scary.....

kmchugh · Oct 29, 2003

I think most anesthesia providers agree that people who don't do anesthesia daily probably should not be giving anesthesia drugs. I've heard or read about ER docs whose favorite sedating agent is propofol, and some have mentioned that they think ketamine is better for sedating kids. We have oral surgeons using, as indicated in this thread, propofol and other anesthesia agents.

There is a reason they are called "anesthetic agents" as opposed to "sedation agents." Yes, you can "with the turn of a dial" change the depth of most patients' sedation when using propofol. However, there is an extremely fine line when using this drug between "sedation" and "apnic" and "dead." You don't really have an appreciation for that until you see, through experience, how fine that line can be. Generally, in the hands of a competent MDA or CRNA, these are great drugs. But we are ready for the patient who stops breathing with 30 mg propofol on board (and I've seen that happen). A dentist, as good as s/he may be, just isn't ready. And I've noticed that anesthesia providers spot apnea long before just about any one else in the room.

I'm rambling a bit, but the point is that the ASA and the AANA are both right. Anesthetic drugs should not by administered by anyone unless they are anesthesia providers. Or at a minimum, by a health care professional under the direct supervision of an anesthesia provider. Like it or not, this isn't an issue of turf, or money, or anything else. It's an issue of patient safety.

Kevin McHugh

deepz · Oct 29, 2003

Originally posted by athomas91
... but i have to say - i woke up on top the world - my husband got a kick out of it - ....

Euphoria (and even a certain boost in libido ... go figure!) is a commonly observed side effect after propofol.

BTW Some folks find a small bolus useful in PACU as an anti-emetic.

Tenesma · Oct 30, 2003

a small dose does a great trick on post-op shakes

kmchugh · Oct 30, 2003

Originally posted by Tenesma
a small dose does a great trick on post-op shakes

Tenesma

First I've heard this. What dose do you find effective for this? (Up to this point, I've used 12.5 of demerol. Stops the shakes every time.)

KM

Tenesma · Oct 30, 2003

depends on how awake they are... depending on situation i will give 3-10mg of it

g8rlimey · Oct 30, 2003

I don't know if this link has come up here before, but this kind of touches what has been being discussed, very scary:

http://www.outpatientsurgery.net/2003/os07/rns_pushing_propofol.php

I share the sentiments of others posting here. As a newbie in school, I have only recently come to appreciate the pharmocologic value of propofol in the induction process. I eagerly await being able to use this drug for the higher purpose it has.

loisane · Oct 30, 2003

Sam, this was a great link, thanks for sharing it.

The debate over appropriate provider for various levels of sedation is a complex one. Many issues involved-pt safety, professional standards, pharmaceutical labeling, economic/reimbursement motives.

I thought this article was well balanced. It did a fair job of presenting the pros and cons of the debate as related specifically to propofol use. It also was balanced in terms of the mda/crna "issue". I have run across many outpatient surgery pieces that are nothing but anti-crna propoganda.

I do believe that it is important for us all to remember that appropriate standards of care do evolve, and change over time. So we need to be careful that we are not trying to justify turf protection simply by hanging on to old traditions.

Even so, I still believe that the preponderence of the argument favors maintaining propofol (and other examples of "deep sedation" agents) as "anesthesia only" delivered drugs. The clinical examples given by Tenesma and Kevin are self explanatory. It is a great drug, and in our hands we make it look easy. But there is potential disaster lurking around every corner, you never know when it is going to nip you in the you-know-what.

The bottom line is that the person giving sedation should be capable of managing one level deeper than the level planned for the procedure. If a procedure requires deep sedation, the person responsible of the sedation and associated monitoring must be capable of handling a general anesthetic.

loisane crna

stevierae · Oct 31, 2003

Originally posted by Tenesma
a small dose does a great trick on post-op shakes

Where I've worked and we had to recover patients, we always used Demerol for post-op "shakes--" I am more comfortable using that than I am using Diprivan, especially in an ambulatory surgery clinic post-op--but, then again, I am not an anesthesia provider, who WOULD have the skills needed to administer Diprivan properly and competently--

I agree with kmchugh that people not giving anesthesia on a daily basis should NOT be giving anesthesia drugs--I never could understand the big push among some OR supervisors I have worked for to force the RNs (not CRNAs, mind you, but us lowly OR nurses) to administer drugs for local standby cases instead of waiting for an anesthesiologist to be freed from another room, thus getting the cases moving, which seemed to be her biggest concern.

