propofol

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do ya'll push it fo concious sedation?

Hmm, interesting. The juxtaposition of two comments from the same poster:

"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."

"you really think that in the er we haven't had to use lmas etc???"

So, I’m left wondering. If you have had to use LMA’s, "etc," you have physicians who can’t intubate anything that "walks in the door?" Why on earth are you allowing them to practice in your ER?

My point is simple. I am not trying to belittle the education or experience of ER physicians. Neither am I trying to knock ER nurses (I was one, at a level one trauma center). As an ER nurse, we used to call anesthesia in for ALL level one traumas. Called them for a LOT of medical intubations, too. Why? Even the ER physicians, who were generally competent at intubation, knew when to push their ego aside and allow the experts do what they do. I do not have the med school that your ER docs have. But I guarantee you, I have 100 times the experience they (or you) have with drugs like ketamine, propofol, and etomidate. In one day, I’ll do more intubations before lunch than most ER physicians do in a week.

Look at it another way. Suppose you need a lumbar laminectomy. You have a choice between two surgeons. One is an orthopod who did a fellowship in spine surgery, and does 6 or 8 lamis a week. The other is a general ortho, who learned everything he knows about spine surgery in his residency, and only does 6 to 8 lamis a month. Both are board certified. Which physician would you choose to do your surgery?

And, there are other issues we have not yet even raised. What about cricoid pressure? Do you even know what it is, or why it is done? And do you do it for EVERY patient that must be intubated in your ER? I guarantee you would if anesthesia were involved in the intubation. (One for you to go look up.) You say you have used LMA’s. Great, but on a patient being intubated in the ER, when the LMA is in and working, you can’t wipe your brow and say "whew, good save." You STILL have to secure the airway by getting an ET tube in. Now what?

All that, though, is beside the main point, which is the drugs used for general anesthesia. There is a reason why anesthesia providers, almost universally, say they should only be given by folks experienced in anesthesia. These drugs have a nasty habit of biting back. Even propofol. What’s worse, you may have 10, or 100, or 1000 cases where you give the drug with no problem. Will you take comfort in that when the 17 year old athlete with the dislocated shoulder dies because that’s when the drug does something you’ve never seen before, and were not prepared for?

Again, I ask you my main question, and tridil, I’d really like it if you would answer this: Do you think YOU are competent to provide a general anesthetic in the operating room? If not, why do you claim you are competent to do so in the less well-controlled environs of the ER?

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Canoehead

You wrote:

"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."

My point really has not been whether or not the doc could intubate the patient, though it seems as though that is direction this discussion has been dragged. My point is that each of these drugs has effects beyond simply rendering the patient unconscious. In anesthesia, by weight of the sheer number of times we use these drugs, we have seen what they are capable of, and have drugs to remedy these situations at hand. Using the example I gave earlier, let’s assume the ER doc is able to quickly and competently intubate that 50 year old patient. Unfortunately, the patient still is very hypotensive, and if that is not corrected right now, the patient will be a very well oxygenated corpse.

As to your doc who chafes, let him. You are doing the minimum number of things that MUST be done before administration of general anesthetic agents. I have a routine I follow before EVERY case. That routine includes drawing up the appropriate drugs for the case, checking the anesthesia machine out, checking the laryngoscope, and ensuring I have at least two different kinds of blades readily available, and making sure that the suction and monitors are working. Until these tasks are done, we don’t even bring the patient into the room. And no general anesthetic agents are given to the patient until the monitors are hooked up and I have a baseline set of vitals. That’s just normal prudence. So hang in there with what you are doing, and don’t let an impatient doc (who probably doesn’t even know what he doesn’t know) make you do things against your better judgement.

"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 often get called to our ER and our ICU for urgent and emergent intubations. Any anesthesia provider will tell you this is the highest anxiety intubation we do. We consider these to be far less well controlled environments, and as such, we respect them. Generally in such cases, I don’t give a paralytic. If time and the situation permits, I will spray the patient’s oropharynx one to three times with cetecaine, then I will give some versed (usually around 5 mg). Then I intubate. The literature actually supports what your docs are doing. However, I always have succs with me, though it is very rarely used.

"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?"

Your first conclusion is both safe and correct. No one, not even 30 year anesthesiologists, are 100% dependable at intubation. As I said, there are patients out there who simply cannot be intubated with a laryngoscope. Always keep that in mind. However, as I said, the your docs are probably doing the safest thing for your patients by not giving paralytics. It prevents that moment of horror when you realize you can neither ventilate or intubate the patient who is going to be paralyzed for the next seven minutes.

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And, for those who think they can give these drugs safely, let me pose a question.

