Should RNs administer propofol? Providers stand on both sides of issue
Should RNs administer propofol? Providers stand on both sides of issue
Is nurse ready to rescue a patient who slips into general anesthesia?
Most same-day surgery providers agree that propofol offers great advantages in outpatient surgery: It hastens patient recovery and is easy to titrate.
But is it legal and safe for RNs who aren’t certified registered nurse anesthetists (CRNAs) to provide it? Therein lies the million-dollar question. The issue is drawing the attention of RNs, nurse anesthetists, anesthesiologists, state boards of nursing, state legislatures, and others.
While it generally is accepted for RNs to administer propofol on a slow drip in intensive care units where most patients are intubated and mechanically ventilated, nurse-administered propofol is expanding to gastrointestinal endoscopy, ophthalmology, plastic surgery, and dental surgery.1 In outpatient surgery, where there are always time and cost pressures, propofol is seen as one way to alleviate those pressures. While propofol makes the total cost per case higher, the costs can be made similar to standard sedation costs if a registered nurse administers the drug, some sources say.1
"We can’t afford anesthesiologists," says John A. Walker, MD, president of Gastroenterology Consultants in Medford, OR. "I think that if I were to do every single case with an anesthesiologist, the insurance company would come knocking on our door and ask, What’s going on here?’" Also, there is a shortage of anesthesiologists, he points out.
At the same time, RNs increasingly are being educated at a higher level, says Sandra Tunajek, CRNA, ND, director of practice at the American Association of Nurse Anesthetists in Park Ridge, IL.
Many providers question whether it is safe for RNs to administer propofol. Some states laws restrict who can administer propofol, providers say. Thirteen states forbid the practice in their nurse practice acts, but many state boards of nursing have not issued a statement or opinion.1
"Physicians and nurses don’t seem to understand that their licenses could be at risk," Tunajek says. "[Nurses] believe that physicians gave them an order, so it’s OK if the hospital doesn’t prohibit them."
The American Society of PeriAnesthesia Nursing in Cherry Hill, NJ, and the Association of periOperative Registered Nurses in Denver don’t have formal positions on nurse-administered propofol. The Society of Gastroenterology Nurses and Associates (SGNA) in Chicago does not recommend nurse-administered propofol at this time. However, at the spring 2003 SGNA conference, a paper presented on nurse-administered propofol sedation (NAPS) concluded, "State laws or local institutional policies may prohibit NAPS, but should relax as authorities and anesthesiologists become aware of the evidence base supporting NAPS."2
For it’s part, the American Society of Anesthe-siologists in Park Ridge, IL, recommends that any practitioner who administers propofol be qualified to rescue patients from any level of sedation, including general anesthesia.3
Additionally, some nurses are reluctant to administer propofol, even in states where it is allowed.
But there are strong proponents of the practice. "We’ve done 15,200 cases with beautiful results," Walker says. Of those cases, there was one definite aspiration, which required hospitalization, he says.4
At Indiana University Medical Center in Indianapolis, a study of 2,000 endoscopic cases of RN-administered propofol resulted in no endotracheal intubation or hospital admission.5
Walker supports nurse-administered propofol, as long as it is performed with adequate training and a strict protocol that protects patients’ safety. For some facilities, nurse-administered propofol requires extra staffing in the endoscopy suite, he says. Facilities should have a registered nurse and a technician, because the nurse should have no other tasks except to administer sedation and monitor the patient, Walker maintains.4 However, some facilities, such as Walker’s, used this staffing pattern before converting to nurse-administered propofol.
Same-day surgery providers warn that providers need to realize that with propofol, a patient easily can slip from conscious sedation to general anesthesia.
"And additionally, every patient responds differently to the drug, so what might be a normal dose for one individual is an overdose for another," Tunajek warns. "The problem is the ability of the person giving the drug to rescue patients from that deeper level of consciousness who fall into an unconscious state or general anesthesia. This often requires a qualified anesthesia provider to assist in resuscitating the patient."
