Diprivan outside Anesthesia - I had to do it ;)

[MmacFN]

Ok

Lets start off by saying that this is not acceptable.

At the end of the day, no matter how many good experiences one person may have had with Diprivan, the fact is it says right on the package "to be given by anesthesia".

If for no other reason, the liability alone should be enough to avoid the use.

Besides that, my largest concern is aspiration. While many hospitals have it well documented that the RN does not give the drug and the MD (GI or ER) does, this isnt what is happening in practice most of the time. An extra 5ccs end in a patient near resp arrest and hypotensive.

Why take the risk?

Please post here about the dangers so we can have this well established before people come in saying it is "OK"

[Seneca]

You're talking about a non-intubated pt. right? It's pretty routine in the several ICU's that I've had experience in w/ vented patients, but I have heard rumblings about "only by anesthesia"

[yoga]

Last week, six cases, PS 1 and 2, having cosmetic surgery. Should be easy. With propofol induction, 2 had respiratory depression requiring ventilation and 1 had major drop in blood pressure. They had valium p.o for pre-med and nothing else. I know how to recognize and manage these problems, what would a non-anesthetist do in this situation in an unintubated patient?

They don't know what they don't know and that is the problem

yoga

[JenSICUCCRN]

Staff nurse here in the process of applying for CRNA school, and I won't IVP diprivan...AT ALL!!!! We do have intubated pt's on drips, especially neuro/hear traumas for easier assessment when turned off. If you are a non-neuro/head trauma pt. in our unit (Trauma/SICU) our surgery team will put you on versed and fentanyl....no diprivan drips hardly ever secondary to the dangers and infection risk in long term use. If they come up from ER with it, we change it ASAP.

Interesting story....I had 'words' with a CRNA about propofol one night. She came to our unit to intubate a patient (they will usually bring their own drugs, but she didn't) and asked me to push diprivan and I told her No, that I couldn't do that...that she had to and she was very nasty to me about it. She said, I'm standing right here with you, and I told her that I didn't IVP diprivan that she was supposed to even if she was standing there or not. Needless to say, she wasn't happy about it, but she did it herself. The only time I've EVER had a CRNA ask me to do that....thankfully.

I have always thought that some nurses are too eager to give drugs and do procedures that they aren't supposed to be doing. Just my opinion of course.

Jenny

[yoga]

Jenny,
I understand your reluctance to inject propofol, however you will find many times in your career as a CRNA when you need the circulating nurse or surgeon to help you by pushing drugs. It happens to me very frequently and I believe it is much more important for me to do airway things and have the nurses help with medications.

It is NOT a legal issue, it is what is best for patient care. I work in California where the Board of Nursing have specifically stated that it is permissable for an RN to take orders from a CRNA.

My point with propofol is nurses administering it to an unintubated patient when there is no anesthesia professional present.

I am not trying to be hard on you, just asking you to keep an open mind in some situations.

Yoga

[athomas91]

just wanted to add - in my institution - the GI lab does their own "sedation" - the score for anesthesia vs. GI lab
anesthesia - 0 adverse outcomes
GI lab - 2 deaths in the past year and over 10 calls for anesthesia to bail them out.

[MmacFN]

wow

How is it that the hospital keeps it going? The liability should be enough alone to stop that practice

[JenSICUCCRN]

Yoga,

I don't take any offense to your reply at all-LOL. I'm pretty hard to offend. I am still a staff nurse in the application process to CRNA school, and you guys are the experts in this area. However, in my state (WV) it is against our nurse practice act to IVP diprivan at all...no ifs, ands or buts. That is why I won't do it. If we are found in my facility (large county hospital) to have pushed diprivan we get in trouble. Not to say that I don't know RN's that have done it, but I won't do it.

I also agree that you should have the primary responsibility for the airway, and my question is this? Is it different in the OR for the nurses since the CRNA is there to manage the airway? I work in a Trauma/SICU and we don't do conscious sedation on a regular basis, but we have done them. Almost all of our patients are intubated when we drop lines, PA caths, etc. and are already sedated and on pain drips.

