Propofol Use by Non-Anesthesia Providers

[Noyac]

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It's good to know that a 4-year-old has never died under the care of an anesthesiologist.

So where in the quote does it say that a 4 yr old has never died under the care of an anesthesiologist? And if this dentist had walked up on an apniec kid on the street or at a social event, would he have thought about mouth to mouth resus. or would he have just watched the kid die without attempting to correct it. This is a problem. I was not there but from the description from someone that was closely related tot he event, it sounds like there was no attempt to correct the problem. Well if you can't intubate, at least you can breath can't you?


Now, back to the subject at hand. We are presently attempting to train our EP's, Cardiologists, Gi docs, and every other physician that uses deep sedation, to manage an airway with more than just a ETT. They will be doing cases in the OR with propofol to see its effects first hand. As Desperado said, anesthesia is not always available and I don't know about you guys but I don't want to be called to the ER every time a kid breaks his arm or when any other sedation is needed. Personally, I think ketamine is awesome and I don't know why its reserved for kids only. Etomidate, well I never have used it for sedation. I don't really see why it has to be reserved for anesthesiologists only. I think with the right training it can be used by others as well. But I do understand how potent this drug is and how fast things can go bad. This is something that I think is coming no matter what we do and we can either be on the forefront or we can resist it and watch them do it without us. 🙁

 

[jetproppilot]

I don't want to be called to the ER every time a kid breaks his arm or when any other sedation is needed. 🙁

Not only do I echo this sentiment, I believe that it is not feasible to have anesthesia at every sedation event.

Thats why they invented "conscious-sedation", or whatever the term is.

Folks that say it can't be done safely are not being realistic. At my old gig, at the surgery center, the GI dudes did about 50 endoscopies weekly...and we werent involved most of the time. Every once in a while (once every 2-4 weeks) the GI dude would call us in to ask us a question...hypertension intervention, etc. Very rarely there was the patient that couldnt be sedated adequately....they'd either tough it out or wait for us to have a window to help them...but again, very rare.

 

[bullard]

Are EPs good enough for what they do? I sure as **** hope so, but I think the poorly-powered studies you've posted (including the additional text you posted) proves very little. And until we have better data, I don't think propofol should be passed around like candy.

Yes, we have complications. But we're not exactly talking about a 10% rate of death and dismemberment.

Are we better at giving anesthesia than anesthesiologists? No. Are we good enough for what we do? I think the literature would suggest the answer is probably.

 

[jwk]

Not only do I echo this sentiment, I believe that it is not feasible to have anesthesia at every sedation event.

Thats why they invented "conscious-sedation", or whatever the term is.

Folks that say it can't be done safely are not being realistic. At my old gig, at the surgery center, the GI dudes did about 50 endoscopies weekly...and we werent involved most of the time. Every once in a while (once every 2-4 weeks) the GI dude would call us in to ask us a question...hypertension intervention, etc. Very rarely there was the patient that couldnt be sedated adequately....they'd either tough it out or wait for us to have a window to help them...but again, very rare.

Jet, how many of those 50 were done with propofol without an anesthesia provider?

And as I've stated before - GI and ER docs have no interest in "conscious sedation" with propofol. They like it because it's deep sedation, and the problem comes when that deep sedation crosses that very thin line into general anesthesia. If your patient's SaO2 is dropping and they've lost their airway relexes, that's a general anesthetic, and it should NOT be done in ER or GI by anyone except an anesthesia provider.

 

[jwk]

jwk- I understand your concerns about propofol re: hypotension, etc
aside from fentanyl/versed what meds/combos are the anesthesia folks"really ok" with em using for conscious or procedural sedation? I use ketamine fairly often with kids and am comfortable with its use.use etomidate rarely. you guys don't have a problem with ketamine or etomidate, do you?
fyi- my preference when at all possible is to use hematoma blocks, regional blocks etc for procedures and I tend to only use bigger guns for behavioral issues.

At my hospital, it's narcotic and benzo, or it's with us. Propofol, pentothal, brevital, ketamine, and etomidate are anesthesia-only drugs by hospital policy.

Realistically - I have a much smaller problem with ketamine than I do with propofol. Ketamine's in a class by itself in the way that it works. Let 'em wake up in a quiet area and they do great. Even with adults, ketamine has a place - but they need some midazolam to help avoid seeing spiders on the wall.

I have zero experience with etomidate for sedation - and I can't think of why I would want to use it for that. I don't even use it in the OR much - I usually just knock my propofol dose way down.

 

[Orchard]

If there was laryngospasm? I would expect my kid to be criched, and I would be glad that the person performing the sedation had the experience to perform a crich. How many of those did you do in residency, by the way?

