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:
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.
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.)
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]
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.
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]
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]