propofol

Jen2 · Dec 17, 2005

We just reccently had a huge debate about this in my facility. Docs wanted ED RN's to push for CS and we didn't want to. So our pharmacist, The ED director, and the director of nursing got together with the state BON and these are our reguatrions how it is stated in our hopital policy and defined by the state board of nursing for my state (By the way I love using it. Gets the patient taken care of and home much faster):

-Definitions of sedation are defined by intent, not by which drugs are used.

-Minimal Sedation (Anxiolysis) Is a drug induced state in which patients

respond normally to verbal commands, although cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions remain unaffected. There is no special requirements for this type of sedation.

-Moderate Sedation/Analgesia A drug induced depression of consciousness during which patients respond purposefully to verbal commands. Either alone or accompanied by light tactile stimulation. Health care providers managing moderate sedation shall be physicians, registered nurses, or other providers that have met the criteria set forth in the policy. Competency shall be tested once then annually in practice. There must be a minimum of two people at bedside, the RN administering the drug and the physician performing the procedure. In the state of WV nurses can push all sedation drugs.

-Deep Sedation Drug induced depression of consciousness during which patients cannot easily be aroused, but repond purposely following repeated or painful stimulation. All guidlines for moderate sedation must be followed.

-Anesthesia Drug induced loss of consciousness during which the patient is not arousable, even by painful stimulation. The ability to indeoendantly maintain ventilatory function is often impaired.

Propfol The mechanism of action is unknown, has a hindered phenolic compound, is unrelated to any other currently used barbituate, opiod, benzo or imidazole. There is no analgesic effect but an amnestic one. The onset of action is a amnestic one within 30 seconds and has a duration of 3-10 minutes. The WV BON allows Registered nurses to push Propofol. There is no standard dosing by the company for moderate sedation and no national guidelines. One suggested way of dosing is 1mg/kg bolus then 20mg boluses until adequate sedation is reached or 20mg bolus with a 30mcg/kg/min drip titrated to effect. Patients with a regular exposure to alcohol can need much higher doses.

This is just a little of the guidlines at my hospital for using propfol. I am not going to get into the whole thing. I just wanted to get the point across that in my state a RN is allowed to push this drug. The MD does not leave the room throughout the procedure. The patient is hooked up to a monitor and there is intubation equipment at bedside. I have used it at least three times thus far to get shoulders back in. We also use Ketamine/atropine for peds, Versed, Fentanyl, and Etomidate. It depends on physician preference as of to which drugs we use.

sjrn85 · Dec 17, 2005

I wouldn't trust the doc I work with to have to be responsible for intubating a pt.; I'd be willing to bet it's been many years (maybe decades) since he's done it. No way would I want him to be responsible for intubation.

I guess right now it's up to the individual nurse until the FDA changes the regs. Not for me, that's for sure.

Jen2 · Dec 17, 2005

Our ED docs intubate constantly in the Level 1 where I work. When I work a twelve hour shift we usually end up with at least 4 intubations. I would never push the drug in an office setting where I know the office physician has never intubated for years, but in a level one trauma center, I feel comfortable.

pinktermite · Dec 22, 2005

There are several alternatives to propofol here. What about versed, etomidate, ketamine, fentanyl, depending on the patient and what you need it for. Propofol should be reserved for intubated head bleeds and/or traumas where quick sedation and short half life are a priority.

jwk · Dec 22, 2005

There are several alternatives to propofol here. What about versed, etomidate, ketamine, fentanyl, depending on the patient and what you need it for. Propofol should be reserved for intubated head bleeds and/or traumas where quick sedation and short half life are a priority.

Wrong on several levels. Propofol should be reserved for anesthesia providers. Head bleeds and trauma? Gimme a break. Yet another example of propofol being used by the wrong people.

pinktermite · Dec 22, 2005

I'm sorry to disagree...times have long passed since "anesthesia providers" can lay sole claim to providing these things without their consumate knowledge. Many level I trauma centers and large facilities ROUTINELY use propofol and these other mentioned medications for sedation and/or anesthesia. Done under the proper monitoring and under the supervision of trained physicians and nurses, these things can be administered responsibly and safely. Anesthetists are not necessarily the only people to provide it. So I disagree, and so do dozens of ERs and critical care units across the country.

louloubell1 · Dec 22, 2005

I'm sorry to disagree...times have long passed since "anesthesia providers" can lay sole claim to providing these things without their consumate knowledge. Many level I trauma centers and large facilities ROUTINELY use propofol and these other mentioned medications for sedation and/or anesthesia. Done under the proper monitoring and under the supervision of trained physicians and nurses, these things can be administered responsibly and safely. Anesthetists are not necessarily the only people to provide it. So I disagree, and so do dozens of ERs and critical care units across the country.

You may disagree with JWK, but more than 20 professional nursing organizations, the AMA, ASA, AANA, and JCAHO disagree with YOU. Current clinical practice guidelines for the provision of procedural sedation state that non-anesthesia providers should not be administering any drug labeled as a general anesthetic, including propofol, ketamine, brevital, etomidate, or STP, for procedural sedation. Joint Commission, though they don't specifically address particular drugs, says that if YOU are pushing any particular drug for procedural sedation than YOU better be able to rescue the patient from any level of sedation, including deep sedation or general anesthesia, that may develop. YOU. Your statement regarding reserving propofol for head bleeds and traumas indicates that you do not possess the knowledge necessary for administering these agents.

