Propofol sedation_ who should administer_

issue Problem: Using propofol ( DIPRIVAN) to sedate patients during endoscopic and other diagnostic procedures is gaining momentum in a growing number of hospitals, outpatient surgery centers, and physician offices.(1) In trained hands, propofol offers many advantages over other drugs used for sedation because it:

Trained nurses in most critical care settings often administer propofol safely to patients who are intubated and ventilated. Pipelle endometrial biopsy However, some practitioners have been lulled into a false sense of security, allowing the drug’s good safety profile to influence their beliefs that propofol is safer than it really is. Endometrial biopsy procedure In untrained hands, propofol can be dangerous, even deadly; administration to a nonventilated patient by a practitioner who is not trained in the use of drugs that can cause deep sedation and general anesthesia is not safe, even if the drug is given under the direct supervision of the physician performing the procedure.(2) After all, how much supervision can the physician provide if he or she is focused on the procedure itself? Not enough, as the following events show.

Believing that propofol was “used all the time in ICU,” a gastroenterologist asked a nurse to prepare “10 mL” (10 mg/mL) of the drug for a patient undergoing endoscopy in his room. Endometrial biopsy side effects The nurse obtained the drug from an automated dispensing cabinet via override before she transcribed the order to the patient’s record.

Liver biopsy recovery time Another nurse who was trained in the use of moderate sedation, but not deep sedation or anesthesia, assisted the gastroenterologist. Abnormal endometrial biopsy results After questioning the physician about the dose (100 mg is a high dose), she began administering the propofol via an infusion pump. Endometrial biopsy recovery The patient suddenly experienced respiratory arrest. Endometrial biopsy video Fortunately, ICU staff were able to help with the emergency and quickly intubated and ventilated the patient.

Another case involved a physician who thought he could safely administer propofol himself while performing a breast augmentation. Pain after endometrial biopsy Unfortunately, his patient, a young woman, died of hypoxic encephalopathy because he failed to notice the patient’s rapidly declining respiratory status, as had his surgical assistant, who was not qualified to monitor patients under deep sedation or anesthesia.(3)

Nurses have also been asked to administer “a little more” propofol if the patient moved after the anesthesiologist left the room. Cervical biopsy recovery In these cases, the anesthesiologist would leave the propofol syringe and needle in the IV port after placing the block and leave the nurses in the room to monitor the patient alone. Endometrial biopsy complications Initially, the nurses reluctantly complied. Hysteroscopy endometrial biopsy Later, they brought the issue to the attention of hospital leaders, citing that they were worried about the safety of this practice.(2)

Strict product labeling. Breast biopsy recovery time AstraZeneca, the manufacturer of Diprivan, states in its product labeling that the drug is intended for general anesthesia or monitored anesthesia care sedation, and that the drug should be administered only by persons trained in the administration of general anesthesia and not involved in the surgical/diagnostic procedure. Endometrial biopsy ivf (For sedation of intubated, mechanically ventilated adult patients in the ICU, product labeling notes that the drug should be administered only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management.)

Unpredictable and profound effects. Endometrial biopsy pain Propofol dosing and titration is variable, based on the patient’s tolerance to the drug. Breast biopsy recovery Profound changes can occur rapidly. Endometrial biopsy results time frame A patient can go from breathing normally to a full respiratory arrest in seconds, even at low doses, without warning from typical assessment parameters.(2)

No reversal agent. Endometrial biopsy results interpretation Unlike other sedation agents (e.g., midazolam, morphine), there is no reversal agent for propofol. Endometrial biopsy results Adverse effects must be treated until the drug is metabolized.

Financial incentives. Bleeding after endometrial biopsy Unwillingness of insurers to reimburse anesthesia care for some procedures such as diagnostic endoscopy has increased the use of nurse-administered propofol.(1,2) Untrained nurses may be caught in the middle of the debate and feel pressured to administer propofol.(2)

Legal barriers. What is endometrial biopsy Nurse-administered propofol falls under each state’s Nurse Practice Act. Endometrial biopsy results how long More than a dozen states specifically consider this function beyond the scope of nursing practice.(2)

Safe Practice Recommendation: At each organization, an interdisciplinary team, including chair of the anesthesia department, should establish policies and practice guidelines for the administration of propofol (or other induction agents such as thiopental, methohexital, or etomidate) to nonventilated patients undergoing surgical or diagnostic procedures. What is an endometrial biopsy To best inform your team’s decision about this controversial issue, consider the following:

Review regulations/position statements. Biopsy endometrial Check with your State Board of Nursing to determine if nurse-administered propofol is deemed within the professional nurses’ scope of practice. Skin biopsy results time If so, explore the various position statements available on this topic from professional societies, including the:

In brief, the ASA, AANA, and AAAASF believe that only persons trained in the administration of general anesthesia, who are not simultaneously involved in the procedures, should administer propofol to nonventilated patients. Pipelle endometrial biopsy The ASA also suggests that, if this is not possible, non-anesthesia staff who administer propofol should be qualified to rescue patients whose level of sedation becomes deeper than intended, and who enter, if briefly, a state of general anesthesia. Endometrial biopsy procedure The ACG, AGA, ASGE, and SGNA endorse nurse-administered propofol under the direction of a physician if state regulations allow it, and if the nurse is trained in the use of drugs causing deep sedation and capable of rescuing patients from general anesthesia or severe respiratory depression.

Define policies. Endometrial biopsy side effects Based on patient safety, professional association position statements, and applicable state laws, determine the qualifications of professionals who can administer propofol to nonventilated patients during procedures. Liver biopsy recovery time If nurse-administered propofol is acceptable, specify the circumstances and required education and mentorship that must be accomplished beforehand, and competencies that must be evaluated and met periodically (ACLS certification alone is not sufficient (2)). Abnormal endometrial biopsy results Decide if the location of propofol administration plays a factor. Endometrial biopsy recovery Location need not be limited if criteria are met, including expertise to intubate patients, which is difficult to meet in physician office settings.(1) Define the intended level of sedation. Endometrial biopsy video However, even if moderate sedation is intended, all patients given propofol should receive care consistent with deep sedation.

Establish a continuous monitoring process and assessment criteria (e.g., vital signs, oxygen saturation, ideally capnography) for nonventilated patients who are receiving propofol. Pain after endometrial biopsy Ensure that equipment is readily accessible at the point of care to maintain a patent airway, provide oxygen, intubate, ventilate, and offer circulatory resuscitation.

Conclusion. Cervical biopsy recovery The debate about who should be allowed to administer propofol may continue, but one thing is clear: whenever propofol is used for sedation/anesthesia, it should be administered only by persons who are: (1) trained in the administration of drugs that cause deep sedation and general anesthesia, (2) able to intubate the patient if necessary, and (3) not involved simultaneously in the procedure itself.

References : (1) Marshall S. Endometrial biopsy complications Pleasant dreams: office surgeries fuel demand for anesthesiologists. Hysteroscopy endometrial biopsy Crain’s New York Business. Breast biopsy recovery time January 10, 2005. Endometrial biopsy ivf (2) Meltzer B. Endometrial biopsy pain RNs pushing propofol. Breast biopsy recovery Outpatient Surgery. Endometrial biopsy results time frame 2003;4(7). Endometrial biopsy results interpretation (3) WFTS ABC Action News. Endometrial biopsy results Doctor still on the hook for ‘accidental’ surgery death. Bleeding after endometrial biopsy ABC Action News Tampa-St. What is endometrial biopsy Petersberg. Endometrial biopsy results how long March 18, 2004.