Coming Into Focus

There is banter of discussion as you enter the nurse’s lounge at the beginning of your shift. Your colleagues are engaged in a heated exchange about what they heard the physician staff reviewing last week.

They were reviewing the utilization of intravenous Propofol for their procedural cases this week. Your practice setting is an outpatient procedure area where patients are sedated by the registered nurses, generally with Midazolam, Fentanyl or Demerol.

This practice for moderate sedation has worked very well for the numerous years you have worked at the facility. However, recently the dynamic changes in healthcare and payment reimbursement have suggested a more streamline method of moderate sedation for procedural care is necessary to support the financials of a unit’s operation.

Querying the charge nurse, she states she has also heard a rumor about a sedation medication change for the procedures. She goes on to say that the unit manager and nursing administration have not reviewed or approved any policy /procedure to begin training for the utilization of Propofol for procedural sedation.

Satisfied with this you draw up Midazolam and Fentanyl for the first procedural case. Entering the suite you find the technologist has the patient on the table and preparing him for the procedure. The physician enters the room and all the consents are reviewed one final time for verification.

You are about to ready to start sedating when the physician says to you, “I think Mr. Johnson’s procedure is going to be very short. I want you to use Propofol for procedural sedation; he will tolerate it better.”

What is your next course of action?

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Evolution of Use

Over the past two decades RN have significantly enhanced their moderate sedation skill sets in outpatient procedural areas, e.g., endoscopy, invasive cardiology, interventional radiology, minor surgeries and critical care settings).

Administration of intravenous medications, such as Midazlom, Fentanyl and Meperidine required additional training and specific competencies by the RN practicing in these areas of use.

During this timeframe the medical community began to see terminology such as “Moderate Sedation” and “Analgesia” emerge in the literature.This described the medically controlled state of consciousness that allows a patient to maintain protective reflexes.

Moderate sedation also allows the patients to tolerate unpleasant procedures while maintaining adequate cardiopulmonary function.

A response to growing questions and concerns from the medical and nursing communities was generated to the American Society of Anesthesiologist (ASA) regarding variability seen in the levels of sedation these medications produced.

 

The ASA recognized a working scale was needed to define the different levels of sedation reported. A measurable criterion was developed to include but not be limited to cardiovascular function, airway maintenance and response to verbal/ tactile stimulation (cognitive function).

Toward the end of the 1990’s, ASA released guidelines to describe four levels of sedation/analgesia. Seeing the safety and efficacy of these guidelines the Joint Commission introduced them into their standard of care expectations. The measured criteria are:

Minimal sedation:

This is a pharmacologically-induced state in which the patient responds normally to verbal commands and tactile stimulation. During this state cognitive function and coordination can be impaired. However, respiration, ventilation and hemodynamic functions are not affected.

Moderate sedation:

(formally known as conscious sedation) This is a pharmacologically drug induced state of depressed consciousness during which the patient responds purposefully to verbal commands, either alone or in conjunction with minimal tactile stimulation. The patient can independently maintain a patent airway; ventilation is spontaneous and adequate. Hemodynamic capability is usually maintained during this state’s duration.

Deep sedation:

This is a drug-induced state of depressed consciousness during which the patient cannot be easily aroused by verbal commands or following repeated painful stimulation. They can experience impaired ability to maintain independent respiratory and ventilatory function. The patient may require assistance in maintaining a patent airway, coupled with inadequate spontaneous breathing. Hemodynamic capability is usually maintained during this state’s duration.

General anesthesia:

This is a pharmacologically drug induced loss of consciousness in which the patient is usually not easily arouseable when painful stimulation is applied. Frequently the ability to sustain independent respirations and adequate ventilation is impaired. Assistance is required because of the drug induced depression of neuromuscular function. Hemodynamic capability is usually maintained during this state’s duration.

Some Clarity Provided

The ASA guidelines significantly improved and provided much needed clarity for procedural sedation delineation for the medical and nursing communities.

Specifically, they defined the patient population appropriate for RNs, anesthesiologists and nurse anesthetists to provide sedation.

Soon thereafter new anesthetic medications appeared from the pharmaceutical industry.

