Propofol use by EM physicians

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An argument had started in our hospital system regarding our insistence that the ED use moderate sedation using ketamine/versed/fentanyl/? etomidate? for joint manipulation/setting fractures/etc.

They want to use propofol for "deep sedation". Which, in discussion, is obviously general anesthesia. As most know, EM's NPO standards are much more lax than ours.

I know ultimately it's more important what the depth of sedation is, but I also feel like propofol gives them a slippery slope.

I'd like to hear how others have dealt with this in the past. And what other policies say. Our EM docs state we are the only system in our state that doesn't allow the use of propofol in the ED, which we doubt.

 

[IMGASMD]

We recently started to let them use prop. But it’s still “our” drug. The policy ended up being they can use it, only if two EM physicians are present. One do the procedure the other monitor the air way. So late at night or on the weekends, when there’s only 1 physician, we go down. When ortho wants to do something, we go down.

Our IR also wanted privilege to use it. We shut that door down fast.

 

[deleted126335]

When I was director, I loosened our policy. Current policy is that a physician who has completed an accredited EM training program and who the director of Emergency Medicine has signed off on can use the drug. Rotating IM or family medicine docs or other physicians doing procedures in the ER have no such privileges.

 

[DrGasPasser]

An argument had started in our hospital system regarding our insistence that the ED use moderate sedation using ketamine/versed/fentanyl/? etomidate? for joint manipulation/setting fractures/etc.

They want to use propofol for "deep sedation". Which, in discussion, is obviously general anesthesia. As most know, EM's NPO standards are much more lax than ours.

I know ultimately it's more important what the depth of sedation is, but I also feel like propofol gives them a slippery slope.

I'd like to hear how others have dealt with this in the past. And what other policies say. Our EM docs state we are the only system in our state that doesn't allow the use of propofol in the ED, which we doubt.

Most institutions follow the Policy Statement from the American College of Emergency Physicians on Procedural Sedation and Analgesia:

https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/clinical-policies/clinical-policy-procedural-sedation-and-analgesia-in-the-emergency-department.pdf

as well as the updated consensus practice guideline:

https://www.annemergmed.com/article/S0196-0644(18)31576-2/pdf

The bottom line on the evidence is that EP’s can safely administer Propofol for deep sedation. Having a second provider is reasonable if the procedure cannot be abandoned if the patient deteriorates, or if appropriate monitoring is difficult with a single provider. Having 2 providers in all cases is probably overkill.

 

[Urzuz]

They are physicians, let them use whatever drug they want. I don't like the practice of creating formalized policies dictating what a physician can/can't prescribe or do. It undermines all of our autonomy and authority. Physicians should be (key word being "should") knowledgeable enough to know what they don't know and know their limitations, and will not use drugs out of their realm of expertise. I don't have any intention of being the first to prescribe a patient Prozac, but at the same time I don't want a psychiatrist saying I am not allowed to.

I also work in a hospital that has an open staff model and every physician/group that works there carries their own independent malpractice insurance, so quite frankly IDGAF what they do down in the ED as long as I don't get called.

 

[DrGasPasser]

They are physicians, let them use whatever drug they want. I don't like the practice of creating formalized policies dictating what a physician can/can't prescribe or do. It undermines all of our autonomy and authority. Physicians should be (key word being "should") knowledgeable enough to know what they don't know and know their limitations, and will not use drugs out of their realm of expertise. I don't have any intention of being the first to prescribe a patient Prozac, but at the same time I don't want a psychiatrist saying I am not allowed to.

I also work in a hospital that has an open staff model and every physician/group that works there carries their own independent malpractice insurance, so quite frankly IDGAF what they do down in the ED as long as I don't get called.

These arguments of “our” drug, procedure, imaging study, etc. get a little bit silly. Unfortunately, they occupy an inordinate amount of oxygen in Credentialing Committee Meetings at hospitals across the country. The ACGME and ABMS (and any other pertinent alphabet soup organization that I’m missing) need to publish regular updates to what is core competencies for each speciality. Things like sedation, ultrasound, fluoro, etc. are always evolving. Hospitals need to have more updated guidance on who is trained to do what so that credentialing decisions aren’t dictated by outdated opinion.

