"RNs Pushing Propofol" (July, page 24). As a nurse who has "pushed" procedural sedation drugs for more than a decade, I thought it interesting that the article presented the risks associated with propofol as if the same risks were not associated with every procedural sedation drug RNs already use. And it should go without saying that every nurse using any procedural sedation medication must be able to monitor the patient and "calmly restore" the patient's airway "immediately and routinely" when it is compromised. If not, she has no business doing it.

Nurses do not administer propofol for procedural sedation in my institution. However, because we see the benefits to our patients, I'm sure we will within the next few years. Before we do, we will have the knowledge, training and equipment to do it safely. Does anyone besides me remember these very same arguments against nurses administering Versed when it first became available? Can we even imagine doing procedures without it now? If nursing is really the profession we claim it is, we need to stop using our fears or opinions to determine our practice, arm ourselves with research, education and training, and move confidently into the future.

Sharon Morisey, RN
John Muir Medical Center
Walnut Creek, Calif.
[email protected]

In Defense of Nurse-Administered Propofol Sedation (NAPS)
? ?I read with interest the various opinions (many negative) on nurse-administered propofol sedation (NAPS) in your recent article. Most opinions were expressed by persons with no experience and/or no training in NAPS. I would like to emphasize several factors that should bear on the development and appropriateness of NAPS.

You noted that the American Society of Anesthesiology guideline does not preclude administration of propofol by registered nurses. Similarly, the American Society for Gastrointestinal Endoscopy guideline on deep sedation does not forbid the administration of propofol by registered nurses.

Second, the American Society of Gastrointestinal Endoscopy guideline on deep sedation states, "the routine assistance of an anesthesiologist for average-risk patients undergoing standard upper and lower bowel endoscopic procedures is not warranted and is cost-prohibitive." The reason it is cost-prohibitive is that anesthesia specialists have traditionally submitted separate fees, which are often quite substantial, and which must be covered by payers in addition to professional fees for performance of the endoscopic procedures. This is true even though CMS and many private payers consider that the professional fee for performance of endoscopic procedures includes a component for delivery of sedation. Cost issues are driving development of NAPS. In order to be fair to payers and to society, the administration of propofol by registered nurses is the only feasible mechanism, from a cost perspective, to accomplish propofol sedation for routine endoscopic cases.

Finally, it should be evidence more than opinion that determines the appropriateness of NAPS. Those persons who took a negative stance regarding nurse-administered propofol sedation in your article have no evidence base on which to make their claims or opinions. Similarly, AstraZeneca has no evidence base on which to make the statement in its package insert that the drug should only be given by anesthesiologists. In fact, the evidence base from Indiana University (>7,000 cases), from a private practice group in Medford, Oregon (>14,000), and from two groups in Switzerland (>15,000) is that nurses have administered propofol in more than 38,000 endoscopic cases (more than 26,000 cases are published fully or in abstract form) without a single instance requiring endotracheal intubation or resulting in death or neurologic sequelae. Thus, the available data supports the safety and feasibility of NAPS, and its continued development by responsible clinical investigators.

Douglas K. Rex, MD
Professor of Medicine
Division of Gastroenterology/Hepatology
Director of Endoscopy
Indiana University Hospital
[email protected]

A Poor Choice for Conscious Sedation
? ?Propofol used with any other sedative or narcotic is a poor choice for conscious sedation. Fentanyl has Narcan. Versed has Romazicon. But there is no reversal agent for propofol except for time. The lack of monitoring while using propofol for conscious sedation is unacceptable. Aspect's BIS monitor measures the level of consciousness. I think what nurses think they are doing is conscious sedation, but in reality they are giving unconscious sedation.

Alan Matthews, CRNA
[email protected]

Propofol Editorial Was Flawed
? ?Re: "RNs Should Not Push Propofol" (July, page 6). I found many flaws and examples of poor nursing practice in the editorial. Why would a prudent nurse give a drug she had "never even heard of?" The nurse you referenced should not have given propofol unless she knew how to administer it, about its formula and how to rescue a patient. My real concern is why was the circulating nurse giving propofol and then circulating the room? Her focus should have been the patient, not circulating. If the clinic she was working in expected her to do both, then there is the error - not the fact that an RN was administering propofol. I would hope that the majority of RNs would have more intelligence if not common sense than your example.

Deb Richards RN, BSN, CGRN
Endoscopy Charge Nurse
[email protected]

Making NAPS Safe
? ?I would not wish my comment "that propofol takes effect in 40 seconds and patients wake up faster is the biggest argument in favor of NAPS (nurse administered propofol sedation)" to in any way be construed to mean that I either endorse or condone this practice. The sad reality is that there is more demand for anesthesia services than can be supplied by both professional anesthesia provider groups. That having been said, I would humbly suggest that dripping a dilute propofol solution (1-2 mg/ml) via mini drip might greatly add to the safety of NAPS.

Barry L. Friedberg, MD
Costa Del Mar, Calif.
[email protected]

Developing a Propofol Policy
? ?I found this article very interesting, as our little hospital (23 beds with endoscopy and outpatient surgery) has had ongoing debates regarding the propofol issue. Our RNs are not pushing propofol per the recommendation of our CRNA, but one of our physicians insists that they "could" as long as he is in the room. We are developing a policy addressing this issue and would like to have a competency exam for our nurses giving conscious sedation.

Sue Higgins, RN/DNS
Clearwater Valley Hospital
Orofino, Idaho
[email protected]

Fueling Misconceptions About Pediatric Anesthesia
? ?Re: "Safety First in Pediatric Sedation" (August, page 6). I think you should have specifically written under what circumstances do infants cared for by general anesthesiologists have higher incidence of arrests/hypoxia during surgery versus those cared for by pediatric anesthesiologists. Were these stats only involved at one institution? Were the cases restricted to cardiac procedures or general "bread-and-butter" cases? Misconceptions will tend to occur when one generalizes too liberally.

Marc Reichel, MD
[email protected]

Thanks for Taking Me to AORN
? ?Re: "What I Saw at AORN" (July, page 52). As an ASC administrator for a freestanding physician-owned facility, I am not afforded the opportunity to attend all of the major trade shoes such as the recent AORN convention. The article by Scotty Farris was excellent. Next time, I want to go with him so I can hear his product-to-product comparisons on the spot.

Diana Procuniar, RN, BA, CNOR
[email protected]