Now, I am ACLS certified and yes, I know how to recognize dysrhythmias, as well as give Atropine,Narcan, etc. as indicated--but I really don't think it is fair to a patient to have an OR nurse in charge of his airway and, literally, his LIFE, nor do I think they pay us enough, or provide the proper training, to assume this responsibility--

I remember having to take a 2 hour "inservice" taught by a pharmacist; essentially it was a "crash course" in various anesthesia drugs that we RNs were supposed to become comfortable enough in our newly mandated (by one of these supervisors) role to give IV sedation during local standby cases-- (to me, a contradiction in terms, since "standby" is SUPPOSED to mean an ANESTHESIA PROVIDER--CRNA or anesthesiolgist--standing by)

Anyway, one of the drugs they expected us to be able to use was Diprivan. I seemed to be the only one that had a problem with that, or maybe my colleagues were just afraid to make waves--I felt everybody was just a little too cavalier about it--i.e., "You give Sublimaze, don't you? And Versed? What's the difference?"

The difference, to me, is what others have already pointed out in this thread--Diprivan is generally used in a general anesthesia setting or in an intubated ICU patient in situations where there are people around who are experts in airway management, who intubate on a daily basis--and I don't know any operating room nurse who meets that criteria--I know I don't.

There was another drug they wanted us to be comfortable giving for hypertensive crisis; one that I remember could be administered ONLY by an anesthesiologist--it was NOT Apresoline, but I THINK it did start with an "A--"and it even SAID ON THE PACKAGE "To be given only by an anesthesiologist"-- does anybody know which drug I am thinking of? The name escapes me---this was in the early '90's--

The funny thing is, the anesthesia staff did not seem to object to this new plan of our old supervisor's, I am not sure why--probably because they were salaried and got paid regardless of how little work they actually did while they were there--I know the private practice anesthesia staff I had worked with in the past would not have gone for it--

I even worked registry for a day at a samll community hospital where the anesthesia staff went home at noon (no OB department, so no anesthesia in house, either) and the OR nurses would give sedation during local standby cases--there was literally no one experienced in intubation left in the OR during these afternoon cases, should a crisis occur.

When I expressed to their supervisor how horrified I was with this practice, she said, very defensively, "Well, they can always call a code if there's a problem---the ER doctor could come intubate---" She made it very clear that she thought I was criticizing how she ran her operating room, and that I was out of line--

I never worked there again; in fact, I wish I had reported this practice to the state--I still might do so. I have heard from other registry colleagues it is still done there, and that they refuse to be involved, so they won't go back.

This hospital, and I suspect there are others like it, doesn't even have any standing orders to follow for these "local standby" cases which are in reality light generals, nor are the surgeons directing the amounts on the IV sedation--- ---the nurses who participate just give a little of this, a little of that; including Diprivan; often they have to slip in an airway and ventilate by mask after they have given a little too much; sometimes they have to reverse too much Versed with Romazicon; or give Narcan for too much Sublimaze. I haven't heard of anybody having to be intubated yet, (or at least I haven't read about it in the local newspaper!) so I guess so far they have been lucky.

In this particular hospital, the OR nurses involved have really started to get big egos over the fact that they are "giving anesthesia," and I think they truly believe themselves to be far more skilled than they really are. I think this is a recipe for an impending disaster.

