Carolyn Buppert, MSN, JD

Disclosures

January 09, 2018

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Question

Should I Push the Propofol?

We received the following question from a registered nurse (RN). The answer may be of interest to nurses working in many different healthcare settings:

I've been discussing, with my nurse colleagues, whether it is legal and appropriate for an RN to push (bolus) propofol. There were wide-ranging opinions. In intensive care units (ICUs), patients are frequently on propofol drips for sedation. The medication is titrated up and down; sometimes boluses are even given off the pump. When a patient is being intubated, we may be ordered by the physician to bolus the sedation. I have heard RNs say, "It is illegal for RNs to push propofol." We are allowed to titrate the drug, so where is that line drawn?
Response from Carolyn Buppert, MSN, JD
Healthcare attorney

In my opinion, the default position of an RN who is asked to bolus propofol should be, "no." My rationale is this: Nurses are authorized by many state boards of nursing to administer moderate sedation. Propofol is meant to cause deep sedation. It can cause apnea, bradycardia, and hypotension. The difference between moderate sedation and deep sedation is elegantly explained by the Texas Board of Nursing (page 20).

What could turn the default response "no" into a "yes"? If an anesthesiologist or certified registered nurse anesthetist (CRNA) with ACLS training is present, gives the order, and has the management of the patient's airway as their sole responsibility, an RN might feel safe pushing propofol.

I recommend that an RN not change his or her default response of "no" just because there is a physician order, a facility policy, or the RN has ACLS certification. I am not alone in my opinion. The Massachusetts Nurses Association has a statement about this.

I think the issue of titrating propofol according to physician orders, when the patient is intubated and in a critical care unit, is a different matter. It's still not risk-free because the dose could cause bradycardia, and there are no reversal agents for propofol. Presumably if a nurse increased the dose according to physician orders to titrate, and the nurse noted a fall in the heart rate, the nurse would discuss that issue with the ordering physician.

The best writing on the issue of nurses administering propofol is on the Texas Board of Nursing website. I recommend a full reading of that board's document. Here are some excerpts:

Of concern to the Board is the growing number of inquiries related to RNs and non-CRNA advanced practice registered nurses administering propofol, ketamine, or other drugs commonly used for anesthesia purposes to non-intubated patients for the purpose of moderate sedation in a variety of patient care settings. It is critical for any RN who chooses to engage in moderate sedation to appreciate the differences between moderate sedation and deep sedation/anesthesia.
Although propofol is classified as a sedative/hypnotic, according to the manufacturer's product information, it is intended for use as an anesthetic agent or for the purpose of maintaining sedation of an intubated, mechanically ventilated patient. The product information brochure for propofol further includes a warning that "only persons trained to administer general anesthesia should administer propofol for purposes of general anesthesia or for monitored anesthesia care/sedation." The clinical effects for patients receiving anesthetic agents such as propofol may vary widely within a negligible dose range. Though reportedly "short-acting," it is also noteworthy that there are no reversal agents for propofol.
Therefore, it is the position of the Board that the administration of anesthetic agents (eg, propofol, methohexital, ketamine, and etomidate) is outside the scope of practice for RNs and non-CRNA advanced practice registered nurses except in the following situations:
  • When assisting in the physical presence of a CRNA or anesthesiologist (the CRNA or anesthesiologist may direct the RN to administer anesthetic agents in conjunction with the CRNA or anesthesiologist intubating or otherwise managing the patient's airway);

  • When administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (ie, when functioning as a student nurse anesthetist)

  • When administering these medications to patients who are intubated and mechanically ventilated in critical care settings;

  • When assisting an individual with current competence in advanced airway management, including emergency intubation procedures; or

  • When utilizing a US Food and Drug Administration (FDA)-approved Computer-Assisted Personalized Sedation System in accordance with the US FDA approval requirements, where appropriate safety requirements are met (such as availability of anesthesia providers) after completing appropriate training.

The Board again stresses that the nurse's duty to assure patient safety [Rule 217.11(1)(B)] is an independent obligation under his/her professional licensure that supersedes any physician order or facility policy. It is important to note that the nurse's duty to the patient obligates him/her to decline orders for medications or doses of medications that have the potential to cause the patient to reach a deeper level of sedation or anesthesia. [1]

Whether RNs may push propofol is ultimately a decision for the state board of nursing. Check with your state's board before deciding on your own personal policy about pushing propofol. Just because the board in your state hasn't posted a policy doesn't mean the board thinks it's OK. It is appropriate to submit a query to the board.

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