There are credentialing committee meetings where hours were spent debating between who in the hospital should have moderate sedation privileges and who should be allowed to put a foot on fluoro pedal or plug in an ultrasound. The anesthesiologists wanted to de-credential the intervention radiologist from all sedation unless they passed an institutional merit badge course; the radiologists responded by making the anesthesia pain group pass their merit badge before touching fluoro. You can’t make this up...

 

[zizzer]

I didn't even know this was an argument. Our ER physicians were using it when I was rotated through as a resident. I don't like the idea of telling other physicians which medications they can't use.

 

[Modanq]

These arguments of “our” drug, procedure, imaging study, etc. get a little bit silly. Unfortunately, they occupy an inordinate amount of oxygen in Credentialing Committee Meetings at hospitals across the country. The ACGME and ABMS (and any other pertinent alphabet soup organization that I’m missing) need to publish regular updates to what is core competencies for each speciality. Things like sedation, ultrasound, fluoro, etc. are always evolving. Hospitals need to have more updated guidance on who is trained to do what so that credentialing decisions aren’t dictated by outdated opinion.

There are credentialing committee meetings where hours were spent debating between who in the hospital should have moderate sedation privileges and who should be allowed to put a foot on fluoro pedal or plug in an ultrasound. The anesthesiologists wanted to de-credential the intervention radiologist from all sedation unless they passed an institutional merit badge course; the radiologists responded by making the anesthesia pain group pass their merit badge before touching fluoro. You can’t make this up...

Agree, And the reverse works for anesthesiologists. We are physicians first. Ultrasound, Fluro, surgical airway.
One area we should start making headway is in the cath lab. Many of our cardiology colleagues are very open to allowing us procedural access there and TEE access. If you are doing a complex cardiac case in the cath lab...No one is preventing you from using the C-arm for swan guidance, etc.
Time to open the gates.

 

[DrGasPasser]

I didn't even know this was an argument. Our ER physicians were using it when I was rotated through as a resident. I don't like the idea of telling other physicians which medications they can't use.

Most places settled it more than a decade ago.

Many EP’s consider an ongoing Propofol debate to be a red flag when looking at jobs. Medication restrictions and requirements that EM attendings maintain merit badge certifications like ACLS/PALS by hospitals is a good indication that a EP will not be welcomed as an equal member of the staff.

 

[deleted171991]

The bottom line on the evidence is that EP’s can safely administer Propofol for deep sedation. Having a second provider is reasonable if the procedure cannot be abandoned if the patient deteriorates, or if appropriate monitoring is difficult with a single provider. Having 2 providers in all cases is probably overkill.

I am sorry, but it's not. The exceptions should be truly minor and very short cases (e.g. minutes of suturing in kids), if any.

There is a reason Sedasys didn't catch on; one can easily go from moderate sedation to general anesthesia (loss of airway) in minutes or less, and then one may not have much time to fix the problem.

Also, these cases are waaaaay more prone to emesis on a full stomach than your usual RSI., where the patient is muscle-relaxed. So you need an airway expert at the head, because seconds can matter. I am speaking as somebody who's had an NPO patient throw up A LITER of intestinal contents in the middle of a propofol sedation case (he had undiagnosed autonomic dysfunction). Had I not been at the head, it would have been a massive aspiration; there was none.

 

[IMGASMD]

I am all for physicians first approach. But how many times they call us for airway emergencies after botched intubation attempts. Just because they can doesn’t mean they should.

Had a discussion with an IR physician regarding they also want to use prop in their procedures for tough cases. I preceded on asking how does she feel about pain docs ordering films at outside facility and billing for reading CT. Shut her up pretty fast.

The standard is always be able to rescue airways. Sure slap on some oxygen 95% of the time would be fine. I had a TEE the other day after 50 of prop, I stayed in the procedure room for another 45 min because the sat would dip down to low 80s even with mask. Patient did not wake up fully even with good stimulation.

Sure most of the cases in ED would probably be “okay” but, not a big fan to rescue someone else’s messes especially when I am stuck somewhere else.

