious sedations, and 2) encouraging use of paralytics might be beneficial for our patients. Am I correct, and if so are there any articles backing up the use of paralytics that you could refer me to?

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