Suppose your ER doc ordered you to give a patient a potent chemotherapeutic drug, would you do so? I submit you probably would not. Unless you have worked on an oncology floor, you are not qualified to give those agents, and your doc is not an oncologist, and therefore not really qualified to order them.

Anesthesia drugs are every bit as potent as chemotherapy drugs, and can kill a patient just as quickly, maybe even more quickly. Why do you assume that being an ER RN qualifies you to do anesthesia, if it doesn't qualify you to do chemotherapy?

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And, there are other issues we have not yet even raised. What about cricoid pressure? Do you even know what it is, or why it is done?

YES!!! any er nurse should!!!!!!!!!!!!

And do you do it for EVERY patient that must be intubated in your ER?

about 90% require it.

I guarantee you would if anesthesia were involved in the intubation. (One for you to go look up.) You say you have used LMA's. Great, but on a patient being intubated in the ER, when the LMA is in and working, you can't wipe your brow and say "whew, good save." You STILL have to secure the airway by getting an ET tube in. Now what?

with propofol, it's short acting and the lma can stay in for hours. our crnas want to change them over as primary airways for sds.

All that, though, is beside the main point, which is the drugs used for general anesthesia. There is a reason why anesthesia providers, almost universally, say they should only be given by folks experienced in anesthesia. These drugs have a nasty habit of biting back. Even propofol. What's worse, you may have 10, or 100, or 1000 cases where you give the drug with no problem. Will you take comfort in that when the 17 year old athlete with the dislocated shoulder dies because that's when the drug does something you've never seen before, and were not prepared for?

Again, I ask you my main question, and tridil, I'd really like it if you would answer this: Do you think YOU are competent to provide a general anesthetic in the operating room? If not, why do you claim you are competent to do so in the less well-controlled environs of the ER?

i would only give it as an a 'helping hand to you' so to speak. if you, or anyone else who was proficcient at intubation was there prepared to intubate, and the pt was on the monitor, with fluids gong etc and the reverse agents and crash cart were right there at my our side.

be assured, unlike canoehead, we use it, but take it seriously and the situation IS treated like a sds procedure you might see in or.

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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?

canoehead! i can not believe what i am reading! now i see the picture and agree that you and your patients are in a very unsafe situation!!!

for example, would you actually push this on a pt in hallway bed?

holy moly!

yes, the situation HAS to be set up with a crash cart and the dr needs to be ready to intubate. that is unanimous.

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Specializes in ER.
Suppose your ER doc ordered you to give a patient a potent chemotherapeutic drug, would you do so?

Been there and NOT done that on a pediatric floor. The statement was, "if you look it up as you should it's just like any other medication." Nope.

Ketamine IM in the ER- yea or nay? (no IV access) I'm still unsure although our policy says it's OK.

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Hi all- this is all very interesting & stimulating conversation, clearly over my head as I am an LPN & know very little about anesthesia- I don't pretend to understand this topic well. I am posting simply in hopes that I might remind all involved- that in my case I was given Diprivan (propofol) NOT intubated & had to be bagged back (as far as I know this is what happened) & now have atelectasis in ALL the lobes of my lungs that was NOT there prior to the Propofol deal & was immediately AFTER- clearly a result of that ONE dip-stick deal...& now a "thickening area in my lungs" (clearly someone goofed as many have posted here to me since the nurse went out & got my husband & scared him half to death telling him "she stopped breathing!" I was given it as a means of relaxing me during a situation that had become quite stressful - MRI. Anesthesia was ordered by my Oncologist due to many procedures I had been thru in a short period of time (many folks are claustrophobic & cannot handle the tube) at that specific time I did not know going in that a MRI would be ordered if I had we would have planned open MRI when anesthesia was ordered I felt at ease that I would be safe- I WAS NOT SAFE CLEARLY & the one thing that was supposed to make me more at ease caused me much grief & many problems. I was told they do 10 or more cases this way on a daily basis in MRI (propofol w/out intubation) to me? now that I know more about it? IT IS JUST PLAIN STUPID & I would of course never allow it to happen to me again- but here in the interim I have damage to my lungs that cannot be undone- on-top of dealing with cancer- things I did not need (further problems to exacerbate the many issues I was already facing)... So despite all the "who should do whats"- it might serve patients well if EVERYONE could take a step back & consider that ONE patient in a co-zillion who's life IS ALTERED by doing things the WRONG way... I do not feel that I should not HAVE to be afraid of an anesthetic or a procedure while facing a terrifying diagnosis with a poor prognosis at the same time. Funny when I went back & got copies of that procedure - the notes of how it all went down the only mention of anything was- "Pt. tolerated the procedure well" Clearly some serious "CYA" going on there! I just hope all here can recall that as medical professionals we must remember to "FIRST DO NO HARM" it was always my main goal as a care giver & nurse... I feel it is the goal of many here or you all would not feel so passionate about your profession...& doing things the way you believe are the "right way" Best to you all! I appreciate all of the good nurses & other heath professionals I encouter on a regular basis. Those who administer anesthetics are very important to pheo & paraganglioma patients! Thanks! :thankya:

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Been there and NOT done that on a pediatric floor. The statement was, "if you look it up as you should it's just like any other medication." Nope.