Jenny

[TranMan]

I was recently called to Radiology to give sedation for a patient with dementia so that the radiologists (?) can do a spinal tap under radiography. Transerring a demented patient onto their table seem like a huge Pain in the Ass, so I offered to turn him on his side in the stretcher and do the tap w/o radiography. Everyone, including the radiologists glared at me in amazement as if to say you can do that without the aid of radiography? I was like.."yeah we do it day in and day out". Well, I asked one of the techs to push some additional versed for me while I was sterile and doing the tap. One quickly obliged while another person was clearly very uncomfortable with it, stating it was outside the realms of her practice as a tech. I would have used an RN, but none where around. I felt comfortable with it b/c I was there and could handle the consequences. I also would not ask anyone to do anything they are uncomfortable with.

Jenny, I understand where you are coming from. Maybe one of these days as a CRNA, you'll find yourself in that situation and remember your earlier experience and laugh about it.

[JenSICUCCRN]

Its also great to see the other point of view...from the CRNA perspective that is. I hope that I get to see it from that point of view soon

Jenny

[MmacFN]

good example

On the otherhand. If the BRN dosent have provisions for the RN to do something your asking regardless of the need, they may well be fired for doing it. I like how you approached that situation Tran, respectful of the assistants situation.

[athomas91]

I am sure those of you who were at the national conference are aware of this - but i just learned of it today...
apparently there is a new drug ?aqua something? and it is a prodrug of propofol that is in trials to be approved for conscious sedation (to be administered by those OTHER than anesthesia providers)
apparently the sedation at the same mcg/kg is less than w/ propofol - and in patient trials there were too many OD's - so it is back to animal trials...
boy - they are trying anything to get around having trained providers give meds.

[NursePink]

Not to drudge up an old thread, but I ran across something today that you guys might find interesting. I was helping a friend look up scopes of practice for RNs & I found this little ditty in the Oklahoma nursing guidelines. :)

Rapid Sequence Intubation Guidelines -
Medication Administration by Registered Nurses
I. Introduction/Purpose:
A. In accordance with the Oklahoma Nursing Practice Act, specifically §
567.3a.10.a, it is within the scope of practice of a certified registered nurse
anesthetist (“CRNA”) to administer anesthesia, under the supervision of a medical
doctor, an osteopathic physician, a podiatric physician or dentist licensed in this
state and under conditions in which timely onsite consultation by such doctor,
osteopath, podiatric physician or dentist is available, and pursuant to national
certification and recognition by the Oklahoma Board of Nursing (“Board”).
B. Advanced Registered Nurse Practitioners, Clinical Nurse Specialists, Certified
Nurse Midwives, Registered Nurses and Licensed Practical Nurses are not
allowed to administer deep sedation/ analgesia or general anesthesia, except in
accordance with the Oklahoma Nursing Practice Act and Rules of the Board or in
compliance with Declaratory Rulings and/or guidelines authorized by the Board.
C. According to the American College of Emergency Physicians, rapid sequence
intubation is an important technique for airway management of patients in the
emergency department and is in the domain of emergency medicine practice.
Anesthetic agents are commonly used to facilitate emergent intubation. To
require the licensed provider who is managing the patient’s airway to leave the
airway in order to administer the anesthetic agent compromises patient safety.
D. Registered nurses may assist a *licensed provider by administering anesthesia
agents/paralytic agents/sedative analgesics in situations where the provider is
present but unable to personally inject the agents because the provider is
performing the critical task of airway management for the patient during rapid
sequence intubation, provided the registered nurse has the educational preparation
and clinical competence to inject such agents.

[kmchugh]

This is one of those things guaranteed to get my goat. I get so tired of RN’s, particularly those studly ER RN’s claiming to be sufficiently competent to give IVP propofol, etomidate, or ketamine. What really gets me is “I’m ACLS certified, I can handle an airway if the patient stops breathing!” I’ve said it (and heard lots of other CRNAs say) “it isn’t what you don’t know that bothers me so much. Its that you are completely unaware of what you don’t know that frightens me so much.” I think lately I’d add to that “and your arrogance in wanting to lecture those who DO know what you don’t want to know.”

Of course there is the issue of the airway, but it goes so far beyond that. I don’t care if they have given the drug ten thousand times without incident. When 10,001 dies because they couldn’t ventilate or intubate the patient, and the patient’s pressure fell into the toilet, how much solace will they take in all the times it didn’t happen? More to the point, how much solace can the patient’s family take from the fact that their kid just happened to be that one in ten thousand.

I swear, I really believe they are putting their ego’s WAY ahead of their patients’ safety. (And all this applies to those “stud” ER docs who think they can intubate anything cause they do it at least once a week.

Kevin McHugh