propofol

FlyingSquirrel · Dec 27, 2005

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.

OK, I see that you are one of those types who is incapable of having a productive discussion with someone who thinks or is used to doing things a little differently than you. You assume that I'm cocky and incompetent just because I'm comfortable doing something that you think I shouldn't be? That's a pretty ballsy and closed-minded assertion considering how little you know about me and my experience.

No, I didn't miss that part of the insert. If I based my entire practice on the warnings listed on drug inserts I would never give anything to anybody.

More than one lawyer, more than one medical director, more than one anesthesiologist, and more that one state board of nursing disagrees with your legal interpretation of that statement. I'm not the only non-anesthesiologist in the world who uses propofol and is comfortable with it.

jwk · Dec 27, 2005

OK, I see that you are one of those types who is incapable of having a productive discussion with someone who thinks or is used to doing things a little differently than you. You assume that I'm cocky and incompetent just because I'm comfortable doing something that you think I shouldn't be? That's a pretty ballsy and closed-minded assertion considering how little you know about me and my experience.
No, I didn't miss that part of the insert. If I based my entire practice on the warnings listed on drug inserts I would never give anything to anybody.
More than one lawyer, more than one medical director, more than one anesthesiologist, and more that one state board of nursing disagrees with your legal interpretation of that statement. I'm not the only non-anesthesiologist in the world who uses propofol and is comfortable with it.

I never said you were incompetent, but your statements pretty much prove the "cocky" part. You should read this entire thread, and read the several other threads on this board regarding adminstration of propofol by non-anesthesia providers. It's certainly not just my opinion. There's plenty of non-anesthesia folks using propofol, and I'm sure most of them are comfortable with it. The point is that they shouldn't be.

Your previous post stated "I can also find nothing in the package insert..... that indicates that we should not be using it or that we are using it innapropriately". Now you're saying that you've read it, but ignore it. That package insert statement leaves little room for interpretation. The lawyer for the hospital isn't the one to be concerned about - the one to worry about is the plaintiff's lawyer when you get sued. Why do you think there's such a huge fight right now to get the wording on the package insert changed? If the wording on the insert didn't matter, it wouldn't be an issue. Why is it an issue? Because nurses and GI docs and others who use it inappropriately and against the FDA-mandated warning in the package insert KNOW that if their patient has a problem, they'll get nailed in a lawsuit.

austin heart, BSN, RN · Dec 27, 2005

Quoted from the Propofol Injectable Emulsion package insert located in the Pyxis of my ED, in BOLD letters....."Warning, for general anesthesia or monitored anesthesia care (MAC), propofol should be administered only by persons trained in administration of general anesthesia and not not involved in the conduct of the surgical/diagnostic procedure."

I guess I was sick the day they gave the lecture that trained us RN's to administer general anesthesia. If we are expected to do that they should be paying me more.:uhoh21:

originalred · Dec 28, 2005

Hang in there guys. Our BON recently had a review of our practice act and RN administered propofol for endo...

THEIR anesthesiologist stopped the rebuttal being offered by the BON exec after our Docs presented their data, and wanted to review our data in depth before any decision was made. His statement was "they have scientific evidence that needs to be reviewed before any decision is made".

In the past, any time anesthesia providers were involved it was automatic...NO. We took this as a good sign.

The package insert is a tough one to overcome. For years droperidol stated a 12 lead should be done prior to admin...Did I ever do that ...no. Did any one else...I don' know. Was anyone sued...I don't know.

If you look at any insert you can probably find something to limit it's use.

I do know that if I am having a procedure done...RN propofol is OK with me.

Airway management....give me a trained, field tested paramedic any day of the week.

Just like ACLS does not qualify you to manage an airway according to some opinions...3 more years of school does not qualify you to give a drug that is so damn dangerous.

Not meant to offend anyone but the "tribal mentality" drives me crazy.

Show me numbers of patient's that have had poor outcomes with dip vs those with the other agents used. 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.

Jen2 · Dec 28, 2005

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.

I am not so sure about this statement. The head Neuro surgeon at the hospital I work in sets the standards of care for neurological related problems in the country. His patients fly in from Italy, China, India, and all over the United States. The standard of care that he sets for head bleeds and trauma especially is to use Propofol for the drug of choice.

jwk · Dec 28, 2005

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.
I am not so sure about this statement. The head Neuro surgeon at the hospital I work in sets the standards of care for neurological related problems in the country. His patients fly in from Italy, China, India, and all over the United States. The standard of care that he sets for head bleeds and trauma especially is to use Propofol for the drug of choice.

Hmmm, we don't generally have the neurosurgeons setting standards for the anesthesia department.

Jen2 · Dec 29, 2005

Hmmm, we don't generally have the neurosurgeons setting standards for the anesthesia department.

