Deep Sedation by nurses?

[Arantius]

So I want to check that I’m not being gaslit by the admin at one of the main hospitals I work at- they are saying nurses (not CRNAs) can do deep sedation for cases like D&Cs, radiology, etc.

This is mostly driven by the proceduralists not wanting to fit into the allotted times that the group is providing a CRNA (and not wanting to show up on time, but rather late… all the time). Also, not wanting to wait for a CRNA to be available when they want to do a case…

Last I checked and remember, any level of sedation deeper than moderate sedation is a MAC and requires an anesthesia provider… right?

Has something changed?

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[abolt18]

So I want to check that I’m not being gaslit by the admin at one of the main hospitals I work at- they are saying nurses (not CRNAs) can do deep sedation for cases like D&Cs, radiology, etc.

This is mostly driven by the proceduralists not wanting to fit into the allotted times that the group is providing a CRNA (and not wanting to show up on time, but rather late… all the time). Also, not wanting to wait for a CRNA to be available when they want to do a case…

Last I checked and remember, any level of sedation deeper than moderate sedation is a MAC and requires an anesthesia provider… right?

Has something changed?

MAC means nothing more than that the patient is being monitored by "anesthesia". It does NOT define level of sedation.

Sedation goes from light/mild, to moderate, to deep, to general anesthesia. Someone providing sedation needs to be qualified to handle "one deeper" than what they're supposed to be doing, meaning if the nurse is providing moderate sedation, (s)he needs to be able rescue a patient that accidentally drifts into the level of deep sedation. If someone is providing deep sedation, they need to be capable of handling a patient under general anesthesia to rescue them.

No, nurses are not qualified to be regularly and intentionally providing DEEP sedation.

 

[abolt18]

Practice Guidelines for Sedation and Analgesia by... : Anesthesiology

An abstract is unavailable.

pubs.asahq.org

"Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (Conscious Sedation) should be able to rescue patients who enter a state of Deep Sedation/Analgesia , while those administering Deep Sedation/Analgesia should be able to rescue patients who enter a state of general anesthesia."

"Minimal Sedation (Anxiolysis) = a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia (Conscious Sedation) = a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep Sedation/Analgesia = a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General Anesthesia = a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired."

 

[Hoya11]

So I want to check that I’m not being gaslit by the admin at one of the main hospitals I work at- they are saying nurses (not CRNAs) can do deep sedation for cases like D&Cs, radiology, etc.

This is mostly driven by the proceduralists not wanting to fit into the allotted times that the group is providing a CRNA (and not wanting to show up on time, but rather late… all the time). Also, not wanting to wait for a CRNA to be available when they want to do a case…

Last I checked and remember, any level of sedation deeper than moderate sedation is a MAC and requires an anesthesia provider… right?

Has something changed?

It means they are to give 10 of versed and 400 of fent

 

[deleted1130227]

It means they are to give 10 of versed and 400 of fent

Yup. Maybe remimazolam crap. Make sure that you are clear that this is not a good idea AND that you will not take ANY oversight or ownership of this process in any way. They will try to rope you in medicolegally.

 

[GassYous]

Why are they talking to you about it? They can do whatever they want. But they shouldn't expect you to be immediately available for the inevitable complications.

 

[MTGas2B]

What do the faculty sedation guidelines say about non-anesthesia sedation?

What do the med staff bylaws and privileging documents say about supervising sedation?

 

[Maverikk]

This is a bylaws question. On the west coast one of the GI docs took the sedasys algorithm, trained nurses on it and it is being used at many hospitals as NAPS (nurse administered propofol sedation). It works...but only if the GI doc has good patient selection, it works at outpatient centers, the CRNAs were raging about this. Honestly healthy outpatient endo doesn't need MDs or CRNAs...but the GI doc has to be cognizant to pick the right patients. I've seen this done at tertiary care centers too with limited anesthesia availability. It was a mess, they'd 'consult' anesthesia when they're about to do a food impaction, COPDer on home o2 for nurse sedation. The endoscopist was a pure proceduralist, the patients were worked up by a GI NP/PA, most came in through the NAPs pathway unless true disaster. It's the implementation that matters

 

[secretasianman]

Why trust a crna to do the right thing, when you can trust a gi doc lol. What could possibly go wrong..

 

[Arantius]

Why are they talking to you about it? They can do whatever they want. But they shouldn't expect you to be immediately available for the inevitable complications.

