Pushing IV Propofol as an RN under Surgeon who is Board Certified in Anesthesia

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I have 2 and a half years of hospital experience as an RN. I recently got a job working under the direction of a Triple Board triple-certified surgeon (certified in Cosmetic Surgery and Maxillofacial Surgery). He is also Board Certified in Anesthesia by the American Dental Board of Anesthesiology. He owns a small practice and has a small team. One RN (myself) and several surgical techs. He mostly performs oral surgeries and Facial Cosmetic/Reconstructive surgeries. Getting to my point, when he performed wisdom teeth extraction, the two techs and I assisted by monitoring the patient's airway and vitals along with passing the surgical instruments. This was my first day shadowing and he explained to me that the job description includes starting IVs and pushing IV meds (under his direction). He drew up the Propofol and connected the IV push to the pts IV. The pt was under general anesthesia (a combination of Nitrous oxide and IV Propofol). He pushed part of the dose and several minutes later (as he was operating), he then directed me on when to push the remaining dose. This is new to me. This is my first job working in the operating room. I am not a CRNA but am just an RN, BSN. I want to make sure I am practicing within my legal scope. This is in the state of Florida by the way. Any input is appreciated, thanks! 

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This is one of the shadiest things I've heard in a very long time. As I'm not licensed in Florida I'd advise you to contact your BON asap and ask for clarification. I know it's a NO where I'm currently licensed, RNs can't push propofol. 
 

A patient under GA needs constant 1 :1 observation by a licensed / trained individual (CRNA or anesthesia provider) whose only role is to monitor the patient. Having the surgeon also be the anesthesia provider isn't really appropriate (safe). If it were just moderate sedation - nitrous, fentanyl, versed it would be fine for you to monitor but again monitoring should be your only role. I've never seen more than 1 tech needed to circulate for any dental case so I don't understand why they need 2 and an RN. 

Is this the way all the cases are done or only the extractions?

I would be looking for a new job asap. 

 

 

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This was written by the board of nursing in your state. It says you can under his demand BUT only if the patient is also being monitored etc. So you can't be doing both at the same time and neither can the surgeon. 

"(15) Practicing beyond the scope of the licensee's license, educational preparation or nursing experience, including but not limited to: administration or monitoring the administration of any medication intended to create an altered level of consciousness that is a deeper level than moderate sedation for a surgical, diagnostic or therapeutic procedure by a registered nurse or licensed practical nurse; provided:

(a) A registered nurse may, pursuant to physician order, administer or monitor the administration of medications to achieve deep sedation to a patient who is continuously monitored and mechanically ventilated with a secured, artificial airway. Examples of medications used for deep sedation in this situation include, but are not limited to, propofol, pentothal and dexmedetomidine. Due to the potential for rapid, profound changes in sedative/anesthetic depth and the lack of antagonist medications, even if moderate sedation is intended, patients receiving propofol should receive care consistent with that required for deep sedation. Therefore the administration of propofol should only be performed by a practitioner experienced in general anesthesia and not by a registered nurse, with the exception of a patient who is continuously monitored and mechanically ventilated with a secured, artificial airway. When a physician is actively managing a patient's sedation, a registered nurse may monitor the patient under circumstances that may include both moderate and deep sedation.

(b) A registered nurse may administer prescribed pharmacologic agents to non-mechanically ventilated patients for the purpose of moderate sedation in anticipation of anxiety and or discomfort during a time-limited surgical, diagnostic or therapeutic procedure. The registered nurse must continuously monitor the patient throughout the procedure and have no other responsibilities that would require leaving the patient unattended or would compromise continuous monitoring during the procedure. The registered nurse must document the patient's level of consciousness at least every five minutes during the procedure. In the event a deeper level of sedation (such as deep sedation or general anesthesia) results from the administration of prescribed pharmacologic agents, the procedure must be stopped and the level of sedation returned to moderate sedation with the assistance of the prescribing physician or credentialed anesthesia provider."

