My SRNA research group is looking into the safety of RNs (non-CRNAs) using propofol for conscious/moderate/procedural sedation.
I would like to know, for the RNs that are allowed to use propofol/Diprivan for conscious sedation, if you have ever had any adverse reactions/outcomes that required advanced interventions (such bagging the patient, inserting oral/nasal airways, starting pressor or anything else you would like to share).
I will chime in a little later and tell you guys what the vast majority of the literature states.
Specializes in OR, PACU, GI, med-surg, OB, school nursing.
i work in vermont doing gi endoscopy. rns do not administer propofol; if there is a patient who needs more than versed and a narcotic, an anesthesia provider will come in and give the "milk of amnesia".
the only time i was responsible for giving propfol was on the med-surg floor, where we were giving it to a young woman dying of cancer. her pain was just terrible and her morphine tolerance was through the roof. it was the first time anyone had given propofol on the floor and everyone was very nervous about it. it allowed her to die a peaceful death.
"The best use I've ever see was a 19 year old male prostitute that was standing, naked, in the middle of his ICU bed. He was swinging his IV bag by the tubing and had already DC'd his Foley (bet THAT hurt the next time he had a trick!). He had his pulse ox cable and was threatening to hang himself from the ceiling, all because his hospitalization for a CHI from a assault made him miss is regular weekly well paying "john". He forgot he had a second IV and the charge nurse managed to get behind him and slide about 4 cc of propofol in his line. In about 30 seconds he just kinda wilted into a naked pile on the bed at which point in time he aquired a new hospital gown, 4 point restraints and a dose of geodon."
1. I hope that no one that reads this and thinks this is standard practice because it is not. You would not run up to a psych patient in crisis and push verced......
....(bet THAT hurt the next time he had a trick!).
2. Way to make fun of and exploit your patient, that's super professional.
"The only time I was responsible for giving propfol was on the med-surg floor, where we were giving it to a young woman dying of cancer. Her pain was just terrible and her morphine tolerance was through the roof. It was the first time anyone had given propofol on the floor and everyone was very nervous about it. It allowed her to die a peaceful death."
I am all about no pain and peaceful death, and also take patient advocacy to the extreme. But, did you know you publicly posted that you took part in what some may consider "Euthanasia"? We all have our "nursing secrets" but we prolly should be cognisant of the things that we share with others........because .......you never know!!
"The only time I was responsible for giving propfol was on the med-surg floor, where we were giving it to a young woman dying of cancer. Her pain was just terrible and her morphine tolerance was through the roof. It was the first time anyone had given propofol on the floor and everyone was very nervous about it. It allowed her to die a peaceful death."
I am all about no pain and peaceful death, and also take patient advocacy to the extreme. But, did you know you publicly posted that you took part in what some may consider "Euthanasia"? We all have our "nursing secrets" but we prolly should be cognisant of the things that we share with others........because .......you never know!!
Legally it's not considered euthanasia as long as it is being given with the intention of making the patient more comfortable, even if it is recognized that giving propofol may hasten the patient's death. It's a fine line. I had this clarified for me when we had an ICU patient who was completely with it and was being taken off the vent (by his choice) because he was never going to wean. He was given a propofol infusion to make him more comfortable. Perfectly legal. I suppose there are some who would be against this (likely because of their own religious views) and would try to call it euthanasia, but legally it's not.
The choice of the physician to use propofol for consious sedation turns it into a MAC case. There is no way to tell at what dose the patient transitions from moderate to deep (until after the fact). All you OR/PACU nurses know that during a case the MD cannot perform Anesthesia duties and vice versa. (thus there needs to be 2) The nurses who use it in the ED need to be aware of the effect that it has on cardiac output. Even though the clinical effect is minutes, the half life of the drug is still hours. :) You may have never had an emergency yet but...... it happens!
The choice of the physician to use propofol for consious sedation turns it into a MAC case. There is no way to tell at what dose the patient transitions from moderate to deep (until after the fact). All you OR/PACU nurses know that during a case the MD cannot perform Anesthesia duties and vice versa. (thus there needs to be 2) The nurses who use it in the ED need to be aware of the effect that it has on cardiac output. Even though the clinical effect is minutes, the half life of the drug is still hours. :) You may have never had an emergency yet but...... it happens!
Actually using propofol does not constitute monitored anesthesia care/MAC. MAC a is term used for billing anesthesia services when an anesthesia provider provides moderate/conscious sedation. For a more detailed explanation see: http://www.asahq.org/Newsletters/1998/12_98/ASAupdates_1298.html (although it can be a CRNA that provides and bills for MAC without the need for an anesthesiologist).
All sedating medications can drop cardiac output. Propofol is quite safe when compared to other sedating medications, but it can be quite detrimental just like any other medication when not used properly. I have coded a patient in the OR after giving 6mg of Etomidate (normal induction dose is usually somewhere around 20+mg), and etomidate is supposed to be one of the safest drugs for cardiac instable patients there is.
The half-life of propofol is hours, but like all drugs its duration of effect is directly related to redistribution (which is minutes in the case of propofol when given as a single injection and not as a infusion).