One in particular, Propofol, demonstrated impressive results as an anesthetic agent. A Lipid-based medication, Propofol was released to the anesthesia community with remarkable effect for improved patient response in sedation recovery.

Classified as a Sedative/Hypnotic by the manufacture and Physicians’ Desk reference (PDR), Propofol offers a rapid onset (approximately 30-40 seconds), and has a very short duration of action.

The medication allows patients to wake up, recover and return to base line activities quicker than most forms of sedation.

Of particular interest, Propofol reduced the need for benzodiazepines and opioids, while clinically decreasing postop nausea and vomiting.

Increased Clinical Acceptance

Critical care clinical staff quickly saw the benefits of Propofol for intensive care patients. The medication allowed for effective sedation in neurological critically ill patients.

Propofol’s quick “wake up” abilities allowed for neurology physicians to access their patient without the impairing effects of benzodiazepines and opioids. Propofol’s prescription spread to diffuse ICU utilization for intubated ventilated patients.

Propofol’s manufacture indicates it is for general anesthesia or monitored anesthesia care and should only be administered trained anesthesia providers who are not involved in the surgical or diagnostic procedure. When used in an ICU patient who is intubated and mechanically ventilated, the medication should be managed by providers skilled in the care management of critically ill patients.

As with many medications, patients can have unpredictable and profound side effects with administration, including to this medication. A patient can go from breathing normally to full respiratory arrest and hypotension with low doses. These changes can occur without warning during typically utilized monitoring and assessment parameters.

The adverse physiological side effects must be treated until the patient can fully metabolize the medication. Unlike frequently utilized sedation agents (fentayl, meperidine, midazolam), there is no medicinal reversal agent for Propofol. Clinical staff has to be aware of the sedation continuum from moderate sedation through deep sedation tat this powerful medication can provide.

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Safe Practice & Legal Issues

Each organization should have an interdisciplinary team including the chair of the anesthesia department to set policy and procedure guidelines for the administration of Propofol.

Other medications readily available which should be considered for policy action include but are not limited to: thiopental, methohexital, etomidate and ketamine. Like Propofol, these medications generate a higher level of risk to non-ventilated patients undergoing surgical or diagnostic procedures.

RN who are placed in the position of administering Propofol need take a moment to consider the legal ramifications to this practice. Currently there are a growing number of states that have language in their nurse practice acts, or that have position statements which speak to Propofol’s administration for procedures on non-intubated patients.

There are also a growing number of state boards of nursing that have indicated administering Propofol, for procedural sedation, to a patient who is not being intubated or ventilated is not in the scope of practice of the registered nurse. The more progressive BONs have recognized Propofol has clinical efficacy, but have not made clear definition as to the scope of practice for Propofol’s administration.

Guidance for Propofol administration needs to be clearly outlined for use in the controlled critical care settings, in patients with an established intubated/ventilated airway by trained RN care skilled in hemodynamic change recognition. There is still significant debate as to the appropriateness of nurse-administered Propofol for procedural sedation, to intubated patients who are not being intubated.

The ASA, American Association of Nurse Anesthetists and American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) all agree Propofol administration should be done by only trained persons in general anesthesia, which does not include RNs at this time.

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Driven by Economics

There is momentum to use Propofol for RN administered moderate sedation during endoscopic and other diagnostic/invasive procedures.

The financial incentives and unwillingness of insurers to reimburse anesthesia providers for some of these procedures has increased the movement toward registered nurses administering Propofol.

However, untrained registered nurses may find themselves in the uncomfortable position to use this medication for moderate sedation for procedures. The discussion relating to Propofol administration will likely continue as reimbursement for procedures grows smaller.

More so, the focus will surround RN moderate sedation for procedures in non-intubated patients. Institutional policy and procedural guidelines need to be developed at each organizations practice groups.

Ultimately, competencies, levels of accountability and periodic policy review will dictate who will administer these powerful agents.

References for this article can be accessed here.

Douglas E. Sutton is manager of Interventional Radiology, Nursing Service in Radiology, Ultrasound and the Nursing Vascular Access
Team, Vermont Children’s Hospital at Fletcher Allen Health Care, Burlington, VT.

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