From the November 3, 2005
: 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:
- Has a rapid onset (about 40 seconds) and a short duration of action
- Allows patients to wake up, recover, and return to baseline activities and diet sooner than some other sedation agents
- Reduces the need for opioids, thus resulting in less nausea and vomiting.(2)
Trained nurses in most critical care settings often administer propofol safely to patients who are intubated and ventilated. 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. 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. The nurse obtained the drug from an automated dispensing cabinet via override before she transcribed the order to the patient's record. Another nurse who was trained in the use of moderate sedation, but not deep sedation or anesthesia, assisted the gastroenterologist. After questioning the physician about the dose (100 mg is a high dose), she began administering the propofol via an infusion pump. The patient suddenly experienced respiratory arrest. 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. 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. 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. Initially, the nurses reluctantly complied. Later, they brought the issue to the attention of hospital leaders, citing that they were worried about the safety of this practice.(2)
There are several compelling reasons why all healthcare providers should be worried about nurse-administered propofol.
Strict product labeling. 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. (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. Propofol dosing and titration is variable, based on the patient's tolerance to the drug. Profound changes can occur rapidly. 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. Unlike other sedation agents (e.g., midazolam, morphine), there is no reversal agent for propofol. Adverse effects must be treated until the drug is metabolized.
Financial incentives. 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. Nurse-administered propofol falls under each state's Nurse Practice Act. 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. To best inform your team's decision about this controversial issue, consider the following:
Review regulations/position statements. Check with your State Board of Nursing to determine if nurse-administered propofol is deemed within the professional nurses' scope of practice. If so, explore the various position statements available on this topic from professional societies, including the:
· American Society of Anesthesiologists (ASA)
· American Association of Nurse Anesthetists (AANA)
· American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
· American College of Gastroenterology (ACG)
· American Gastroenterological Association (AGA)
· American Society for Gastrointestinal Endoscopy (ASGE)
· Society of Gastroenterology Nurses and Associates (SGNA).
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. 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. 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. 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. 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)). Decide if the location of propofol administration plays a factor. 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. 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. 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. 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. Pleasant dreams: office surgeries fuel demand for anesthesiologists. Crain's New York Business. January 10, 2005. (2) Meltzer B. RNs pushing propofol. Outpatient Surgery. 2003;4(7). (3) WFTS ABC Action News. Doctor still on the hook for 'accidental' surgery death. ABC Action News Tampa-St. Petersberg. March 18, 2004.