The reason for this thread was to see if nurses had detrimental outcomes using propofol for conscious sedation that would show possibly an ancedotal difference versus the published research studies for nurse administered propofol sedation.
I am neither for or against RNs using propofol for conscious sedation, but I think if RNs are going to use it they need to have extra training in its use and there should be strict limits on the amount of propofol and other sedating medications used on individual per procedure.
I am not disputing what MAC means.... As the link states, its not just for billing. In AZ both our hospital and outpatient surgery center policies clearly define that the use of propofol in a procedural setting requires "Monitored Anesthesia", because the training is not universal. We had an incident just last week when our anesthesiologist instructed our circulator to push 40 of diprivan during a lumbar pain block and VS were only taken twice during the 40 min procedure, pt was prone, no anesthesia cart, no airway available. She was unfamiliar with the drugs and gave it anyway, and anesthesia had it "under control". The patient was fine (it's not a question of skills) but her medical record is not. There is a plethera of evidence based practice utilizing these meds however the education is drastically different throughout the specialties of our profession. Mistakes will be minimized if the issue is more black and white instead of gray. Of course, CRNA experiences are on a more advanced level.
I am not disputing what MAC means.... As the link states, its not just for billing. In AZ both our hospital and outpatient surgery center policies clearly define that the use of propofol in a procedural setting requires "Monitored Anesthesia", because the training is not universal. We had an incident just last week when our anesthesiologist instructed our circulator to push 40 of diprivan during a lumbar pain block and VS were only taken twice during the 40 min procedure, pt was prone, no anesthesia cart, no airway available. She was unfamiliar with the drugs and gave it anyway, and anesthesia had it "under control". The patient was fine (it's not a question of skills) but her medical record is not. There is a plethera of evidence based practice utilizing these meds however the education is drastically different throughout the specialties of our profession. Mistakes will be minimized if the issue is more black and white instead of gray. Of course, CRNA experiences are on a more advanced level.
The whole idea behind MAC was so anesthesia providers could provide and be reimbursed for conscious/moderate sedation. The term/definiton was introduced for the purpose of providing a way for anesthesia providers to be reimbursed for a service that we do quite often, but that insurance companies do not want to pay for. FYI: A lot of insurance companies still won't pay for MAC so another term that is used quite often instead of MAC is total IV anesthetic/TIVA.
See excerpt below from the ASA on MAC:
"Because monitored anesthesia care is a physician service provided to an individual patient and is based on medical necessity, it should be subject to the same level of reimbursement as general or regional anesthesia. Accordingly, the ASA Relative Value Guide provides for the use of proper basic procedural units, time units and age and risk modifier units as the basis for determining reimbursement.*"
Here is few reference ariticles on nurse administered propofol sedation.
Aisenberg J, Cohen LB, Piorkowski JD, Jr. (2007). Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications. American Journal of Gastroenterology, . 102(4), 707-713.
Akin A, Guler G, Esmaoglu A, Bedirli N, A B. (2005) A comparison of fentanyl-propofol with a ketamine-propofol combination for sedation during endometrial biopsy. Journal of Clinical Anesthesia. (17), 187-190.
Cohen LB, Dubovsky AN, Aisenberg J, Miller KM. (2003). Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist. Gastrointestinal Endoscopy, 58(5), 725-732.
Cohen LB, Hightower CD, Wood DA, Miller KM, Aisenberg J. (2004). Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endoscopy, 59(7), 795-803.
Fanti L, Agostoni M, Arcidiacono PG, et al. (2007). Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomized controlled trial. Digestive and Liver Disease, 39(1), 81-86.
Fanti L, Agostoni M, Casati A, et al. (2004). Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP. Gastrointestinal Endoscopy, 60(3), 361-366.
Gasparovic S, Rustemovic N, Opacic M, et al. (2006). Clinical analysis of propofol deep sedation for 1,104 patients undergoing gastrointestinal endoscopic procedures: a three year prospective study. World Journal of Gastroenterology, 12(2), 327-330.
Harrington L. (2006). Nurse-administered propofol sedation: a review of current evidence. Gastroenterology Nursing, 29(5), 371-383; quiz 384-375.
I'm glad you are learning about how to get your reimbursement. In the clinic, we reference MAC as a type of anesthesia and are not thinking in insurance terms. You know, like "nursing slang"....... Thanks for the info!
I'm glad you are learning about how to get your reimbursement. In the clinic, we reference MAC as a type of anesthesia and are not thinking in insurance terms. You know, like "nursing slang"....... Thanks for the info!
Actually since I am military I care little about reimbursement issues. It was actually a former AANA president that pointed what MAC is actually used for and the reason behind the term.
Booty Nurse, BSN
93 Posts
i work in vermont doing gi endoscopy. rns do not administer propofol; if there is a patient who needs more than versed and a narcotic, an anesthesia provider will come in and give the "milk of amnesia".
the only time i was responsible for giving propfol was on the med-surg floor, where we were giving it to a young woman dying of cancer. her pain was just terrible and her morphine tolerance was through the roof. it was the first time anyone had given propofol on the floor and everyone was very nervous about it. it allowed her to die a peaceful death.
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