 

[DrGasPasser]

I am sorry, but it's not. The exceptions should be truly minor and very short cases (e.g. minutes of suturing in kids), if any.

There is a reason Sedasys didn't catch on; one can easily go from moderate sedation to general anesthesia (loss of airway) in minutes or less, and then one may not have much time to fix the problem.

Also, these cases are waaaaay more prone to emesis on a full stomach than your usual RSI., where the patient is muscle-relaxed. So you need an airway expert at the head, because seconds can matter. I am speaking as somebody who's had an NPO patient throw up A LITER of intestinal contents in the middle of a propofol sedation case (he had undiagnosed autonomic dysfunction). Had I not been at the head, it would have been a massive aspiration; there was none.

I was referring to procedures like cardioversion where a single dose of propofol or etomidate is given and the procedure involves a nurse pushing a button. These types of procedures are relatively common in EDs and don’t need a second doctor. Otherwise, I agree that a second physician provider is a best practice guideline for deep sedation whenever possible.

I appreciate that you may disagree based on your personal experience. However, this topic has been covered quite well by ACEP, ASA, and the Joint Commission:

Procedural Sedation and Analgesia in the Emergency Department |…

AUTHORS Caleb P. Canders, MD, Department of Emergency Medicine, UCLA Ronald Reagan Medical Center, Los Angeles Gregory E. Tong, MD, Department of Emergency Medicine, UCLA Ronald Reagan Medical Center, Los Angeles Nadine El Fawal, University of California at Los Angeles PEER REVIEWER Frank…

www.reliasmedia.com

ACEP, ASA, and The Joint Commission guidelines agree that the provider who oversees the PSA, usually a physician, should be responsible for the patient’s global management, including supervision of personnel and identification and management of adverse events.6,12 In a “single-coverage” ED, this provider also may be expected to perform other brief procedures (e.g., fracture/dislocation reduction), as long as the non-PSA procedure can be halted.13-15In ACEP’s guidelines, the second provider, usually a nurse or respiratory therapist, primarily is involved with continuous monitoring of the patient and documentation, although this provider can assist with minor, interruptible tasks that do not interfere with monitoring.6

 

[dannyboy1]

I am all for physicians first approach. But how many times they call us for airway emergencies after botched intubation attempts. Just because they can doesn’t mean they should.

Had a discussion with an IR physician regarding they also want to use prop in their procedures for tough cases. I preceded on asking how does she feel about pain docs ordering films at outside facility and billing for reading CT. Shut her up pretty fast.

The standard is always be able to rescue airways. Sure slap on some oxygen 95% of the time would be fine. I had a TEE the other day after 50 of prop, I stayed in the procedure room for another 45 min because the sat would dip down to low 80s even with mask. Patient did not wake up fully even with good stimulation.

Sure most of the cases in ED would probably be “okay” but, not a big fan to rescue someone else’s messes especially when I am stuck somewhere else.

ED and IR are worlds apart. From what I have seen an IR doc would not be able to rescue an airway any better than some dude off the street. ED docs should be able to rescue airways.

 

[Mman]

I don't like the idea of telling other physicians which medications they can't use.

I probably felt that way a long time ago and then I heard/saw too many things that either directly killed or wounded a patient by a physician giving a medicine they should not have been giving.

Ever see a medicine doc ask the nurse to give some neuromuscular blocker because they patient was moving to much during their bedside procedure? And the patient was not intubated????

 

[D P356]

Ever see a medicine doc ask the nurse to give some neuromuscular blocker because they patient was moving to much during their bedside procedure? And the patient was not intubated????

Have you seen this? I’m hoping this was rhetorical.

 

[Urzuz]

Ever see a medicine doc ask the nurse to give some neuromuscular blocker because they patient was moving to much during their bedside procedure? And the patient was not intubated????

Think about how much harm this clown is doing on a daily basis. A physician like this is bound to find some other way to kill a patient and harm countless along the way, so the sooner they have their license revoked the better. You can’t save people from themselves.