I'm not trying to flame you in any way, pinktermite, but I have done considerable reading on this subject as it is the crux of my master's thesis. This topic always brings out the heat from folks, and it's difficult for me to understand why. It's not about questioning anyone's clinical skills really, it's about providing the safest care for patients, and the safest thing is to leave the general anesthetics to those trained in administering general anesthesia.

austin heart, BSN, RN · Dec 23, 2005

You may disagree with JWK, but more than 20 professional nursing organizations, the AMA, ASA, AANA, and JCAHO disagree with YOU. Current clinical practice guidelines for the provision of procedural sedation state that non-anesthesia providers should not be administering any drug labeled as a general anesthetic, including propofol, ketamine, brevital, etomidate, or STP, for procedural sedation. Joint Commission, though they don't specifically address particular drugs, says that if YOU are pushing any particular drug for procedural sedation than YOU better be able to rescue the patient from any level of sedation, including deep sedation or general anesthesia, that may develop. YOU. Your statement regarding reserving propofol for head bleeds and traumas indicates that you do not possess the knowledge necessary for administering these agents.
I'm not trying to flame you in any way, pinktermite, but I have done considerable reading on this subject as it is the crux of my master's thesis. This topic always brings out the heat from folks, and it's difficult for me to understand why. It's not about questioning anyone's clinical skills really, it's about providing the safest care for patients, and the safest thing is to leave the general anesthetics to those trained in administering general anesthesia.

Well said, I think that you said everything that I wanted to say :).

It is so scary that so many nurses are quick to use these sedation medications when it is obvious from their posts that they have no clue of their uses or the ramifications of over sedation. This is not directed at anyone in particular, but sometimes I think it is swelled ego syndrome and the fact that they don't know what they don't know. Wait till the first time they put a patient into respiratory arrest and a doctor has to save their back sides.

FlyingSquirrel · Dec 24, 2005

Propofol is a safe drug as long as it is given carefully and slowly and someone is present who can quickly perform airway management if necessary. Like ALL drugs, the person using it needs to be familiar with all of its effects.

Propofol is extremely short acting and the negative effects of propofol usually wear off much more quickly than those of versed, which, in my opinion, is no more predictable than propofol. The same precautions should be taken during any CS, no matter the specific medication used.

We use it routinely for conscious sedation in the ED and in flight. Granted, when we use it in flight we are usually using it for induction for intubation, but not necessarily.

jwk · Dec 27, 2005

Propofol is a safe drug as long as it is given carefully and slowly and someone is present who can quickly perform airway management if necessary. Like ALL drugs, the person using it needs to be familiar with all of its effects.
Propofol is extremely short acting and the negative effects of propofol usually wear off much more quickly than those of versed, which, in my opinion, is no more predictable than propofol. The same precautions should be taken during any CS, no matter the specific medication used.
We use it routinely for conscious sedation in the ED and in flight. Granted, when we use it in flight we are usually using it for induction for intubation, but not necessarily.

It's rarely used for "conscious" sedation in the ED. And inducing general anesthesia in-flight ain't my idea of a great thing to do either.

I'm tellin' ya boys and girls - read that package insert, then decide how you'll EVER defend yourself if something bad happens. All your hospital-lifeflight-nursing-ED-GI-I've been inserviced-protocols won't mean SQUAT to a jury.

FlyingSquirrel · Dec 27, 2005

It's rarely used for "conscious" sedation in the ED. And inducing general anesthesia in-flight ain't my idea of a great thing to do either.
I'm tellin' ya boys and girls - read that package insert, then decide how you'll EVER defend yourself if something bad happens. All your hospital-lifeflight-nursing-ED-GI-I've been inserviced-protocols won't mean SQUAT to a jury.

I don't know what to tell you...the ED docs I work with are comfortable with it, the hospital administration is comfortable with it, the clinical pharmacists are comfortable with it, myself and the other nurses are comfortable with it, and frankly, I have never even heard of any problems with it. Personally, I am more comfortable with propofol than I am with large doses of versed.

I can also find nothing in the package insert or my states' nursing practice act that indicates that we should not be using it or that we are using it innapropriately.

You can dislike the idea of "general anesthesia" in flight all you want...I can tell you it's a very common practice. I've personally been doing it for several years now and have never had a single problem.

jwk · Dec 27, 2005

I don't know what to tell you...the ED docs I work with are comfortable with it, the hospital administration is comfortable with it, the clinical pharmacists are comfortable with it, myself and the other nurses are comfortable with it, and frankly, I have never even heard of any problems with it. Personally, I am more comfortable with propofol than I am with large doses of versed.
I can also find nothing in the package insert or my states' nursing practice act that indicates that we should not be using it or that we are using it innapropriately.
You can dislike the idea of "general anesthesia" in flight all you want...I can tell you it's a very common practice. I've personally been doing it for several years now and have never had a single problem.

You should read that package insert again - you're missing the part about it being used ONLY be those trained in administering general anesthesia which you are NOT. And again, it doesn't really matter what you or your hospital thinks is appropriate.

And I'm glad you NEVER have a problem. Trust me, some day you'll get humbled. There is a huge difference between competent and cocky, which obviously you and many others have not figured out yet.