They asked my thoughts because I guess I’m one of the more “approachable” docs. It’s 100% locums at that site so no leadership in anesthesia. I did say I will not be anywhere near this and they could pay me a consulting fee for any duties above clinical, like asking me to opine on this…. There’s a reason they can’t hire anyone full time

 

[dannyboy1]

This is a bylaws question. On the west coast one of the GI docs took the sedasys algorithm, trained nurses on it and it is being used at many hospitals as NAPS (nurse administered propofol sedation). It works...but only if the GI doc has good patient selection, it works at outpatient centers, the CRNAs were raging about this. Honestly healthy outpatient endo doesn't need MDs or CRNAs...but the GI doc has to be cognizant to pick the right patients. I've seen this done at tertiary care centers too with limited anesthesia availability. It was a mess, they'd 'consult' anesthesia when they're about to do a food impaction, COPDer on home o2 for nurse sedation. The endoscopist was a pure proceduralist, the patients were worked up by a GI NP/PA, most came in through the NAPs pathway unless true disaster. It's the implementation that matters

Plaintiffs attorneys are no doubt salivating over this. Nurse with no airway training pushing propofol. Sooner, rather than later, a disaster will strike.

 

[deleted1130227]

Plaintiffs attorneys are no doubt salivating over this. Nurse with no airway training pushing propofol. Sooner, rather than later, a disaster will strike.

This is a bylaws question. On the west coast one of the GI docs took the sedasys algorithm, trained nurses on it and it is being used at many hospitals as NAPS (nurse administered propofol sedation). It works...but only if the GI doc has good patient selection, it works at outpatient centers, the CRNAs were raging about this. Honestly healthy outpatient endo doesn't need MDs or CRNAs...but the GI doc has to be cognizant to pick the right patients. I've seen this done at tertiary care centers too with limited anesthesia availability. It was a mess, they'd 'consult' anesthesia when they're about to do a food impaction, COPDer on home o2 for nurse sedation. The endoscopist was a pure proceduralist, the patients were worked up by a GI NP/PA, most came in through the NAPs pathway unless true disaster. It's the implementation that matters

Both right. The above average proceduralist who is smart and hungry, but not too hungry, and cherry picks their staff can push the envelope and get away with it....For a long time in our community we have had an above average cosmetic surgeon who does a lot (but not all) of his stuff at his CRNA staffed surgicenter. Over the years he has been careful with patient selection and cherry picked above average CRNAs and PACU RNs and not had any disasters. Not everybody is above average. Not everybody hires above average.

 

[nimbus]

Both right. The above average proceduralist who is smart and hungry, but not too hungry, and cherry picks their staff can push the envelope and get away with it....For a long time in our community we have had an above average cosmetic surgeon who does a lot (but not all) of his stuff at his CRNA staffed surgicenter. Over the years he has been careful with patient selection and cherry picked above average CRNAs and PACU RNs and not had any disasters. Not everybody is above average. Not everybody hires above average.

Deep sedation for GI cases by a sedation nurse is an a much different animal than an above average CRNA doing anesthesia for cosmetic surgery. I’d argue that anesthesia for cosmetic surgery is completely within the CRNA wheelhouse.

 

[jwk]

Honestly healthy outpatient endo doesn't need MDs or CRNAs...but the GI doc has to be cognizant to pick the right patients.

Good enough for you and your family I guess. Certainly not mine.

 

[Maverikk]

Good enough for you and your family I guess. Certainly not mine.

Would you demand it for a cataract? What about all the office procedures done under local. Think about the big picture. Currently non-anesthesia endo is done with versed/fentanyl, I think propofol is much better. Anesthesia is a scarce resource nowadays. For the healthy ASA1s it can be done, the problem comes when the GI doc tries to slide in sicker patients. My GI friend does a lot under nurse administered versed/fentanyl, those who don't pass the screening get put with anesthesia. He told me his waitlist for elective colonoscopies is 2,000 people; working through all the COVID backlog. He can't book anesthesia time and the CRNAs at his clinic are demanding more per hour. That's colon CA given time to grow, metastasize. If done correctly, on the correct patients and with trained nurses it can work. If done incorrectly (I've seen it, food impactions, ASA3/4s) it's a disaster

 

[CopaceticOne]

He can't book anesthesia time and the CRNAs at his clinic are demanding more per hour.

Sounds like they know their worth. How much is he getting per scope?

If done incorrectly (I've seen it, food impactions, ASA3/4s) it's a disaster

And this is the point. F around and find out. It only takes one patient getting too deep and having a hypoxic event to make the house of cards come crashing down. Even routine ASA 1s can cause trouble.

