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My Turn
RNs Should Not Administer Propofol
David Barinholtz
Publish Date: October 10, 2007

When three leading gastroenterological associations issued a statement advocating physician-supervised, RN-administered propofol for endoscopy, I was shocked. Propofol is riskier than anesthetic regimens traditionally administered during endoscopy. There's also the possibility no code team will be in place in an office environment. If you then burden the physician with RN supervision on top of the clinical risks of an aging population, you place hundreds of thousands of patients at unnecessary risk.

Propofol's inherent risks
Traditionally, GI endoscopy sedation comprises modest doses of short-acting reversible agents to achieve anxiolysis, amnesia and mild sedation, usually a benzodiazepine/narcotic regimen. Propofol's deeper, faster sedation and more rapid cognitive and functional recovery have made it more popular - I've found it significantly hastens the procedure, increasing GI endoscopy efficiency by more than 50 percent.

But propofol is far riskier than traditional regimens. Contrary to the statement by the Ameri-can College of Gastroenterology, American Gas-troenterological Association and American Soc-iety for Gastrointestinal Endoscopy, propofol is not conscious sedation. It's an irreversible general anesthetic that requires well-honed skills.

Additional risks
An office-based surgeon can make his facility as safe as the hospital, but he doesn't always have to; the regulations governing offices are less restrictive, sometimes nonexistent. Global reimbursements are often significantly lower for offices, which presents financial pressures that can tempt even the most conscientious surgeon to forego ACLS staff training or hiring an anesthesia provider to administer propofol. Some argue the cost of hiring anesthesia providers for office endoscopy is prohibitive.

Thirteen states now prohibit RN-administered propofol. The American Accred-itation Association for Ambulatory Surgical Facilities recently said accredited facilities must have a CRNA or anesthesiologist administer propofol. In May, the American Association of Nurse Anesthetists and American Society of Anesthesiologists issued a joint statement condemning propofol administration by anyone other than a qualified anesthesia provider.

The propofol product label supports use by only those trained in deep sedation and general anesthesia. Finally, nearly three-fourths of surgical facility managers, many of whom are RNs themselves, believe that RN-administered propofol is a patient-safety risk that is beyond the RN's scope of practice, according to an Outpatient Surgery reader survey.

Why, then, would gastroenterologists want to be responsible and liable for RNs' administering propofol? The societies claim to have a large case series indicating the practice is safe and effective. But they should not rely on this data; the studies are too small to be conclusive. Critical incidents with propofol, such as cardiac and respiratory arrest with failure to rescue, happen about 1 in 200,000 times to qualified anesthesia providers, yet this "large case series" involved only about 3,000 patients. Until sufficient-sized studies are performed, no one other than a CRNA or anesthesiologist should administer propofol. Period.