Sedation in an outpatient setting

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I am a nurse of five years. Right out of school I worked in the neuro-ICU for about one and half years, then I worked as a PICC nurse for the last 4 years. I just landed a job as the only nurse for a pain management clinic in a larger imaging company. We currently give oral sedation for some procedures but will be starting IV sedation soon. I am ACLS certified and have had experience giving IV sedation in the ICU setting. I have given sedation many times in the ICU settting but am having anxiety about giving sedation in the outpatient setting. I have been studying up on the medications, what to look out for, etc...but I need a resource in the techniques of administration.

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Specializes in multispecialty ICU, SICU including CV.

Be very wary of this situation. I would find out exactly what the expectations are and what drugs you are going to be giving, what level of sedation is expected, what procedures they are performing, etc. before I would commit to anything. This is especially important if you are going to be the only nurse there and might not have anyone to back you up if you run into problems.

Let me tell you about my situation, which was somewhat similar. I moved to another area after about 18 months of hospital experience on a stepdown unit. I took a job in a freestanding endoscopy center. I was trained initially to work pre- and post- procedure. Eventually, they started training me to work in the procedure suites. The nurses that worked in the rooms sedated with PROPOFOL and fentanyl with NO PROTECTED AIRWAY. Being a relatively new grad and not having any ICU background at the time, I didn't realize what a big huge issue this was. The patients were typically totally out and I would classify the level of sedation the patients generally received as what anesthesia refers to as a MAC (monitored anesthesia care.) This is a level of sedation beyond conscious sedation, which in many states, is out of the scope of practice of an RN if the patient does not have an ETT in place. We had no anesthesia staff supervising us and our GI doctors probably hadn't intubated a patient since their residency. Eventually the parent hospital corporation that owned the endoscopy center caught wind of this (I think) and put the kabosh on nurses using propofol there (yes, it was against this states nurse practice act.) The doctors continued to want it and got around the guidelines by having the nurse hook it up to the IV line, pushing it themselves, and signing off on the "conscious sedation" paperwork the RNs used for their procedural documentation. I feel that it was very unsafe. The crash cart was like 100 years old and to my recollection, there were no ETTs on it. I left there after about 6 months for unrelated reasons.

Please at a minimum do yourself a favor and investigate your state's nurse practice act with regards to what is acceptable in RN practice and what falls into the practice of the CRNA/MD. I sincerely doubt your employer would back you up if an adverse event happened to your patient if you were working outside of your scope of practice, even if they asked you to do it.

I feel that many small practices want to hire an RN to do these types of jobs because they are a lot cheaper than a CRNA, and are hoping that the RN doesn't know any better. DO NOT let that be you.

Many pain specialists these days are former anesthesiologists, which may cover you legally if there is someone qualified there to supervise you at all times these drugs (whatever they are) are being given.

Please, please, please do your research. Don't get caught in an unsafe situation that could potentially ruin your licensure.

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Specializes in Anesthesia.

If your going to do moderate sedation (old term conscious sedation) anywhere you should have the same basic supplies you would have available in the ICU.

1. Suction

2. Oxygen

3. BVM

4. Oral/Nasal airways

5. A reliable way to automatically take BP (every min if needed), continuous pulse ox/EKG, and preferably end tidal CO2 monitor.

6. Up to date crash cart with everything you need for a code.

7. Designated code plan (such as how do get the patient to the nearest ER/how are the EMTs going to easily get to you, if you can't ventilate the patient with a BVM who attempts to intubate the patient)

8. You also need to have an established protocol to determine which patients are too sick/unqualified to have outpatient sedation done by nonanesthesia providers (such as ASA 3-4pts, patients over a certain BMI, patients with moderate to severe OSA, chronic pain patients on high dose narcotics etc).

I personally don't have anything against RNs administering low dose propofol, but this subject is highly controversial and only about 20+ odd states allow RNs to administer propofol/fospropofol along with few other drugs like ketamine for sedation purposes. Fospropofol is a new drug and carries the same anesthesia only labeling as propofol just so you don't get tricked into using one over the other.

Just a personal pet peeve of mine and please don't take offense: MAC is a billing term that anesthesia uses to describe sedation when it is administered by an anesthesia provider. When you administer moderate sedation you should know that there are 4 levels of sedation: Minimal, Moderate, Deep and General anesthesia. As an RN in the outpatient setting with a nonsecured airway you should try to stay within minimal to moderate sedation realm, and know what to do if it goes beyond that level.

Here is website that I have found that is at least worth a look through if you are considering outpatient sedation. SedationFacts.org: Moderate Sedation (Conscious Sedation) Information

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Specializes in multispecialty ICU, SICU including CV.

I thought MAC automatically meant deep sedation...beyond moderate at any rate. I didn't know it was a billing term. TY. :clown:

Sedation level used at previous place of employment posted above -- deep.

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Specializes in Anesthesia.
I thought MAC automatically meant deep sedation...beyond moderate at any rate. I didn't know it was a billing term. TY. :clown:

Nope, I can walk in to do anesthesia for cataracts give nothing more than 0.5mg of Versed or nothing for the whole case, but because I am in there monitoring the patient for the whole case I can bill for MAC or at least I could if I was civilian and not military.

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Specializes in CRNA, Finally retired.
If your going to do moderate sedation (old term conscious sedation) anywhere you should have the same basic supplies you would have available in the ICU.

1. Suction

2. Oxygen

3. BVM

4. Oral/Nasal airways

5. A reliable way to automatically take BP (every min if needed), continuous pulse ox/EKG, and preferably end tidal CO2 monitor.

6. Up to date crash cart with everything you need for a code.

7. Designated code plan (such as how do get the patient to the nearest ER/how are the EMTs going to easily get to you, if you can't ventilate the patient with a BVM who attempts to intubate the patient)

8. You also need to have an established protocol to determine which patients are too sick/unqualified to have outpatient sedation done by nonanesthesia providers (such as ASA 3-4pts, patients over a certain BMI, patients with moderate to severe OSA, chronic pain patients on high dose narcotics etc).

I personally don't have anything against RNs administering low dose propofol, but this subject is highly controversial and only about 20+ odd states allow RNs to administer propofol/fospropofol along with few other drugs like ketamine for sedation purposes. Fospropofol is a new drug and carries the same anesthesia only labeling as propofol just so you don't get tricked into using one over the other.

Just a personal pet peeve of mine and please don't take offense: MAC is a billing term that anesthesia uses to describe sedation when it is administered by an anesthesia provider. When you administer moderate sedation you should know that there are 4 levels of sedation: Minimal, Moderate, Deep and General anesthesia. As an RN in the outpatient setting with a nonsecured airway you should try to stay within minimal to moderate sedation realm, and know what to do if it goes beyond that level.

Here is website that I have found that is at least worth a look through if you are considering outpatient sedation. SedationFacts.org: Moderate Sedation (Conscious Sedation) Information

Anesthesiologists who also do pain management are not allowed to supervise sedation and do a block simulataneously.

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Specializes in Anesthesia.
Anesthesiologists who also do pain management are not allowed to supervise sedation and do a block simulataneously.

Hmm...where is that written, and how is that different than a GI doc or any other physician/practitioner supervising sedation during a procedure. The anesthesiologist can't be the one administering/monitoring the patient while doing a pain procedure if that is what you mean. MDAs and other practitioners supervise sedation all the time during pain procedures.

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Specializes in CRNA, Finally retired.

Sorry, I wasn't clear. We're using Propofol for sedation in the pain cases - not conscious sedation.

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