 

[Maverikk]

Yep, the Crnas are way better at getting their worth than doctors. We’ll sit around and be on the hook and get nothing while no nurse would do that. I don’t know how much per scope but his colons are about 10-20 minutes, egds 5-10. One of the most efficient GI docs I’ve worked with and he’s thoughtful and doesn’t cut corners, biopsy for no reason. His crnas were 200/hr…7-3, don’t stick around till pacu is discharged, asa1/2. No call/weekends/nights/holidays. They could pick up elsewhere around the city, then wanted 250…sad part is he’s part of a multi speciality group and they’re going to pay..he’s the one pushing for nurse administered propofol, I’m no longer in that city but he was going over the logistics with me. Wants one MD there. Are you a liability sponge, yes. But no more so than doing QZ 4:1, and the patient population is low risk and your nurses actually call you as opposed to a QZ fiasco. I’d rather work in an endo center using NAPs than crnas, the nurses actually communicate and the patient population is low risk. I’ve done 4:1 QZ, basically done get called until the patient is about to die, that way the CRNA can say they called you. Routine asa1 can sometimes pose problems, I just want someone who will call when there is a problem

I left the hot mess that I was doing locums at and was getting ‘consulted’ on for EF30, recent heart attacks and food impactions. Multiple nurses had left that area because of what they were doing. The devil is in the details

 

[nimbus]

In our community most endoscopies are done with sedation nurses but the patients aren’t getting deep sedation with propofol. They’re getting versed and fentanyl.

 

[nimbus]

Would you demand it for a cataract? What about all the office procedures done under local. Think about the big picture. Currently non-anesthesia endo is done with versed/fentanyl, I think propofol is much better. Anesthesia is a scarce resource nowadays. For the healthy ASA1s it can be done, the problem comes when the GI doc tries to slide in sicker patients. My GI friend does a lot under nurse administered versed/fentanyl, those who don't pass the screening get put with anesthesia. He told me his waitlist for elective colonoscopies is 2,000 people; working through all the COVID backlog. He can't book anesthesia time and the CRNAs at his clinic are demanding more per hour. That's colon CA given time to grow, metastasize. If done correctly, on the correct patients and with trained nurses it can work. If done incorrectly (I've seen it, food impactions, ASA3/4s) it's a disaster

I’d argue that a cataract is lower risk and requires less sedation than endoscopy. The only reason they’re not done with sedation nurses is because the average ophthalmologist is not as cavalier as the average gastroenterologist.

 

[Maverikk]

Yeah, there’s multiple studies of versed/fentanyl vs propofol both administered by nurses in the GI journals. People go home faster, patient satisfaction etc. The GI doc that pioneered it just used the sedasys algorithm, took it to Virginia Mason then univ of Chicago is what my GI friends say. Their biggest obstacle is hospital bylaws for propofol administration

 

[Maverikk]

I’d argue that a cataract is lower risk and requires less sedation than endoscopy. The only reason they’re not done with sedation nurses is because ophthalmologists are not as cavalier compared to gastroenterologists.

I’d agree…what I’m saying is pragmatically speaking you don’t need a CRNA for endo in the right setting and the right patient population. Patients that are getting versed/fentanyl now could be getting prop, shorter stays, more patient satisfaction. I’d argue that nurse administered propofol is better than nurse administered fentanyl/versed. The problem is when the GI doc blurs the lines of someone who does and does not need an anesthesiologist. The ones that I know do nurse administered propofol have an anesthesiologist available. The massive backlog of people who’s bmi is 31 instead of 29 and having to wait a year for a colonoscopy just pragmatically seems wrong

 

[CopaceticOne]

Riddle me this - what are the reversal agents for the following:
Versed = flumazenil
Fentanyl = narcan
Propofol = ???

I don’t agree that patients should be getting 10 of versed and 250 of fentanyl (something I saw recently), but at least there is a way to undo if they went too far.

The ones that I know do nurse administered propofol have an anesthesiologist available.

No way is covering non-anesthesia trained people doing deep sedation going to pass muster by a malpractice carrier for an anesthesiologist.

Sadly, I think it will be bottom of the barrel anesthesia docs that agree to situations like that. They’ve got to put food on the table somehow and once things get shady, they will move on to the next unsuspecting job.

The massive backlog of people who’s bmi is 31 instead of 29 and having to wait a year for a colonoscopy just pragmatically seems wrong

Show me the money. Seriously, if the guy is that fast, he can afford the pay.

 

[CopaceticOne]

I’d rather work in an endo center using NAPs than crnas,

Sounds like you should work for your friend. Have you offered your services?

