propofol

[popbob]

do ya'll push it fo concious sedation?

[qanik1]

I will state it this way. After you have pushed the propofol, How many of your patients can respond to your questions appropriately verbally and can squeeze your hand and follow commands? If they can't you have gone beyond conscious sedation and are now in deep sedation or anesthesia. If you have a bad outcome you will be found liable. In the majority of ED settings there are certainly people that can manage the airway- but remember if you had to intubate or bag or even do a jaw thrust you have gone beyond the definition of CS. If you chip a tooth intubating, the patient gets some air in the belly and vomits during mask ventilation, larygospasms during suction etc etc. you have no legal footing. Also remember there are plenty of small ED's I have been to in my flight career where the ED doc is a family practice guy with no airway skills. Or the outpatient lab with no one trained in advanced airway. If your going to use it you had better have your **** together and be prepared for the legal outcome should something go wrong.

Respectfully,

Qanik

[penguin2]

I'm a traveler and have seen Propofol used for Concious Sedation. I am not fond of this. Usually I prefer Versed, or Ketamine (though ketamine does get squirrley sometimes.)

I actually will not do CS with Propofol. So, at my current facility, when I get a CS patient, if the MD wants to used it, the patient gets another nurse.

Edited to correct where I put Midazolam, instead of Prop. I guess its about time for sleep, just got off my 4th shift in a row of nights LOL.

I've never heard of RNs giving Ketamine- do you have to be certified to give it? I know some places require RNs to be Propofol certified. I don't think I'd be comfortable giving either w/out some further training. There has been some discussion in the media lately about using Propofol for endoscopy- there was an article in the paper just this wk re: the benefit of Propofol over Versed, but insurance companies don't want to pay for an anesthesia provider for this. Maybe the wave of the future is to train RN's to give these drugs previously only given by anesthesia providers, all in the name of saving a buck. I'm not sure that's a good trend though.

[CEN35]

just for the record, patient response after propophol is no different than any other drug. It is based on the amount given. In reality, you can give someone 2 mg of versed IV, and have them become unresponsive and need bagging. So that statement is a vague statement.

Your answer, I have had many patients, squeeze my hand or follow a command after propophol, although some times uncordinated. Which I have seen with versed and/or narcotics also.

As far as family practice guys? I couldn't answer that question. The physicians I worked with were all (except 1) board certified and trained emergency physicians.

also as far as ketamine? I have only seen it used on pediatrics in the form of a sucker.

Sony - that would be a CRNA.

[Jen2]

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.

I am not talking about a patient in the OR either. I am talking about the drug being the choice to be used in certain situations, and it is the standard of care. Furthermore, it is in my hospital policy that I can push this drug, it is inside my practice according to my State Board of Nursing. Therefore I am operating with in my scope of practice and within my hospitals policy.

[qanik1]

"just for the record, patient response after propophol is no different than any other drug. It is based on the amount given."

You signed CRNA but I hope not with that above statement. Perhaps you should go back and revisit some of those pharm books we had to use during school. Maybe age, weight, fluid status, circ time, biotransformation, metabloism and a few hundred other factors might play a role. The majority of the post are regarding the use of propofol with CS. Go open up your Miller and reread the definition of CS from the ASA and AANA- " a medically controlled state of consciousness in which all protective reflexes are retained- the patient retains the ability to maintain their airway can can respond appropriately to stimulation or verbal commands such as open your eyes, tell me your name and squeeze my hand" -doesn't seem to vague to me. I am not trying to put down propofol- I use it everyday to induce my patients. I am not trying to prevent it from the ICU or ED. WHat I am pointing out is that when your patient needs airway assistance or is unresponsive during the CS proceudre you are no longer doing CS. You are the one who said lets face it who doesn't know how to use a nasal or oral airway or bag somone- My point is made. If you had to do any of those listed you weren't doing CS. ANd whether the order is written or your BON says you can use it or your CS protocol calls for it if something happens you will be held liable. Go and look up the conscious sedation litigation regardless of what drug was used. If the patient needed assistance or ws unresponsive at anytime during the CS procedure with a porr outcome it was and open and shut case.

Qanik

[spidermonkey]

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[spidermonkey]

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[CEN35]

Quanik - I didn't say you were downing the use of propophol.

On your quote "Maybe age, weight, fluid status, circ time, biotransformation, metabloism and a few hundred other factors might play a role."

That all goes back to amount given. If the patient responds appropriately (i.e. neuro checks, etc) with propophol, then it is still CS.

As far as my quote: "lets face it who doesn't know how to use a nasal or oral airway or bag somone" - My point being, I have seen people get to that point after just 1mg of versed. So the person there better be able to know how to do these things, not to mention anything else neccessary that may occur.

Maybe my initial wording was not correct.

The CRNA thing was directed at, SONNY who said: "Maybe the wave of the future is to train RN's to give these drugs previously only given by anesthesia providers......"

__________________________________________________________

Spidermonkey - One thing I have to wonder about your posted incident. If the doc is yelling to give more and more, and the person was not comfortable with it, they should not have.

A common side effect of fentanyl when given to quickly is muscle rigidity, most common the chest wall.

Fortunately, I have anesthesia available within 90 seconds.

That's all Im saying, didnt mean to stir the pot.

Have a nice new years all!

[spidermonkey]

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[Jen2]

GIVE MORE! GIVE MORE!!"

Had a doc do this to me once with versed as he was sewing up a head lac and it was me the lowly RN that told him, "If you want to give more than this you need to go to the OR." The OR was phoned and the patients procedure was finished in the OR.

[NurseNili]

we are trying to get propofol (aka milk of amnesia) into our ed to sedate our ventilator dependent patients while boarding them when there are no icu beds. it is a great drug for just that, but we use versed for conscious sedation. ketamine is used for our cs peds patients...love that drug, works great, great induction time and shorter half life than other drugs...:rotfl:

[subee, MSN, CRNA]

AMEN TO THAT!!!!

I understand the dilemma hospitals have when they have more patients to be sedated than they have anesthesia to provide the services. HOWEVER, the package insert says it all and anyone outside of anesthesia is being way to casual in their practice if they're pushing propofol on unintubated patients. In someone who's already received other CNS depressants, it can get you into big trouble before you even know it. Before Medicare started paying anesthesia to be at colonoscopies the patients here received Demerol and Valium. OK, nobody wants to use valium anymore, but when Versed came into endo., we anesthesia folks received mailings from the drug companies that several deaths had happened in endo units. At least demerol can be reversed before the patient goes home. However, most patients were pretty darn comfortable before anesthesia got into the endo unit. You don't have to knock someone out cold to keep them comfortable but I think it requires an anesthesia person to have the experience to apply that kind of finesse. Remember, we all part of the medical industrial complex and some of us are parts of other people's money making machines.