 

[Arch Guillotti]

Ever see a medicine doc ask the nurse to give some neuromuscular blocker because they patient was moving to much during their bedside procedure? And the patient was not intubated????

No. Have you?

 

[Mman]

Have you seen this? I’m hoping this was rhetorical.

yes have seen it. Obviously resulted in a code and a sentinel event. There is a reason some medicines are restricted as to who can order them.

 

[jwk]

I probably felt that way a long time ago and then I heard/saw too many things that either directly killed or wounded a patient by a physician giving a medicine they should not have been giving.

Ever see a medicine doc ask the nurse to give some neuromuscular blocker because they patient was moving to much during their bedside procedure? And the patient was not intubated????

We had the same issue when midazolam was released 30 years ago. GI docs pretty much directed their own sedation. We had numerous codes in the GI lab - turns out they were pushing 10mg of midaz just like they were giving 10mg of diazepam. No difference there, right? 😉

 

[DrGasPasser]

I probably felt that way a long time ago and then I heard/saw too many things that either directly killed or wounded a patient by a physician giving a medicine they should not have been giving.

Ever see a medicine doc ask the nurse to give some neuromuscular blocker because they patient was moving to much during their bedside procedure? And the patient was not intubated????

I’m going out on a limb that this was not a Board Certified Emergency Physician. In fact, I bet it was someone who was not credentialed to perform sedation or intubation at your institution.

 

[Mman]

I’m going out on a limb that this was not a Board Certified Emergency Physician. In fact, I bet it was someone who was not credentialed to perform sedation or intubation at your institution.

as I noted, it was a medicine subspecialty, not EM. And I am not making any comment on propofol in the ED, simply pointing out the idea that all docs should be able to order whatever med they want is not a wise idea.

 

[deleted875186]

I agree that restricting certain medications to certain specialties in the hospital is appropriate. Nobody can argue with the fact that propofol has serious potential to harm or kill a patient, from respiratory or cardiovascular compromise, even if the doctor is able to rescue the airway.

 

[Lexdiamondz]

I agree that restricting certain medications to certain specialties in the hospital is appropriate. Nobody can argue with the fact that propofol has serious potential to harm or kill a patient, from respiratory or cardiovascular compromise, even if the doctor is able to rescue the airway.

But you can say the same thing about lidocaine, insulin, beta antagonists, calcium channel blockers, amiodarone, every induction agent ever and a whole host of medications that ER docs (and IM docs) use on a daily basis.

Procedural sedation has been a core competency of training in emergency medicine for a while now and I'd say the vast majority of EM docs who have graduated in recent years are fairly comfortable with it. I don't think it's unreasonable to have a separate operator for the airway and one for the procedure (in fact that's how we are trained at my institution), it's probably the safest setup for both patient and physician. That being said, saying that we can't use propofol on what are generally healthy people when we use much more haemodynamically active agents on sick people on regular basis is kind of silly.

 

[DrGasPasser]

as I noted, it was a medicine subspecialty, not EM. And I am not making any comment on propofol in the ED, simply pointing out the idea that all docs should be able to order whatever med they want is not a wise idea.

I’d say you are exactly right.

On the other hand, I get the sense that people in this thread advocating for liberal access to medicines do so with the understanding that it is within the confines of their credentials and scope of practice. That is to say, physicians who are competent and credentialed to perform a procedure should not have vital tools for that procedure arbitrarily restricted.

I’m just unsure where an example of criminal negligence falls into this discussion of what is a core competency in EM. That doctor you cited should be sharing a cell with MJ’s.

 

[deleted875186]

But you can say the same thing about lidocaine, insulin, beta antagonists, calcium channel blockers, amiodarone, every induction agent ever and a whole host of medications that ER docs (and IM docs) use on a daily basis.

Procedural sedation has been a core competency of training in emergency medicine for a while now and I'd say the vast majority of EM docs who have graduated in recent years are fairly comfortable with it. I don't think it's unreasonable to have a separate operator for the airway and one for the procedure (in fact that's how we are trained at my institution), it's probably the safest setup for both patient and physician. That being said, saying that we can't use propofol on what are generally healthy people when we use much more haemodynamically active agents on sick people on regular basis is kind of silly.

