sedation and anesthetics

Editorial Team / Admin · Mar 7, 2015

I think you are going to find that this varies a lot from facility to facility. While the scope of practice may permit nurses to do certain things, facilities may have policies that are more restrictive. Here's how it is at mine:

Are you all allowed to bolus propofol

No. Only CRNAs and anesthesiologists may bolus propofol. For patients going direct to ICU from the OR, the anesthesia provider carries emergency drugs, including a syringe of propofol if a bolus is needed prior to the infusion starting.

and titrate drips?

Yes, and the parameters are included in the order set.

What about ketamine?

I've never seen ketamine used, but since I work OR and not critical care, it could be that it just isn't something I see on my patients. We seem to use a lot of propofol, precedex, and fentanyl for sedation.

Also do you all do conscious sedation as a staff nurse?

Conscious sedation requires a course on how to do it and yearly competencies.

Do you push induction meds for intubation or does the doctor? Just curious.

Whoever is doing the intubation, either CRNA or anesthesiologist.

YanMinor · Mar 8, 2015

+1 with what Rose-Queen said. If you bolus an induction agent like propofol, you are now practicing anesthesia.

Have I seen nurses do it? Maybe.

EDIT: Typically, orders for fentanyl and midazolam drips (among others) also come with PRN bolus orders that allow the nurse to use their own judgment. At my facility, propofol never comes with this, but some nurses see blurred lines. I don't.

jamisaurus · Mar 8, 2015

We're allowed to bolus propofol if MD is present at bedside.

Do I do a small bolus if MD is not present, patient is freaking out and I cannot leave to get PRN versed and nobody is around to get it for me? Absolutely. I'm protecting that airway.

ausrnurse · Mar 8, 2015

Wow, I can't imagine not being allowed to bolus propofol or titrate meds! We can bolus as much as we need to taking into account the pts blood pressure, letting the MO know if the pt is requiring large amounts of boluses to remain settled. Same with fentanyl and midazolam. We don't really use ketamine often and although I think you can bolus it, I prefer not to unless asked to by a doctor. I work in a referral centre however and I believe that in smaller units that only hold ventilated pts until they can be transferred to us they don't and is mainly because of a lack of experience with the medications.

MunoRN, RN · Mar 8, 2015

In every state and facility I've worked RN's can bolus propofol, I can't imagine managing a propofol drip without being able to bolus, that seems sort of pointless. What we can't do is give propofol to a patient who is not intubated, that is outside our scope.

We push RSI meds with the MD in the room and ready to go.

RN's do conscious sedation once they've established that competency.

We do ketamine drips both in the ICU as well as on the floors.

Greenclip · Mar 8, 2015

We don't bolus propofol, per facility protocol. Only anesthesia can do that. I can titrate a propofol drip or any other drip that is prescribed with titration orders. I am responsible for conscious sedation for procedures done on the unit and didn't take a special course. I push induction meds for RSI. We don't use ketamine at all.

Argo · Mar 8, 2015

Do RNs to it, yes.

Is it against ASA guidelines for anyone but an anesthesia provider to push the drugs mentioned, yes. When you are doing it, you are putting yourself at risk with very little to fall back on when you do it for both you and the facility. Most facilities have gotten away from having any wording allowing nursing to push these meds outside of the order set with the use of a pump. I typically tend to stay within my scope. If there is an anesthesia provider present I will do it. If it is a surgeon/gi doc/cardiologist present I will only push versed/fentanyl/Demerol.....

francoml, ASN, RN · Mar 8, 2015

to be clear when I said bolusing propofol I was talking about when anesthesia orders induction meds for intubation. After intubation we can titrate the drips such as propofol ect. I do not bolus propofol at my own discretion.

Julius Seizure · Mar 8, 2015

Depends on the state AND facility! I started on in a state to didnt allow RNs to bolus propfol or ketamine (Florida), and when I went to Michigan, it seemed insane to me that nurses could push ketamine (the nurse practice act there doesn't address this as a no-no) in my facility. Always check the policies of your hospital and the laws for your state. Better to know for sure :)

Here.I.Stand, BSN, RN · Mar 16, 2015

We bolus propofol from the infusion all the time. When someone needs to be intubated, generally two CRNAs or an anesthesiologist and CRNA come; one of them has always pushed meds. At my previous hospital, I pushed RSI drugs all the time. I've never given ketamine. Our pts get it a lot in the ED, and I *think* the RN gives it, but not 100%. The main sedated procedures we do is trach'n'PEG, and the bedside RN administers the sedation and paralytics, monitors the VS and BIS, all that jazz.

RNMeg · Mar 16, 2015

At my facility we cannot push propofol under any circumstances - a nurse actually recently got fired for doing it. We can push anything else under the sun, though, it seems like - etomidate, fentanyl, versed, paralytics. I've not seen ketamine used much outside OR here. We can run propofol drips, too, on the Alaris using guard rails and we can titrate based on RASS score per the orders.