NAPS Receives Support

Nurse-administered Propofol Sedation Gets Thumbs-Up from GI Heads

On March 8, 2004, the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA) and the American Society for Gastrointestinal Endoscopy (ASGE) issued a jointly sponsored statement on sedation for endoscopy. The statement clarifies billing issues related to the administration and/or supervision of sedation/anesthesia, summarizes current data on sedative agents and makes recommendations regarding the appropriate use of anesthesia specialists for endoscopy and appropriate patient surveillance during sedation.

The statement, approved by the governing boards of the three societies, is the product of a six-member committee composed of representatives from each of the three societies. The committee addressed recent developments and trends in sedation practice, including the use of propofol.

The Society for Gastroenterology Nurses and Associates (SGNA) revised its position statement on deep sedation in Feb. 2004, and plans to release a joint statement with the ASGE in May.

“The reason that we have modified the position is due to new clinical studies that have been published,” says SGNA president Jo Harbaugh, BS, RN, CGRN. “There has been more data that we have seen that is more supportive of nurse-administered deep sedation.”

Deep sedation is not limited to propofol. Other anesthetic agents may not have the same benefits — more rapid onset of sedation, more rapid recovery, improvements in patient satisfaction. “Propofol definitely has some advantages,” says Harbaugh, “but it does have its risks in addition to the advantages.”

The primary risk, says Harbaugh, is that propofol has the ability to take a patient into a much deeper level of sedation, including passing them over into a state of general anesthesia. A more extensive skill is required to manage those patients — the nurse must be able to rescue a patient from general anesthesia.

SGNA’s position is that most endoscopic procedures can be performed under moderate sedation. “But for those patients that do require a deeper level of sedation, we are recommending that there be additional training with emphasis on advanced airway management and treatment of cardiorespiratory complications. We are also saying that that may include advanced cardiac life support (ACLS) or pediatric advanced life support (PALS). They must have additional advanced airway training and advanced training on medications that can be used.

“If it is determined that a patient can benefit from deeper sedation, there have to be protocols in place that provide safety for that patient,” continues Harbaugh.

“A controversy exists due to whether or not one agrees or disagrees that registered nurses should be allowed to give it,” says Douglas K. Rex, MD, professor of medicine for Indiana University. “Basically with propofol, some patients become apneic — they have severe enough respiratory depression that you have to assist their ventilation.”

The controversy is complex. “Different people will tell you that its basis lies in different things,” continues Rex. “There are 12 states in the United States that have laws against administration of propofol by nurses. That’s an issue. There are many anesthesiologists and anesthesia specialists who feel that nurses should not be allowed to give it.

“The last guideline from the American Society for Anesthesiology (ASA) did not exclude non-anesthesiologists from giving propofol. But the recent joint three-society press release stated that it should only be given by people who are trained in general anesthesia.”

The source of the controversy is twofold, says Rex: money and availability of anesthesia specialists. “The money issue is that when we do nurse-administered propofol sedation, we don’t submit any bills for it. For insurers, patients and everybody else, it’s less expensive. When anesthesiologists do it, they do submit a bill, for which they are paid. Sometimes those bills are pretty substantial. People that have been interested in NAPS have been trying to keep a handle on the costs of endoscopy — which are surging because of demand for endoscopy.”

The main red flag in terms of risks for patients is respiratory depression, says Rex. “We’ve treated about 11,000 patients. There hasn’t been a single patient who has required endotracheal intubation or who had any neurological deficits or anything else. This has been done in Switzerland, and the last time I saw their data abstracted, there were about 15,000 patients. Altogether, more than 50,000 patients have been given propofol by nurses for endoscopic procedures with nothing bad happening. Not all of that is published yet, but our hope is that as the evidence base emerges, it will drive the discussion — as opposed to peoples’ opinions. We all know that people may have the best intentions, but they may be shown to be wrong when the evidence comes out. “The key is that nurses have to be adequately trained, and there isn’t a real set of recommendations about how to get that training at the present time.”

Harbaugh stresses that regulations governing the administration of any anesthetic medications by registered nurses varies from state to state, and the healthcare providers must be aware of the limitations of their state licensing acts, nurse practice acts and their current institutional policies. “Not everyone is going to be able to administer deep sedation,” she says. “We still have to follow those guidelines, which vary state to state.”

“The primary reason we wanted to come out with a statement to provide the caregivers with some type of guideline and protocol to follow, was because there are states that do say it’s okay for registered nurses to administer the deep sedation. There are several states that have not committed one way or the other, and there are a few that have taken a stand and said that no, it is not within the Nurse Practice Act. Because of the fact that there are some states that do recognize that this is okay to do, we felt that it is important to provide protocols and standards that have to be in place to provide patient safety.”

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