Sure, but that is also the point. Propofol in certain sick patients is far more dangerous than any of the drugs you listed above, by far, and much more dangerous than any other induction agent ever created. It’s not even close.

I agree that for healthy people it is appropriate. But it is a slippery slope.

 

[deleted875186]

But you can say the same thing about lidocaine, insulin, beta antagonists, calcium channel blockers, amiodarone, every induction agent ever and a whole host of medications that ER docs (and IM docs) use on a daily basis.

Procedural sedation has been a core competency of training in emergency medicine for a while now and I'd say the vast majority of EM docs who have graduated in recent years are fairly comfortable with it. I don't think it's unreasonable to have a separate operator for the airway and one for the procedure (in fact that's how we are trained at my institution), it's probably the safest setup for both patient and physician. That being said, saying that we can't use propofol on what are generally healthy people when we use much more haemodynamically active agents on sick people on regular basis is kind of silly.

I’m also not sure what medicines your using that are more hemodynamically active than propofol. In fact, when I need to lower someone’s BP quickly and reliably, propofol is usually one of the most reliable.

 

[Lexdiamondz]

Sure, but that is also the point. Propofol in certain sick patients is far more dangerous than any of the drugs you listed above, by far, and much more dangerous than any other induction agent ever created. It’s not even close.

I agree that for healthy people it is appropriate. But it is a slippery slope.

And if a patient is sick and needs to be sedated for a procedure other than RSI, it should be done in the OR rather than an ER.

I’m also not sure what medicines your using that are more hemodynamically active than propofol. In fact, when I need to lower someone’s BP quickly and reliably, propofol is usually one of the most reliable.

Lol wut?

 

[Mman]

Lol wut?

if you know a faster way to lower the blood pressure of an already anesthetized patient than simply bolusing the propofol syringe that is already in line in their IV, I'd be curious to know what it is.

 

[nimbus]

Lol wut?

It’s true. A bolus of propofol reliably drops blood pressure. However, if somebody only checks BP every 15min, they wouldn’t notice.

 

[Lexdiamondz]

if you know a faster way to lower the blood pressure of an already anesthetized patient than simply bolusing the propofol syringe that is already in line in their IV, I'd be curious to know what it is.

It’s true. A bolus of propofol reliably drops blood pressure. However, if somebody only checks BP every 15min, they wouldn’t notice.

Ah there's the disconnect - I didn't realise you guys were talking about intra-op management.

 

[vector2]

But you can say the same thing about lidocaine, insulin, beta antagonists, calcium channel blockers, amiodarone, every induction agent ever and a whole host of medications that ER docs (and IM docs) use on a daily basis.

When the ED or IM is "giving" these meds, what you really mean is that they're putting in an order into the EMR and the nurse is administering it according to a certain protocol. The protocol pretty much prevents anyone from doing anything pants-on-head *****ic. The order for dilt will set off a bazillion alarm if the bolus is too high or the drip rate is something crazy. The computer will tell the nurse that amio 150 must be given over 10 minutes so they don't inadvertently IV push it and cause cardiovascular collapse. Even down in the trauma bay when the ED is intubating, half the time they just shout out some cookie cutter etomidate and sux dose to the nurse and the nurse administers it.


Propofol sedation OTOH is much more an art than protocolizable IMO, and speaking as someone who has pushed propofol a couple thousand times, you can get yourself into much more trouble much faster personally doing sedation vs entering an order for all the other meds you mentioned.

 

[nimbus]

Ah there's the disconnect - I didn't realise you guys were talking about intra-op management.

Not just intraop. When I give 30-50mg of propofol to an awake patient for a cardioversion, their blood pressure drops. If somebody doesn’t know this, they shouldn’t be using propofol.

 

[Arch Guillotti]

And if a patient is sick and needs to be sedated for a procedure other than RSI, it should be done in the OR rather than an ER.

Why? Don't you do off-site sedations?

 

[deleted875186]

And if a patient is sick and needs to be sedated for a procedure other than RSI, it should be done in the OR rather than an ER.