... And given that choice with my kid, I'd take the EP.

WOW! Dude, I hope you NEVER have children and if you do, do not bring them to the ED for "sedation" by an ER doc. You're either an idiot or just beginning your training because anyone that would expect their child to undergo an invasive, risky procedure to secure an airway is nuts! If your kid went into laryngospasm ANY anesthesiologist would give Succinylcholine and intubate rather than performing a cricothyroidotomy! Do you know how quickly a 4 year old would desaturate while the ER doc is performing a cric? I'll spare you the respiratory physiology since you need to educate yourself; suffice it to say let's hope they can perform the procedure pretty damn quickly.

Also, I didn't perform any crics during residency since I know how to manage an airway. By following the ASA Difficult Airway Algorithm, I have NEVER had a problem managing an airway so cric training is unnecessary.

 

[toofache32]

...If there was laryngospasm? I would expect my kid to be criched, and I would be glad that the person performing the sedation had the experience to perform a crich...

I'm surprised that nobody has mentioned that crichs are not a good idea in kids under the age of 10-12 years old because of the size of the membrane and probablity of subglottic stenosis. Obviously that's not as bad as a dying of a lost airway.

 

[jwk]

I'm surprised that nobody has mentioned that crichs are not a good idea in kids under the age of 10-12 years old because of the size of the membrane and probablity of subglottic stenosis. Obviously that's not as bad as a dying of a lost airway.

I've seen two surgical airways in 25 years of anesthesia - crich's, in general, are for people who don't have the SKILLS required to intubate. If you can't intubate, than ya damn well shouldn't be doing sedation with propofol.

 

[etherRN]

Propofol is used on a daily basis in my unit. Too frequently, I see RNs push pt's dangerously close to deep sedation. A hospital close to where I live had to fire over a dozen RNs for incorrectly using the drug.

http://www.wave3.com/Global/story.asp?S=1469399&nav=0RZEIM3P

What the article does not tell you is that they pushed it, stored it in their lockers (hello! emulsion!), etc. As a former nurse aide, I remember a bunch of nurses who pushed it. They'd actually count to ten as they pushed and laughed when the pt was out. Now regionally, an MD or CRNA must be at the bedside w/an emergent intubation to necessitate a Propofol push. Yet, many physicians will write orders for Propofol gtts. My concerns r/t pt safety and RN knowledge deficit of Propofol are as follows:

1) Most nurses think it's a benzo.
2) Most nurses feel uncomfortable weaning it, causing the level to stay on board, lipid-bound for days.
3) Most nurses do not take into consideration the pt's full caloric intake, being that a max PRN dose of 50mcg/kg/min constitutes nearly 24 bottles/day of extra kcal (not to mention that extra 2.4L/day for a VENTILATED pt).

 

[toofache32]

I've seen two surgical airways in 25 years of anesthesia - crich's, in general, are for people who don't have the SKILLS required to intubate. If you can't intubate, than ya damn well shouldn't be doing sedation with propofol.

I agree with this. However, I've seen 2 emergent surgical airways in my residency this far. One was in the medicine ER with angioedema, the other was in the OR when anesthesia could not intubate nor rescue the airway after Vec was pushed. They went down the algorithm through LMA and everything but it wouldn't work for whatever reason. So the patient got a #15 blade through the crico followed by a 6.0 ETT shoved through the hole. Talk about a "wish I had worn my brown scrubs" kind of day...

 

[Noyac]

Yes, cricothyrotomies happen. I saw my first one, secondhand last week. One of my partners was called in the middle of the night to take a HUGE guy to the OR after he had the **** beat out of him at a local bar. His belly was filling up with blood right in front of their eyes from a ruptured spleen. The Er doc wanted to intubate him before going to the OR but my partner said no and wisked him away. He looked normal as far as his airway goes except that he had a short THICK neck. RSI induced and blade inserted- nothin. He could see absolutely nothin. Tried everything without success. LMA wouldn't ventilate him, niether would the mask with oral airway. They performed a crico and on with the case. He received 8 unit PRBC's and 15 liters of crystalloid over the next 6 hours. When I came to work the next morning my schedule had changed. The surgeons and my partner wanted me to intubate the guy from above so they could close his trachea. I said sure because I thought I could intubate anyone in a controlled environment. Let me tell you Itried everything, even a retrograde wire, and I couldn't get anything in there. Now, he was so swollen after the resuscitation effort that nothing looked normal but still nothing would pass. He got trach'd.
Just my .02 about cric's. I had never seen one until this case. And still never seen one first hand. Hope this is the last one.