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CONSCIOUS SEDATION...
According to the manufacturer, Precedex is indicated for the sedation of initially intubated and mechanically ventilated patients and should be administered by continuous infusion not to exceed 24 hours. It is the only relatively selective alpha2-agonist approved for continuous intravenous (IV) sedation in the intensive care setting. It can be used before, during and after extubation.
“Although many practitioners in the endoscopy suite may disapprove, it is nonetheless true that the package insert information for propofol specifically states that when the drug is used in patients who are not intubated, mechanically ventilated or being treated in a critical care unit, the drug ‘should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure,'” says John P. McDonough, CRNA, EdD, ARNP, professor and director of the nurse anesthetist program at the University of North Florida in Jacksonville.
“The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) concurs with the American Society of Anesthesiologists and the American Association of Nurse Anesthetists in their 2004 joint statement regarding propofol, which created new standards to address the growing Propofol concern,” says David Brimm, press contact for the association.
“The statement mandates that whenever propofol is used for sedation/ anesthesia, it should be administered only by those trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. This restriction is in accord with specific language included in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death,” he points out.
The fact that there is no reversal agent for propofol is one of the reasons behind some practitioners' preferences for older drugs. They may cause more side effects, but they also have a reversal agent if things go sour.
The ACG has filed a citizen's petition with the U.S. Food and Drug Administration (FDA) asking for a change in the warning label, so that it would state that only those trained in administration of general anesthesia and not involved in the procedure should administer propofol.
The Society of Gastroenterology Nurses and Associates (SGNA) has also issued a position statement, which gives specific criteria for deep sedation as opposed to moderate sedation, and does not rule out sedation via propofol.
The ASA's guidelines for non-anesthesiologists also differentiates care of the patient receiving moderate sedation and deep sedation, with more stringent requirements for the patient undergoing deep sedation. “As you can see, the jury is still out,” Odom-Forren observes.
Propofol has certainly become more widespread in the last few years, but recent reports submitted to the Pennsylvania Patient Safety Authority show that, in untrained hands, propofol can be deadly.1 “The Pennsylvania Patient Safety Reporting System (PA-PSRS) has received over 100 reports in which the use of propofol has been cited,” according to a news release on Medical News Today, an online news source.
And therein lies the problem. Suggested uses for propofol are clear in that the administering healthcare professional must be solely devoted to the patient's sedation, not busy doing other tasks related to endoscopy. But this is happening despite recommendations.
Respiration can change dramatically in a very short time, deteriorating to full respiratory arrest, even when propofol is given in low doses. Individual responses to this medication cannot be absolutely predicted.
If a facility decides to allow nurse-administered propofol, it is necessary for the multidisciplinary team to specify when a nurse can administer the drug, and what specific education and mentorship she must undergo, as well as how her competency will be evaluated, and how frequently. “Keep in mind that ACLS certification alone may not be sufficient for this purpose,” the authority cautions.
The article, “Who Administers Propofol in Your Organization?” includes several practices to minimize the risk involving propofol and other sedatives. To view a PDF of the article in full, visit www.psa.state.pa.us/psa/lib/psa/advisories/mar_2006_advisory_v3_n1.pdf .
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