Fair point. I agree propofol should be used by the ED for healthy people, but I worry that ED folks may underestimate somebody’s hemodynamics response to propofol based on their underlying comorbidities.

 

[Urzuz]

Sure, but that is also the point. Propofol in certain sick patients is far more dangerous than any of the drugs you listed above, by far, and much more dangerous than any other induction agent ever created. It’s not even close.

I agree that for healthy people it is appropriate. But it is a slippery slope.

I would argue that it’s a slippery slope in the other direction restricting medications that a physician can use or prescribe. Pretty soon, every specialty will lay claim to certain medications in an attempt to protect their territory and ensure job security. You may think it’s ludicrous, but there was already an attempt at our hospital to have an endocrinologist consulted on EVERY diabetic patient having surgery, type 1 or 2, regardless of how well controlled it is. You can guess who was driving that bus, yelling from every mountain top that blood sugars in diabetics need to be closely watched and they were the only ones capable of doing it.

So if it’s a slippery slope in both directions, it must mean we are on a peak. Leave things alone and let physicians police themselves. If they are idiotic and cause harm (eg: giving a paralytic to an awake patient) then restrict THAT physician’s use, don’t have a knee jerk reaction to create a blanket policy in an attempt to prevent further errors. That is what clipboard nurses do - create policies in an attempt to solve every problem, failing to realize that to err is human, and “never-events” will “never” reach zero. They only drive costs up and give otherwise useless people a job in a hospital setting (let us sit around and discuss which medications can be used by which physicians). If a physician is criminally negligent enough to give paralytics or sedation to patients inappropriately, revoke their license and lock them up.

 

[Mman]

If a physician is criminally negligent enough to give paralytics or sedation to patients inappropriately, revoke their license and lock them up.

While that is true, that does not mean a hospital should have no restriction on any medicine on formulary. Plenty of drugs should be restricted either from the insanely high cost or from the potentially fatal consequences of inappropriate usage and I think physicians should be the ones helping create those lists and deciding who gets to give what. That doesn't mean we all decide that only the endocrinologist can order metformin or the cardiologist has to order the metoprolol, but it does mean that maybe there should be an ID consult for treating some MDR organisms or you need an oncologist to order some insanely expensive chemo drug.

The point of restricting access to certain medications is not for a hospital to dictate to physicians how they are going to practice, it's for the physicians in a hospital to determine what is safe and reasonable for local standards of care.

 

[Lexdiamondz]

Not just intraop. When I give 30-50mg of propofol to an awake patient for a cardioversion, their blood pressure drops. If somebody doesn’t know this, they shouldn’t be using propofol.

Yeah but I'm not sure how many people are specifically giving propofol to treat hypertension outside of an OR. Thats the point I was trying to make. It's common knowledge that propofol can drop your MAP, I'd just never heard of anyone every using it solely for the purpose of lowering a patient's BP

 

[IMGASMD]

Yeah but I'm not sure how many people are specifically giving propofol to treat hypertension outside of an OR. Thats the point I was trying to make. It's common knowledge that propofol can drop your MAP, I'd just never heard of anyone every using it solely for the purpose of lowering a patient's BP

Because YOU don’t use it enough? Because if this was done on the floor/in ED even though efficacious, you’d be running into apnea sooner than later?

After all the discussions, I actually feel our department did it right, going back to the original question. Yes ED can use it, but please have two physicians there. There are plenty of drugs for sedation. 2 of verses and 100 of fent still have plenty of rooms to move. If the next drug you’re shouting out is prop, you don’t know your poly pharmacy.

 

[Lexdiamondz]

Because YOU don’t use it enough? Because if this was done on the floor/in ED even though efficacious, you’d be running into apnea sooner than later?

After all the discussions, I actually feel our department did it right, going back to the original question. Yes ED can use it, but please have two physicians there. There are plenty of drugs for sedation. 2 of verses and 100 of fent still have plenty of rooms to move. If the next drug you’re shouting out is prop, you don’t know your poly pharmacy.

I'm not sure what you're getting at here.