Anesthesia providers are more experienced at titrating drugs to patient effect, she adds.
When administered by folks who are not specifically trained in the administration of general anesthesia, propofol can be an extraordinarily dangerous agent, says Jeffrey L. Apfelbaum, MD, professor and chair of the department of anesthesia and critical care at the University of Chicago Hospitals.
"It is for this reason that the package insert — both for the generic and trade formulations — is quite clear on the restriction of use to those practitioners who have been trained in the administration of general anesthesia," Apfelbaum says.
If RNs give propofol to patients for IV sedation for outpatient surgical procedures, they put themselves and their patients at risk, says Rosemary Lane, CRNA, MS, JD, an attorney in New York City. If a patient has a problem, the RN who gave the propofol, "negligently" disregarding the warning, will have a liability problem, she warns.
The medication insert cautions that the person administering propofol should not be involved in conducting the surgical procedure, Lane points out.
"This means that the physician performing the procedure should not be directing an RN in the administration of propofol," she says.
If RNs are using it frequently, it is only a matter of time before you will hear about an adverse event, Lane warns. "Many anesthesia providers, with years of experience using propofol for sedation, have had to deal with a patient with the sudden onset of airway obstruction, loss of consciousness, or apnea," she says.
If you do have nurses administer propofol, you may want to look at the training conducted by Walker’s facility.4 Nurses had approximately two weeks of training. Nurses observed the anesthesiologist administer propofol, watched a video of conscious sedation guidelines, passed a written examination on the pharmacokinetics and properties of propofol, then observed the anesthesiologist administer propofol in the endoscopy suite. The final step was for nurses to administer propofol under the supervision of the anesthesiologist.
Walker uses nurses who have had extensive experience in the recovery room and as endoscopic assistants and are certified in advanced cardiac life support (ACLS).4 However, some sources maintain that ACLS alone isn’t sufficient.1 They point to the fact that rescuing a patient involves practice such as endotracheal intubation and placing a laryngeal mask airway. They also say that ACLS skills may not be used often enough in outpatient settings so that nurses can be confident in using them.
Walker’s study recommends that patients who are at high risk — seriously ill, at risk for aspiration, or have difficult airways — be excluded from nurse-administered propofol.4
In the meantime, expect more action at the state level on nurse-administered propofol, Tunajek predicts. "Every state is looking at setting standards for physician office practices," she says. "Those regulations could include language that could forbid RNs" from administering propofol, Tunajek says.
References
1. Meltzer B. RNs pushing propofol. Outpatient Surgery July 7, 2003. Accessed at www.outpatientsurgery.net.
2. Rex D, Overley C, Walker J. Registered nurse administered propofol sedation (NAPS) for upper endoscopy and colonoscopy: Why? When? And how? Presented at spring conference of the Society of Gastroenterology Nurses and Associates. Chicago; March 2003.
3. Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Park Ridge, IL: American Society of Anesthesiologists; October 2001.
4. Walker JA, McIntyre RD, Schleinitz PF. Nurse-administered propofol sedation without anesthesia specialists in 9,152 endoscopic cases in an ambulatory surgery center. Am J Gastroenterol 2003; 98:1,744-1,750.
5. Rex DK, Overley C, Kinser K, et al. Safety of propofol administered by registered nurses with gastroenterologist supervision in 2,000 endoscopic cases. Am J Gastroenterol 2002; 97:1,159-1,163.
Sources and Resource
For more information on nurse-administered propofol, contact:
- Sandra Tunajek, CRNA, ND, Director of Practice, American Association of Nurse Anesthetists, Park Ridge, IL. E-mail: [email protected].
- John A. Walker, MD, President, Gastroenterology Consultants, Medford, OR. E-mail: [email protected].
For information on where your state board of nursing stands on who can administer propofol, go to www.ncsbn.org and click on "news and views," "state updates," "practice issues," and "conscious sedation."
Most same-day surgery providers agree that propofol offers great advantages in outpatient surgery: It hastens patient recovery and is easy to titrate.Subscribe Now for Access
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