Re: "Keep Propofol in Trained Hands" (August, page 8). I read your editorial with concern. I am an RN with more than five years experience administering propofol in a hospital GI department in conjunction with both a gastroenterologist group and a pulmologist group. Not just any RN may deliver this medication in our department. But you made it sound as though RNs with a great deal of experience and professional training are unable to do what is safe for patient care. Credentialed MDs (gastroenterologists) and RNs properly trained to assess and monitor each patient can deliver propofol in a safe and responsible manner. Any sedation patient undergoing a procedure with any medication is attended by an MD (properly credentialed), a technician (BLS and experience in assisting with airway management) to provide direct assistance to the procedurist, and an RN whose only function is to assess the patient, provide the propofol and continuously monitor the patient's airway and vital signs. We are in charge of monitoring the patient, not being the physician's gopher or handmaiden. If that's needed, we call for someone else.

Elizabeth A. Russell, RN, BSN, BS
Providence Medford Medical Center
Medford, Ore.
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I'm an RN who administers propofol for procedural sedation. I work in an ASC and manage an endo department. Our RNs are ACLS and PALS certified and have to go through a rigorous training program, including spending time with an anesthesiologist in the OR, before they're able to administer this drug. Our gastroenterologists are also airway-trained, including intubation, and must be privileged in deep sedation to perform procedures with nurse-administered propofol. Nurses who administer this drug do so with extreme caution. Our only job is to give the drug and monitor the patient. We never leave the patient, nor do we engage in any other tasks during the procedure.

We nurses are expected to recover patients from general anesthesia in the post-anesthesia care units. And we're also expected to rescue a patient who gets into trouble due to the effects of general anesthesia, so what is the big issue here? Using anesthesiologists or even CRNAs for procedural sedation just drives up costs.

Val Charley, RN
Surgery Center of Southern Oregon
Medford, Ore.
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The problem with propofol is its potency.?A patient can go from mildly sedated to apnic, obtunded and obstructed in the blink of eye. When GI docs join forces with a CRNA doing private billing, patients get the care they need and deserve, and the doc doesn't have to put out money.

Thom Bloomquist, MSN, CRNA
Woodsville, N.H.
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I enjoyed and wholeheartedly support your editorial position on RNs (not) pushing propofol. Botox had, for many years, been used for the treatment of wrinkles before the FDA consented to approve of that use. Similarly, the current FDA labeling of propofol will not prevent gastroenterologists from having their RNs push propofol. Nor will the disapproval of the ASA or AANA make any difference to the gastroenterologists' potentially risky practice.

The biggest contributions anesthesiology has made to patient safety in the past half century have been in improved monitoring. In 1972, I monitored my patients with a finger on the pulse, a hand on the breathing bag and a floor model mercury column blood pressure device. There was no EKG, NIABP, SpO2 or BIS monitor. In the past 33 years alone, anesthesia patient mortality has gone from 1:10,000 to 1:250,000. Improved anesthesia training is, at least, as much to credit as is the vastly improved monitoring. Since we can't prevent the GI docs from having propofol in their suites, we should insist on appropriate monitoring.

Barry L. Friedberg, MD
Corona del Mar, Calif.
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The American Society of Anesthesiologists' "Statement on Safe Use of Propofol," created in October 2004, addresses such important safety measures when administering propofol as:

• Patients receiving propofol should receive care consistent with deep sedation.
• Practitioners must be available and qualified to rescue the patient from deep sedation and general anesthesia when that is needed, whether intended or not.
• The physician responsible for the use of the sedation/anesthesia should have the education and training to manage the airway and cardiovascular complications associated with deep sedation and general anesthesia.
• The practitioner monitoring the patient should be available throughout the procedure and be completely dedicated to that task.

We're actively looking at this issue and continue to emphasize our message of patient safety.

Eugene P. Sinclair, MD
President
American Society of Anesthesiologists
Elm Grove, Wis.
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Ketorolac Far from Perfect
Re: "Sizing Up Non-opioid Analgesics" (2005-06 Manager's Guide to Surgical Drugs, page 25). I read with some alarm the recommendation for ketorolac (Toradol). You made ketorolac sound like the perfect drug to use at the end of every case. But the package insert states that Toradol inhibits platelet function and increases the risk of bleeding. In my experience of 30 years and 30,000 plastic and reconstructive surgery patients, I've had one patient who required a return to the OR for post-op bleeding after a rhinoplasty. Without my knowledge or permission, the anesthesiologist gave that patient Toradol at the end of the case. I have never used this drug since and I urge my colleagues to be careful.

Robert A. Ersek, MD, FACS
Austin, Texas
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