Frankly, I have to wonder about any ER doc who would come running to bail out a nurse who had no business giving some of thse drugs in the first place---and what if he was busy with his OWN code, in the ER?

gotosleep · Oct 31, 2003

Originally posted by stevierae
Where I've worked and we had to recover patients, we always used Demerol for post-op "shakes--" I am more comfortable using that than I am using Diprivan, especially in an ambulatory surgery clinic post-op--but, then again, I am not an anesthesia provider, who WOULD have the skills needed to administer Diprivan properly and competently--

I agree with kmchugh that people not giving anesthesia on a daily basis should NOT be giving anesthesia drugs--I never could understand the big push among some OR supervisors I have worked for to force the RNs (not CRNAs, mind you, but us lowly OR nurses) to administer drugs for local standby cases instead of waiting for an anesthesiologist to be freed from another room, thus getting the cases moving, which seemed to be her biggest concern.

Now, I am ACLS certified and yes, I know how to recognize dysrhythmias, as well as give Atropine,Narcan, etc. as indicated--but I really don't think it is fair to a patient to have an OR nurse in charge of his airway and, literally, his LIFE, nor do I think they pay us enough, or provide the proper training, to assume this responsibility--

I remember having to take a 2 hour "inservice" taught by a pharmacist; essentially it was a "crash course" in various anesthesia drugs that we RNs were supposed to become comfortable enough in our newly mandated (by one of these supervisors) role to give IV sedation during local standby cases-- (to me, a contradiction in terms, since "standby" is SUPPOSED to mean an ANESTHESIA PROVIDER--CRNA or anesthesiolgist--standing by)

Anyway, one of the drugs they expected us to be able to use was Diprivan. I seemed to be the only one that had a problem with that, or maybe my colleagues were just afraid to make waves--I felt everybody was just a little too cavalier about it--i.e., "You give Sublimaze, don't you? And Versed? What's the difference?"

The difference, to me, is what others have already pointed out in this thread--Diprivan is generally used in a general anesthesia setting or in an intubated ICU patient in situations where there are people around who are experts in airway management, who intubate on a daily basis--and I don't know any operating room nurse who meets that criteria--I know I don't.

There was another drug they wanted us to be comfortable giving for hypertensive crisis; one that I remember could be administered ONLY by an anesthesiologist--it was NOT Apresoline, but I THINK it did start with an "A--"and it even SAID ON THE PACKAGE "To be given only by an anesthesiologist"-- does anybody know which drug I am thinking of? The name escapes me---this was in the early '90's--

The funny thing is, the anesthesia staff did not seem to object to this new plan of our old supervisor's, I am not sure why--probably because they were salaried and got paid regardless of how little work they actually did while they were there--I know the private practice anesthesia staff I had worked with in the past would not have gone for it--

I even worked registry for a day at a samll community hospital where the anesthesia staff went home at noon (no OB department, so no anesthesia in house, either) and the OR nurses would give sedation during local standby cases--there was literally no one experienced in intubation left in the OR during these afternoon cases, should a crisis occur.

When I expressed to their supervisor how horrified I was with this practice, she said, very defensively, "Well, they can always call a code if there's a problem---the ER doctor could come intubate---" She made it very clear that she thought I was criticizing how she ran her operating room, and that I was out of line--

I never worked there again; in fact, I wish I had reported this practice to the state--I still might do so. I have heard from other registry colleagues it is still done there, and that they refuse to be involved, so they won't go back.

This hospital, and I suspect there are others like it, doesn't even have any standing orders to follow for these "local standby" cases which are in reality light generals, nor are the surgeons directing the amounts on the IV sedation--- ---the nurses who participate just give a little of this, a little of that; including Diprivan; often they have to slip in an airway and ventilate by mask after they have given a little too much; sometimes they have to reverse too much Versed with Romazicon; or give Narcan for too much Sublimaze. I haven't heard of anybody having to be intubated yet, (or at least I haven't read about it in the local newspaper!) so I guess so far they have been lucky.

In this particular hospital, the OR nurses involved have really started to get big egos over the fact that they are "giving anesthesia," and I think they truly believe themselves to be far more skilled than they really are. I think this is a recipe for an impending disaster.

Frankly, I have to wonder about any ER doc who would come running to bail out a nurse who had no business giving some of thse drugs in the first place---and what if he was busy with his OWN code, in the ER?

terrific post