Sedation by non-anesthesia personel

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Along similar lines as the recent discussion about RNs pushing certain drugs for sedation, how do you feel about the rules which allow non-anesthesia physicians to push these drugs if RNs can't?

For example, in an Emergency Room where I used to work, sometimes the ER MD would want to do some sort of sedation for a procedure and would want to use propofol. RNs there were not allowed to push propofol (they could only administer a drip for mech vent.) so the MD would push it while the RN monitored the pt. Often times, the same MD doing the procedure would also push the drug. Now, to me, that seems like a loophole around adequate monitoring. The RN is still the one monitoring the patient, it's just the MDs hand actually depressing the plunger.

What's the difference here between this situation and the RN doing it and the MD saying, "OK, give another ml."?

Am I missing something? Should an anesthesia provider of some sort (MDA or CRNA) be required to do this? If I'm not understanding something, educate me. :)

bryan

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I was in the GI Lab as a student and the MD was pushing the propofol

without taking his eye off the scope for more than a second or two. The pt

would move a little and he'd just give a bolus and right back on the scope.

The thing I thought strange about the deal is that the RN was behind the doc

setting up for the next procedure, and an unliscensed tech was helping with the pt.???

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My opinion is that an ER physician is trained in advanced airway techniques so I wouldn't have a problem with it. He/she is used to intubating, etc. Propofol esp has such a short half life that the effects should be gone shortly and the RN needs to continue to monitor the airway continuously for some time. As far as folks using it in GI lab, specials, etc it's just too much. I find ER would be ok under certain monitoring situations. I am sure some would disagree.

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My opinion is that an ER physician is trained in advanced airway techniques so I wouldn't have a problem with it. He/she is used to intubating, etc

I don't know. I've seen a disconcerting amount of variability between some of the ER physicians advanced airway skills. Many are quite good...and others are..um...well...terrible.

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My opinion is that an ER physician is trained in advanced airway techniques so I wouldn't have a problem with it. He/she is used to intubating, etc. Propofol esp has such a short half life that the effects should be gone shortly and the RN needs to continue to monitor the airway continuously for some time. As far as folks using it in GI lab, specials, etc it's just too much. I find ER would be ok under certain monitoring situations. I am sure some would disagree.

Well, I would agree with you to a point. There were times when another service, say ortho, was performing the procedure and the ER MD wass totally dedicated to managing the airway and the sedation. But there are also times when the SAME MD doing the procedure is giving sedation. My questioning isn't with the MDs ability to manage an airway (although I agree with the poster who said some are terrible!), it's the lack of attention paid to the sedation. Like the other poster who talked about the GI scenario. That MD was focused on his procedure and not on the sedation. In that situation, why not have an RN (or for that matter, ANYONE, as long as the MD is telling them when to push) push the drug. It just doesn't seem safe to me. It seems like a semantical way around the Nurse Practice Act.

"No, your honor, the RN didn't push the drug. An MD did."

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I recently took care of a pt who went for an ERCP, where anesthesia were not the providers of sedation. At this particular facility, the RN's who work in the GI suite push the drugs for sedation. Well, they give 2mg versed, and 25mcg fentanyl. They lost the airway, and obviously did not know how to intervene, the patient respiratory arrested, went into V-fib, and the rest is history. The pt was resuscitated and I took care of him last week, and extubated him on my shift. The family were furious and were threatening to sue the hospital. When I got report I knew what had occurred without even reading the chart. People just do not seem to realize how dangerous it is to do conscious sedation without appropriate staff being immediately available to manage the airway, be it the intensivist, a respiratory therapist who knows how to open up the airway and ventilate properly, or anesthesia.

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Specializes in Nephrology, Cardiology, ER, ICU.

Although not a CRNA, I am a very experienced ER RN. At our level one trauma center, the RN staff receive additional training in moderate sedation for both adults and peds. Our ER MD's are very skillful in managing airway in very difficult situations and do a very good job. Our hospital does have 24/7 anesthesia coverage. However, in 9 years in the ER, I have seen anesthesia come down less than a dozen times and most of that was due to surgical airway issues in trauma patients.

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it's an anesthesia drug boys and girls. plain and simple. except for use in mechanically ventilated patients in the icu, it should not be used by non-anesthesia personnel.

in our hospital, only anesthesia personnel are allowed to push propofol, pentothal, brevital, and ketamine. nobody else. ever. we have a conscious sedation team. they cannot use propofol. you want propofol and the other drugs i listed? call anesthesia.

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I am not a CRNA. As an experienced critical care nurse CCRN 20+ years) working nights we often administer conscious sedation for emergency cardioversions and bedside endoscopy. I do NOT push propofol, pentothal, brevital, or ketamine.

The practice committe at my hospital solved the problem of an ER doc wanting the same RN who had four patients to administer propofol for orthopedic procedures by asking for the written policy and procedure. This must be approved and signed by pharmacy, medicine, nursing, and administration.

Our BRN advisory was helpful The RN responsible for monitoring the patient must not be distracted with assisting the physician.

http://www.rn.ca.gov/practice/pdf/npr-b-06.pdf

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I am not a CRNA. As an experienced critical care nurse CCRN 20+ years) working nights we often administer conscious sedation for emergency cardioversions and bedside endoscopy. I do NOT push propofol, pentothal, brevital, or ketamine.

The practice committe at my hospital solved the problem of an ER doc wanting the same RN who had four patients to administer propofol for orthopedic procedures by asking for the written policy and procedure. This must be approved and signed by pharmacy, medicine, nursing, and administration.

Our BRN advisory was helpful The RN responsible for monitoring the patient must not be distracted with assisting the physician.

http://www.rn.ca.gov/practice/pdf/npr-b-06.pdf

Some states specifically prohibit RN's from administering propofol, and wisely so. Check out the package insert on propofol - again, it's an ANESTHESIA DRUG. Trust me - the attorneys know this and will hang you out to dry if you ever have a problem with it.

NO ONE uses propofol for "conscious sedation". That's why it's used so much by gastroenterologists and ER types and the nurses that work there. There are plenty of drugs and combinations of drugs to use for conscious sedation. Propofol is used, by and large, inappropriately, to get people to a deeper level of sedation, even though that is totally inappropriate for non-anesthesia professionals to be doing. The key word is CONSCIOUS sedation.

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Propofol is used, by and large, inappropriately, to get people to a deeper level of sedation, even though that is totally inappropriate for non-anesthesia professionals to be doing. The key word is CONSCIOUS sedation.

Do you think they like it for level of sedation, or just turnaround time?

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Yeah, ER docs push the drugs and miss the airway or tear the cuff and call anesthesia to clean up the mess

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