Non-anesthesiologist propofol sedation for GI procedures

[fakin' the funk]

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I haven't seen any threads, or ASA statements, or other commentary on this recent Gastroenterology article, so I thought I'd post this.

Sounds like the basis is, anesthesiologist-administered propofol sedation is not cost-effective for low-risk patients, and safety is adequate for GI docs or nurses to administer propofol to those patients. Thoughts?

http://www.medpagetoday.com/Gastroenterology/GeneralGastroenterology/17316

 

[Planktonmd]

The GI guys have been very aggressively perusing this subject for many years now and they are hoping that by accumulating biased literature that supports their theory (that you don't need trained anesthesia providers to administer Propofol), they are hoping they could convince more and more payers to agree with them.
So far they were pretty successful because their biased literature is unfortunately the only literature out there on the subject.
It is also unfortunate that there are some academic anesthesiologists who decided to be on their side and published articles agreeing with them!
An example to that would be the guy who did a study showing that it is safe to do self administered sedation (a PCA Mode) in these patients without the need for anesthesia providers.
As usual, anesthesiologists are their own worst enemy, and as every one else fights for their turf we choose to hand it over with a smile.

 

[Noyac]

I have a few thoughts on this. One, I don't like doing GI cases if it isn't necessary. But thats just me. I seem to have an aversion to methane, don't know why.
Two, these guys are doctors, right? Propofol is a medicine. Doctors give medicines. THe key is that the doctor understands the medicine he is giving and has the tools to deal with this medicine. It's sort of like telling me I can't suture a laceration because I'm not a surgeon or an ER doc. I know how to suture. I can do a pretty fair job of it. Probably not as good as a plastic surgeon but the job gets done safely none-the-less. The point is training. If the person using the instrument (propofol) is trained (airway management) well enough then why not?

Fire Away.

 

[jwk]

I have a few thoughts on this. One, I don't like doing GI cases if it isn't necessary. But thats just me. I seem to have an aversion to methane, don't know why.
Two, these guys are doctors, right? Propofol is a medicine. Doctors give medicines. THe key is that the doctor understands the medicine he is giving and has the tools to deal with this medicine. It's sort of like telling me I can't suture a laceration because I'm not a surgeon or an ER doc. I know how to suture. I can do a pretty fair job of it. Probably not as good as a plastic surgeon but the job gets done safely none-the-less. The point is training. If the person using the instrument (propofol) is trained (airway management) well enough then why not?

Fire Away.

Apples and oranges.

Do you really want a GI doc (or nurse) responsible for your airway? Technically the GI doc can do open heart surgery as well - do you want him doing that? I used to teach ACLS airway management to physicians (plastic surgeons and GI docs in particular) and there's not a one that I would want to have primary responsibility for managing my airway. Taking a class to be "trained", and being competent at a skill are entirely different.

Most of you are far too young to remember when Versed was released. "Just like Valium" was the line from all the reps. I can't begin to tell you how many codes we responded to in the GI labs.

Regardless, as already indicated, the current GI-doc oriented and published literature is not on our side. However, MANY states restrict RN's from giving IV push propofol UNLESS that patient is on a ventilator, and it doesn't make any difference if the physician is standing over them.

 

[bigdan]

Nice post jwk.

Aetna tried to stop paying for anesthesiologists to administer sedation to colonoscopies a few years ago, and that met significant enough backlash that they ended up retreating on their position to stop paying. I can only imagine it'll be a matter of time before they'll be at it again. At the risk of being attacked, might we gain some good will by admitting we don't need to be getting 2x-3x as much as the GI doc for the procedure?

The recurring misconception, from my point of view, is that anesthesiologists have made for sedation/MAC/GA to seem so safe and so simple that everyone thinks it's a simple job that ANYONE can do; I'd still love to see the ASA come out with some sort of educational campaign to let people know that we are well trained physicians who have worked very hard to make provision of anesthestics a very very safe event.

dc

 

[lfesiam]

Apples and oranges.

Do you really want a GI doc (or nurse) responsible for your airway? Technically the GI doc can do open heart surgery as well - do you want him doing that? I used to teach ACLS airway management to physicians (plastic surgeons and GI docs in particular) and there's not a one that I would want to have primary responsibility for managing my airway. Taking a class to be "trained", and being competent at a skill are entirely different.

Most of you are far too young to remember when Versed was released. "Just like Valium" was the line from all the reps. I can't begin to tell you how many codes we responded to in the GI labs.

Regardless, as already indicated, the current GI-doc oriented and published literature is not on our side. However, MANY states restrict RN's from giving IV push propofol UNLESS that patient is on a ventilator, and it doesn't make any difference if the physician is standing over them.

True story from medschool, was in on a GI case with GI doc + nurse administering sedatives.... pt was over sedated and they had to call a code over the hospital PA system... everyone panic in the room but eventually the doc started CPR, by the time the code team got there pt was quite blue.... ended up intubated...ventilated to the ICU... 🙁

 

[Southpaw]

True story from medschool, was in on a GI case with a only a GI doc + nurse administering sedatives.... pt was over sedated and they had to call a code over the hospital PA system... everyone panic in the room but eventually the doc started CPR, by the time the code team got there pt was quite blue.... ended up intubated...ventilated to the ICU... 🙁

And this is the point. Do I want a GI doc managing my airway? Hell no, and neither would Joe Public if they truly understand who anesthesiologists are and what they do (Hey WTF ASA?!?!).

So GI wants to do their own propofol/sedation? Fine, it'll happen b/c they have the control and they're they only people doing biased studies. We, based on our history and our intrinsic nature, will sit quietly on the sidelines until we hear the code overhead. And then, and only then, will we respond. That's just sad to me. Patient care shouldn't be tossed aside like this.

 

[Noyac]

We can all bring up some sort of catastrophe but that doesn't mean that there are not some well trained GI docs out there with skills at sedation and airway management. The idea is to have these guys well trained. The Gi guys I work with have done over 2000 propofol sedation cases with an incident. My partners that are of age have gone to them for their scopes and have received propofol. We have criteria for anesthesia involvement. Our system works well. Plus we don't have the staff to cover all these cases if propofol is to be used. Would you rather have them continue to push versed and demerol?