In medicine and nursing, there are constant changes occurring. Much of this is due to new advances in technology, pharmacology, and countless studies that help move these into practice. Some of these changes are embraced by the medical community while others are shunned. Is this because of lack of information or how or who is presenting the information?
Currently, there seems to be a great deal of controversy regarding the use of propofol in the endoscopic setting. If propofol is used in the gastroenterology suite, who should administer the drug? Should an anesthesiologist or certified registered nurse anesthetist (CRNA) administer the drug or can a nurse safely do this?
Propofol is a sedative-hypnotic agent that appeals to those in gastroenterology because it works very quickly. According to the Physicians Desk Reference (2004), propofol produces hypnosis with 40 seconds from the start of injection. However, the PDR (p. 666) also warns "Diprivan injectable emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure."
Recently I posted a thread on the SGNA discussion forum on propofol, requesting input from members. I also reviewed previous postings and several articles and would like to share some thoughts regarding the use of propofol including pro, con, and nursing issues.
When I reviewed the SGNA discussion forum, some of the pro comments I received were:
* It works well for patients, especially the hard-to-sedate ones and ASA class III or IV patients.
* Patients seem comfortable throughout the entire procedure.
* There is minimal repositioning of the patient to advance the scope, so cases take less time.
* Patients remember speaking to the physician at discharge.
* The registered nurse does not have to repeat discharge instructions several times.
* Patients seem more steady when they get up.
* There are fewer complaints of nausea and vomiting, which was often associated with narcotic use for conscious sedation.
* Less nursing time is spent in the postprocedure time as the patient was more alert, felt better, and retained information more quickly.
In the March/April 2004 issue of Gastroenterology Nursing, Wurtz and Berstein reviewed 1,056 charts to evaluate the difference pre- and postprocedure in patients using standard conscious sedation (fentanyl/midazolam [Versed]) compared to propofol for moderate sedation. Once some process changes were implemented, a savings of 5.3 minutes per case were noted. Potentially, that would allow for more cases per room per day. Rex et al. (2002) prospectively reported the dose and adverse reactions to nurse administered propofol in 2000 cases. They reported five episodes of oxygen desaturation, no needs for intubation or admission, and no long-term side effects.
On the con side of this issue, members responded that:
* Patients and insurance companies had to pay more for procedures because of the added cost of an anesthesiologist or CRNA.
* If anesthesiology was sedating and monitoring the patient, the endoscopist was performing the procedure and a tech was being used to assisting the endoscopist so that no endoscopy nurse was present during the procedure.
* There was concern regarding informed consent when propofol was being used because the drug label warns it should be administered by someone trained in the administration of anesthesia.
* There is no reversal agent.
* When anesthesiology is overseeing these procedures, they may prefer to do some of these procedures in the operating room.
* Monitoring may expand to the use of capnography to help detect apnea and hypoventilation sooner than pulse oximetry.
* Patients who are undergoing colonoscopy may be more difficult to reposition as they are unable to help under propofol sedation.
Here were some of the nursing issues surrounding propofol administration that have been mentioned in the forum and in recent articles:
* lack of protocols for registered nurses monitoring and administering propofol.
* necessity of requirements for advanced cardiac life support training.
* training and validation of nurse administered propofol.
* staffing issues (nurse vs. tech) when anesthesiology is monitoring the patient.
* Changes in traditional endoscopic nursing roles if nurses begin to administer propofol (e.g., drug administration only).
According to Outpatient Surgery Magazine, American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) have released a joint policy supporting nurse-administered propofol sedation (NAPS) by specially trained gastroenterology nurses. The same magazine reported the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) has received several reports of RNs improperly administering propofol and are trying to ensure only those trained to give general anesthesia or rescue from general anesthesia administer propofol.
Physicians do not dictate nursing practice; nurses do. Therefore, nurses need to be informed on the issue of propofol administration and the stance of their institution and Board of Nursing. Outpatient Surgery July 2003 provides an overview of declaratory statements or advisory opinions by state boards of nursing endorsing or restricting procedural sedation administration and/or monitoring with propofol or other anesthetic agents for non-CRNA practice. The article also highlights if the Nurse Practice Act in the state does not address the issue. The SGNA position statement (2004) on use of sedation and analgesia recommends 1) registered nurses and physicians involved in the administration of deep sedation have additional training and 2) anesthesiologists be considered in patients undergoing prolonged procedures requiring deep sedation.
Is propofol where midazolam was a few years ago? Initially, midazolam was dosed the same as Valium which led to many cases of respiratory depression. Initially, midazolam didn't have a reversal agent. Over time, it evolved into a great drug for endoscopy. The most important point is to be informed. Nurses need to be informed about propofol as it impacts practice in your state, institution, and your concerns regarding patient safety.
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