 

[jwk]

I’d agree…what I’m saying is pragmatically speaking you don’t need a CRNA for endo in the right setting and the right patient population. Patients that are getting versed/fentanyl now could be getting prop, shorter stays, more patient satisfaction. I’d argue that nurse administered propofol is better than nurse administered fentanyl/versed. The problem is when the GI doc blurs the lines of someone who does and does not need an anesthesiologist. The ones that I know do nurse administered propofol have an anesthesiologist available. The massive backlog of people who’s bmi is 31 instead of 29 and having to wait a year for a colonoscopy just pragmatically seems wrong

Where is this wasteland you're talking about? 2000 case backlog because of Covid which was 4 years ago? I don't think so. A year wait now? For what? We've got an extremely busy GI caseload across multiple facilities. Nobody is waiting a year for a screening. The GI docs don't even see them in the office first - they meet 2 minutes prior to their colonoscopy - which is 100% anesthesia-administered propofol. GI nurse sedation hasn't existed in our market in at least 5 years.

And add to that - nurse-administered propofol except on a ventilated patient in the ICU is outside the scope of practice for RNs in many states.

 

[Maverikk]

Where is this wasteland you're talking about? 2000 case backlog because of Covid which was 4 years ago? I don't think so. A year wait now? For what? We've got an extremely busy GI caseload across multiple facilities. Nobody is waiting a year for a screening. The GI docs don't even see them in the office first - they meet 2 minutes prior to their colonoscopy - which is 100% anesthesia-administered propofol. GI nurse sedation hasn't existed in our market in at least 5 years.

And add to that - nurse-administered propofol except on a ventilated patient in the ICU is outside the scope of practice for RNs in many states.

This was two years ago I have moved. Average 14 cases a day (they’re busy but easy days), scope 3 days a week 46 weeks a year. On top of that elective screenings weren’t the top priority when cases were added back on. Add on the flood of people coming back for medical care.

All this is just a response to the OP: nurses do deep sedation, it can be done well or poorly. A lot of Washington, Oregon and NorCal nurse administered propofol for endo is common, including Kaiser which throttles scope of practice more than most.
I told him I would work for him, I also said I would be a firefighter, wouldn’t put my name on the chart or preop everyone for liability, but I’ve moved. I’ve done 4:1 and it felt like a lawsuit waiting to happen and professionally unsatisfactory, if the Crnas worked as a team or communicated better maybe I’d feel different, but it was locums and QZ. The other locums place where the nurses I know who did propofol endo would call anesthesia for anything. They at least communicated. It was poorly set up because it was a tertiary care center and the GI docs tried to push the envelope, the nurses quit because they felt it was unsafe. Doing it as an outpatient in asa1s is a different animal. The devils is in the details.

One of the many problems in medicine is the territorial pissings. If nurse propofol can be safely done, and it can, then implementing it in the best way possible should be the goal. Instead of 6 of versed and 400 of fentanyl they’d get propofol. Don’t worry we’ll all still have jobs.

It reminds me of a midwife friend who came to the US from Britain. She stopped being a midwife here because the system was so messed up: in the EU many more births are through a midwife, they basically handle low risk births. She said she knew she wasn’t an OB and depended on them for questions and would always contact them whenever anything was awry. It was true teamwork. She said the system here was antagonistic, that many midwives wanted to handle problems instead of asking for help. I told her this reminded me of poorly functioning supervision/direction models. And I’ve also had a friend who had unrecognized pph by a widwife.

 

[nimbus]

Riddle me this - what are the reversal agents for the following:
Versed = flumazenil
Fentanyl = narcan
Propofol = ???

I don’t agree that patients should be getting 10 of versed and 250 of fentanyl (something I saw recently), but at least there is a way to undo if they went too far.


No way is covering non-anesthesia trained people doing deep sedation going to pass muster by a malpractice carrier for an anesthesiologist.

Sadly, I think it will be bottom of the barrel anesthesia docs that agree to situations like that. They’ve got to put food on the table somehow and once things get shady, they will move on to the next unsuspecting job.


Show me the money. Seriously, if the guy is that fast, he can afford the pay.

ENA-001 is pretty interesting. If it pans out, it could become a game changer. Don’t want to get too excited but I am.

While not a specific propofol antagonist, it is a carotid body stimulator which can apparently reverse propofol induced respiratory depression. As a “agnostic respiratory stimulant” it could work for respiratory depression from other causes too (eg opioids). Like a pressor but for breathing🙂

Maybe it deserves its own thread.

Reversal of Propofol-induced Depression of the Hypoxic Ventilatory Response by BK-channel Blocker ENA-001: A Randomized Controlled Trial - PMC

The use of anesthetics may result in depression of the hypoxic ventilatory response. Since there are no receptor-specific antagonists for most anesthetics, there is the need for agnostic respiratory stimulants that increase respiratory drive ...

www.ncbi.nlm.nih.gov