 

https://www.flrules.org/gateway/readFile.asp?sid=3&tid=9347422&type=1&File=64B9-8.005.htm#:~:text=Pharmacologic%20agents%20that%20may%20be,package%20insert%20states%20should%20be 

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@kp2016 Thanks the response. I ended up backing out of the job offer. Before I found out how sketchy this new job was, I was planning on putting in my 2 weeks notice today at my current job. Thank god I didn't! I was so excited to get into an OR environment and try something new, so much so that I didn't realize a lot of the warning signs. Glad that I finally saw how unsafe it was. Everything about it seemed unorthodox. I only shadowed for 3 hours and 2 cases were performed. Each case had the same two surg techs. One passing instruments and the other monitoring the pts airway and giving nitric oxide. The oral surgeon was the one who initially hooked up the IV propofol push and gave part of it and then told me to push the rest (he made it seem totally normal but after the research I've done I know that it's not within my scope). It just seemed like the job description wasn't explained in great detail and looking back it seems like he purposely wanted to keep me in the dark (probably b/c he knows he is supposed to hire a CRNA and does not want to pay them more). I still can't find out if it is legal for him to operate and push IV propofol at the same time. But I'm 99% sure it's not legal for me to be doing it. The last step would be going to Florida BON and asking. I might call and see if I can find out. Honestly the whole shadowing is a bit hazy when I try to remember what was going on and who was doing what because it was overwhelming. I think I dodged a bullet here.

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Specializes in ICU, Cath Lab/IR CCRN. SRNA Class 2026.

Good choice in leaving that position. If one reads the BON practice guidelines RNs can only administer it if the patient is mechanically ventilated. 
 

surg techs monitoring the airway? Yikes! Does no one care about losing a license they worked so hard to earn. The Dr. Needs to hire a CRNA. Their poor patients and team members. 
 

Look for a position in IR/ procedural (cath lab if you have ICU experience) if you want to try out moderate sedation in an OR type environment. Versed and fentanyl. If you desire no med administration just go to OR positions. 

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Specializes in CRNA, Finally retired.
kp2016 said:

This is one of the shadiest things I've heard in a very long time. As I'm not licensed in Florida I'd advise you to contact your BON asap and ask for clarification. I know it's a NO where I'm currently licensed, RNs can't push propofol. 
 

A patient under GA needs constant 1 :1 observation by a licensed / trained individual (CRNA or anesthesia provider) whose only role is to monitor the patient. Having the surgeon also be the anesthesia provider isn't really appropriate (safe). If it were just moderate sedation - nitrous, fentanyl, versed it would be fine for you to monitor but again monitoring should be your only role. I've never seen more than 1 tech needed to circulate for any dental case so I don't understand why they need 2 and an RN. 

Is this the way all the cases are done or only the extractions?

I would be looking for a new job asap. 

 

 

So many cosmetic surgeons are cowboys.  Even if the person were a genuine board certified plastic surgeon they can't be administering Propofol while doing surgery.  This is a big no-no.  I had a friend who died in the chair because the surgeon couldn't tell that she had a nightmare of an airway (anesthesia would have known that) and got oversedates and coded because no one in the room had the skills to intubate a difficult airway.  I agree with others who advise running away from this place.

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Hi- I'm sorry you've been put in this situation but it's a learning experience.  You'll know now for the rest of your career!!  Always check your BON.  Scope of practice is different in every state & can change.  Always read through the BON rulings at least once a year.  And each state is different so always do a thorough review of a new state if you move.  
This exact situation has been questioned before the board several times in Florida & the board rules the same way every time.  RN's do not push any anesthesia sedation or paralyzing agents.  You can push versed.  You cannot push propofol.  

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Specializes in Occupational Health.

According to the prior posting from the Florida BON...only if the pt was mechanically ventilated and has a secured airway. Both of which I highly doubt given the dental setting. 

This is shady sounding practice and one that could easily cost you your license not to mention causing a client's death due to poor anesthetic techniques and mismanaged airway practice. 

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