Ketamine IM in the ER- yea or nay? (no IV access) I'm still unsure although our policy says it's OK.

"If you look it up as you should, it's just like any other medication." Yes, that statement troubles me as well. The fact is that it is not just like any other med. It has a nasty habit of biting the unwary, the uneducated, the smugly self assured, right on the backside. Unfortunately, when it bites, it's the patient's backside that loses the meat. They pay the price for you being so sure of yourself.

The fact that Tridil thinks only 90% of patients presenting to the ER in need of intubation need cricoid pressure is not reassuring. You cannot be sure of NPO status, and given the condition most of these patients are in, you MUST assume ALL of them have a full stomach. Given that, thinking it's OK to leave an LMA in for hours is also "non-reassuring." You are setting these patients up for aspiration, a problem they don't need on top of everything else that is going on.

With no insult intended, might I suggest that if your ER is going to continue in this fashion, you need to get a hold of some anesthesia texts. You must know when to do cricoid, why it is done (it isn't to ease intubation), why ALL emergent and urgent intubations, particularly in the ER are treated as "full stomach" intubations, and why NO ONE in anesthesia uses an LMA on a full stomach, particularly not for "hours."

My point all along is that no matter how much easier you might think they make your life, no matter how great an ER nurse you are, drugs used to induce anesthesia are best left to the people who do anesthesia day in and day out. People who are not only prepared to intubate, but have a back up plan in mind when they walk in the room. People who also prepared for the various reactions those drugs may cause.

In all honesty, look back at the thread since I started posting to it. I have pointed out several different things you have talked about doing that I, as an anesthesia provider, would not do. Things you have made incorrect assumptions about (such as my reference to neosynepherine. You thought I was talking about a drip, when that wasn't even close.) My point, which you have made for me all too often, is that people who don't do anesthesia cannot possibly be ready for some of the things these drugs can and will do. That's why the package insert states that the drugs should only be given by experienced anesthesia providers. You have stated that you all use these drugs not just for intubation, but for procedural sedation as well. That is the first place I look for this to bite you, and bite you hard.

You probably are an outstanding nurse. Given that, why is it that in this one area you are so cavalier with your patients' well being?

Canoehead, where ketamine is concerned, I wrote essentially the same things about that drug (plus more) in this thread:

https://allnurses.com/forums/f18/ketamine-conscious-sedation-peds-ed-172683.html

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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.

In my previous posts, I'm talking about Anaphylaxis with shock symptoms. This is much of what is seen in the OR when patients react to medications given. Again, Epi. is the first line drug in doses of 50-100mcq IV and then the rest. Epi IM is also used in your enviornment but not generally in the OR.

http://bmj.bmjjournals.com/cgi/content/full/bmj;327/7427/1332

http://www.aafp.org/afp/20031001/1325.html

skipaway

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Specializes in ER.
Canoehead, where ketamine is concerned, I wrote essentially the same things about that drug (plus more) in this thread:

https://allnurses.com/forums/f18/ketamine-conscious-sedation-peds-ed-172683.html

Thanks, that's what I needed.

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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?

Common misnomer about egg allergies and propofol....People see that propofol is made "from eggs" and simply make their own assumptions without further investigating.

Straight from Morgan and Mikhail:

A history of egg allergy does not necessarily contraindicate the use of propofol because most egg allergies involve a reaction to egg white (egg albumin), while egg lecithin (propofol) is extracted from egg yolk.

Oh yeah, Morgan and Mikhail are the authors of an anesthesia text.

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what if the pt iwas allergic to eggs and you didn't know that? do you have

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!!!

Actually, Neosynephrine causes a decrease in heart rate, not an increase. Neo would be a great choice for a patient with a low blood pressure with a high heart rate, especially if it was due to the vasodilating affect of propofol. Neo, although it has other actions, works primarily by vasoconstriction. This vasoconstriction causes an increase in afterload and venous return, which results in reflex bradycardia. So yes, in anesthesia, we routinely push Neo 100-200 mcg at a time for hypotension that occurs after induction. And yes, we also give fluid, etc...

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