 

[nimbus]

Yeah but I'm not sure how many people are specifically giving propofol to treat hypertension outside of an OR. Thats the point I was trying to make. It's common knowledge that propofol can drop your MAP, I'd just never heard of anyone every using it solely for the purpose of lowering a patient's BP

Ahhh okay. Yes it’s probably used only in the OR to acutely drop blood pressure. Maybe some intensivists do it too on intubated patients.

 

[DrGasPasser]

Ahhh okay. Yes it’s probably used only in the OR to acutely drop blood pressure. Maybe some intensivists do it too on intubated patients.

We lower BP all the time in the CVICU. However, we also like to keep most patients’ RASS between 1 and -2, so anesthetics are generally not what we reach for to drive cardiovascular physiology.

 

[pgg]

I'm just going to repost/paraphrase something I wrote here 6 years ago in a thread about a dental clinic death that morphed into an ER thread.

EM docs are physicians and they can do what they want. The only time conflict seems to come up is when anesthesiologists serve on hospital committees that influence privileges, or govern sedation services. It is, of course, not our place as anesthesiologists to dictate what does and doesn't fall within the standard of care or credentials/privileges of dentists or other physicians.

But for those non-anesthesiologists (EM, dentists, OMFS'ers, etc) who are posting and reading, there's something you have to understand:

When you ask a bunch of anesthesiologists their opinions on things like sedation and anesthesia, the only answer you can expect, and the only answer you're going to get, is one grounded in our own standard of care. What else are we going to say?

Safe sedation requires a qualified person, dedicated to the task of sedation and monitoring, not also doing the procedure, with appropriate monitors (to include etCO2), with appropriate equipment and supplies for resuscitation immediately at hand, with appropriate time space and personnel for recovery prior to discharge.

If you're not doing that to my standards in your corner of the hospital, don't expect me to smile and nod when the hospital credentialing or P&T committee asks my opinion.

 

[deleted171991]

I'm just going to repost/paraphrase something I wrote here 6 years ago in a thread about a dental clinic death that morphed into an ER thread.

EM docs are physicians and they can do what they want. The only time conflict seems to come up is when anesthesiologists serve on hospital committees that influence privileges, or govern sedation services. It is, of course, not our place as anesthesiologists to dictate what does and doesn't fall within the standard of care or credentials/privileges of dentists or other physicians.

But for those non-anesthesiologists (EM, dentists, OMFS'ers, etc) who are posting and reading, there's something you have to understand:

When you ask a bunch of anesthesiologists their opinions on things like sedation and anesthesia, the only answer you can expect, and the only answer you're going to get, is one grounded in our own standard of care. What else are we going to say?

Safe sedation requires a qualified person, dedicated to the task of sedation and monitoring, not also doing the procedure, with appropriate monitors (to include etCO2), with appropriate equipment and supplies for resuscitation immediately at hand, with appropriate time space and personnel for recovery prior to discharge.

Thank you for your wisdom. Why don't you run for an ASA leadership position?

 

[Mman]

EM docs are physicians and they can do what they want. The only time conflict seems to come up is when anesthesiologists serve on hospital committees that influence privileges, or govern sedation services. It is, of course, not our place as anesthesiologists to dictate what does and doesn't fall within the standard of care or credentials/privileges of dentists or other physicians.

But for those non-anesthesiologists (EM, dentists, OMFS'ers, etc) who are posting and reading, there's something you have to understand:

Here's the other thing: CMS mandates that the anesthesia department be in charge of protocols/privileges for sedation in a hospital whether anybody in the anesthesia department wants that responsibility or not.

 

[nimbus]

Then there’s the problem of the package insert.

 

[Urzuz]

While that is true, that does not mean a hospital should have no restriction on any medicine on formulary. Plenty of drugs should be restricted either from the insanely high cost or from the potentially fatal consequences of inappropriate usage and I think physicians should be the ones helping create those lists and deciding who gets to give what. That doesn't mean we all decide that only the endocrinologist can order metformin or the cardiologist has to order the metoprolol, but it does mean that maybe there should be an ID consult for treating some MDR organisms or you need an oncologist to order some insanely expensive chemo drug.