No but you stated that it was inappropriate to use Propfol for head bleeds and traumas, when in fact it is the standard of care for these cases. In order to effectively and safely assess these patients neurological status this is the drug of choice whether the patient be lying in the trauma bay or ICU. It just so happens that sometimes we need our intubated patients to respond to us and follow commands in order to lay out their plan of care and to make critical decisions about their treatment. Propofol allows this to happen. It's not an arguement of getting into a peeing contest of I am the only qualified provider being able to administer this drug, it is an issue of patient care. If a certain drug requires critical decisions to be made in a timely fashion, the administrator is comfortable, there is adequate staff and resources and it was my family member involved, I know what I would choose. The truth is half of the drugs we use every day are not FDA approved for the reasons we use them.

rn29306 · Dec 30, 2005

Airway management....give me a trained, field tested paramedic any day of the week.

So does this mean that a trained, field tested paramedic is present during NAP?

Just like ACLS does not qualify you to manage an airway according to some opinions...3 more years of school does not qualify you to give a drug that is so damn dangerous.

Until you have managed close to 1000 anesthetics and close to the same number of airways, you have no idea of what you are talking about. There is a reason anesthesia providers give an anesthetic drug and chemically cause paralysis - because we can manage it. And yes, 2.5 to 3 years of school does indeed allow us to give 'such a damn dangerous drug'. Too bad you don't realize what you are even discussing here. Got a problem with it - suck it up and go back to school.

jwk · Dec 31, 2005

Hmmm, we don't generally have the neurosurgeons setting standards for the anesthesia department.
No but you stated that it was inappropriate to use Propfol for head bleeds and traumas, when in fact it is the standard of care for these cases. In order to effectively and safely assess these patients neurological status this is the drug of choice whether the patient be lying in the trauma bay or ICU. It just so happens that sometimes we need our intubated patients to respond to us and follow commands in order to lay out their plan of care and to make critical decisions about their treatment. Propofol allows this to happen. It's not an arguement of getting into a peeing contest of I am the only qualified provider being able to administer this drug, it is an issue of patient care. If a certain drug requires critical decisions to be made in a timely fashion, the administrator is comfortable, there is adequate staff and resources and it was my family member involved, I know what I would choose. The truth is half of the drugs we use every day are not FDA approved for the reasons we use them.

1) We're not talking about ventilated patients in the ICU.

2) Neuro patients in my OR get pentothal.

3) Trauma patients, particularly unstable ones, NEVER get propofol. They get etomidate, possible ketamine if no head injury, or NOTHING but a NMB.

4) "...the administrator is comfortable..." Now there's an excellent standard to go by. Use that as a defense when you get sued.

rn29306 - you and I know the real deal. Red, jen, and squirrel ain't gonna get it. I guess as long as they're "comfortable", all is well in their little world.:rotfl:

FlyingSquirrel · Dec 31, 2005

OK, why don't we approach this a little differently.

As I am not a CRNA, I have absolutely no problem admitting that there is alot about propofol and other sedative/anesthetics/paralytics that I don't know about.

However, I also do know that I am pretty well educated and experienced in the uses of various sedatives, analgesics, and paralytics, as well as basic and invasive airway management and the fundamentals of ventilator management. In the ED, of course we always have very competent ED MD's present, along with all kinds of other expert clinical support, like pharmacy, respiratory, anesthesia, etc. In the field however, our RN/Paramedic teams are on their own. We routinely perform RSI and maintain sedation/paralysis and mechanical ventilation without the luxury of anesthesia backing us up. I and many others have extensively used protocols which incorporate etomidate, propofol, succinylcholine, rocuronium, vecuronium, fentanyl, morphine, versed, and valium in this setting. I may not possess a anesthetist or pharmacist-level of knowledge on these meds, but I don't think that is a reasonable expectation or more importantly, necessary to there safe use. Thats what the medical directors who write our protocols and provide medical direction are for. Perhaps it is just because of my ignorance, but I am not aware of any poor outcomes ever occuring specifically because of a medication we used.

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?

teppy · Dec 31, 2005

We use propfol in our ER for CS but the doc pushes it and Respiratory therapist is present in case of the need to entubate

CEN35 · Dec 31, 2005

Our ER is not allowed to use it, without an anesthesiologist present. So the ER docs would use versed and Demerol. Which I did not really like. To long to wear off and hit baseline.

As an ER nurse I also thought propophol was a bad idea. I left ER 3 years ago to go to another department, where we use propophol fairly frequently. Also we use fentanyl about 100 times a day.

Since then I have went bcak to the ER and talked to some of the physicians. Fentanyl & Versed together is an awesome choice for CS procedures. It acts fast, does an awesome job, and wears off quicker than everything but propophol.

As far as propophol, I think that ttoo is a wonderful drug for CS procedures (now). It starts wearing off the minute you stop pushing it, and lets face it? It's not like people don't know how to use nasal/oral airways and ambu bags. Although if you take your time, and push it in increments it's IMO the best drug of choice for CS. But if not available or allowed, fentanyl and versed cannot be beat (and are both reversible in an emergent situation.).