The point of restricting access to certain medications is not for a hospital to dictate to physicians how they are going to practice, it's for the physicians in a hospital to determine what is safe and reasonable for local standards of care.

I understand your points, but these committees are trying to solve problems that don’t need to be solved. How often are non-oncologists ordering ridiculously expensive chemotherapeutic agents? And how often are internal medicine doctors ordering paralytics on non-intubated patients? To think of it in statistical terms, the NNT to see any impact at all with these policies is in the hundreds of thousands, if not millions. So, do you really feel like it is worth forming committees, dedicating countless man-hours to solve problems that are extraordinarily rare? I contend that if you agree that resources in health care are finite, and we should allocate resources properly in the most efficient ways, we should dedicate resources to the low hanging fruit that will actually have a meaningful impact. Streamline processes that don’t prolong futile end of life care. Make sure patients get antibiotics at appropriate times. Make discharge planning a high priority to minimize bounce backs. Fire all the useless clipboard RNs that contribute zero to clinical care. If and when the one off bozo physician inappropriately prescribed a ridiculously expensive chemo drug or gives a patient a paralytic, discipline them individually.

Edit: I also cannot overemphasize how these committees (usually headed by RNs) work to undermine physicians’ autonomy and authority. It’s a slow but sure erosion of being able to do what one thinks is clinically necessary and actually take care of patients. It’s also the same brainwashing that leads RNs into thinking that they want to do a timeout before commencing chest compressions in a coding patient, in the name of patient safety.

 

[pgg]

Then there’s the problem of the package insert.

The package insert says a lot of ridiculous stuff, but I assume what you're getting at is the bit that says:

"For general anesthesia or monitored anesthesia care (MAC) sedation, propofol injectable emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure."

That doesn't say anesthesiologist. An EM doc who rotated on anesthesia for a month to get some airways has been "trained in the administration of general anesthesia" ...

Also, it says "should" ...

For malpractice to be malpractice, a deviation from the local standard of care is required. At places where non-anesthesiologists/non-CRNAs/non-AAs are routinely using propofol for sedation, that standard of care is pretty clear.

 

[Mman]

I understand your points, but these committees are trying to solve problems that don’t need to be solved. How often are non-oncologists ordering ridiculously expensive chemotherapeutic agents? And how often are internal medicine doctors ordering paralytics on non-intubated patients? To think of it in statistical terms, the NNT to see any impact at all with these policies is in the hundreds of thousands, if not millions.

You say the NNT is in the millions? To prevent what? Because I can come up with an NNT of like 5 or 10 for some drugs that should be restricted in their ordering to prevent either some degree of harm or a waste of money in the hundreds of dollars or more.

I am not saying every drug should be limited. I am not saying clipboard holders should be driving the rules. I am saying physicians should decide amongst themselves what needs to have limits placed on it. Either regulate ourselves or some external force will do it for us.

I have stories upon stories from all sorts of hospitals of drug ordering stupidity.

 

[deleted171991]

The package insert says a lot of ridiculous stuff, but I assume what you're getting at is the bit that says:

"For general anesthesia or monitored anesthesia care (MAC) sedation, propofol injectable emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure."

That doesn't say anesthesiologist. An EM doc who rotated on anesthesia for a month to get some airways has been "trained in the administration of general anesthesia" ...

Also, it says "should" ...

For malpractice to be malpractice, a deviation from the local standard of care is required. At places where non-anesthesiologists/non-CRNAs/non-AAs are routinely using propofol for sedation, that standard of care is pretty clear.

That basically means only anesthesiologist or anesthetist. Also, that means a separate provider. End of discussion.

Anything else is the hospital's malpractice risk and fun, but why would a committee piss against the FDA-approved insert? Do they want to be sued individually for bad outcomes? (Yes, committee membership does open one up to liability.)

 

[Iso4ane]

That basically means only anesthesiologist or anesthetist. Also, that means a separate provider. End of discussion.

Anything else is the hospital's malpractice risk and fun, but why would a committee piss against the FDA-approved insert? Do they want to be sued individually for bad outcomes? (Yes, committee membership does open one up to liability.)

But isn’t the Halodol we use ‘For IM use only.’ ?