Successful Elements of  Nurse Administered Propofol Sedation

1.  The patient is fasting, or perhaps allowed clear liquids up to three or four hours prior to a procedure.  The exceptions are that if a person is unreliable, then it is easier to tell them to be NPO after midnight; patients must avoid red and purple liquids before colonoscopy, which is part of the standard prep sheet protocol; patients may need special instructions per their gastroenterologist if they have gastric outlet obstruction or achalasia in regards food the day before, and in the length of fasting.

 2.  The patient’s completed history and physical and PARQ discussion will be in the chart prior to the final words that the patient and the doctor have before proceeding.

 3.  On the day of the procedure the nursing assessment will be present in the chart prior to the initiation of the procedure and sedation.

 4.  The patient will have a reliable designated driver.

 5.  If the patient is supposed to be off anticoagulation, there should be documentation of this on the day of the procedure.

 6.  The patient had been advised about Diprivan sedation and the differences, advantages, that it is relatively new, and of our local experience.  Anyone who requests light sedation so that he or she may watch will be granted at least an attempt at this.  Quite rarely people have requested other forms of sedation that they are familiar with, such as a Surgery Center of Southern Oregon patient who requested Lamaze breathing and low-dose Fentanyl.

 7.  Extra time is allowed for titration if there is cardiovascular disease or pulmonary disease.

 8.  The initial dose is 10-50 mg, depending upon the patient profile, by which we mean the age, size, anxiety level, psychotropic drug use, alcohol use, and the presence or absence of vital organ diseases of any type.

 9.  The physician, sedation nurse, and endoscopic technician are all assembled prior to the initiation of sedation and any final decision making in this regard.

 10. The pulse oximeter and blood pressure monitor will be working correctly and the oximeter will be audible.

 11. There will be a running IV in proper working condition and ideally a proximal forearm vein is used; if not, the anticubital will be used.

 12. Lidocaine for the prevention of pain during injection is added to the Diprivan unless there is a known allergy to Lidocaine.

 13. The nurse is cautious to avoid the rare circumstance in which a superficial aberrant artery is inadvertently cannulated.  There have been no serious sequelae of this in the literature with either form of propofol, but this is a circumstance to be avoided with any intravenous medicine.

 14. The patient will be ascertained not to be allergic to propofol, soy, eggs, or at least certain components of eggs, or metabisulfite if the generic is being used.

 15. The propofol syringe is labeled with the date and time of expiration (six hours after being drawn), and the month is given in letters rather than numbers to avoid confusion with the European system of dates.  Usually the amounts of propofol are drawn in 50, 100, or 200mg amounts to allow flexibility and to reduce to a minimum the amount of the drug that is wasted at the end of the procedure.

 16. A strict aseptic approach is taken.

 17. Special care is taken with people who have sleep apnea.

 18. Propofol for the individual patient is discarded at the end of the procedure and no syringe is carried over to another patient.

 19. The patient is sedated at the proper rate until the eyes close, usually within 45 to 120 seconds, then tiny doses of sedation are given according to the physiologic challenges, the physician's gloved finger on the tongue (the so-called "Western Tongue Scale), and subsequently the posterior oropharnyx to see if coughing is elicited or aversive body language otherwise; the digital rectal exam; and subsequently physiologic testing with the scope itself, particularly the upper esophageal sphincter for EGD and ERCP and certain classic zones of stretching during colonoscopy, the sigmoid and the transverse colon.

 20. Upon retrieval of the scope, particularly colonoscopic retrieval which is longer than endoscopic retrieval, more medication may or may not be needed, according to the patient's response.  The physician and nurse are in constant dialogue about how much more time is needed.  If the patient has discomfort during the phase just prior to the removal of the scope, e.g. targeting a sigmoid polyp in a spastic sigmoid, the nurse and physician will choose how much medication is needed for discomfort, well knowing that the physiologic stimulus of the scope will probably be taken away from the patient in a very short period of time.  Here incremental doses of 5 mg are frequently sufficient (rather than 10 mg).

 21.  The Upper and Lower Endoscopy Nurse Assistants (ULENAs) are to be trained by other pre-existing ULENAs with ample experience and/or by physicians familiar with this technique.

 22. The ULENAs within the protocol decide the timing and amount of dosing, yet within the confines of the protocol, rather than the doctor ordering a dose.  The ULENA decides, again in close coordination with the physician, who is only three feet away from the nurse, according to the profile of the patient, how much it took to get started (range: 5 to 350 mg), how much time has elapsed since the last dose, how much time is left in the procedure, and in general what is going on with the patient, scope-wise.  All of this is correlated with the nociciptive body language of the patient ("Bad Dancing Scale" Grades 1-4).

 23. Suction equipment should be close at hand.

 24. Oxygen is always used.  Usually this is provided by nasal prongs, although the prongs may be translocated to the mouth on certain occasions.

 25. A working telephone is always available in the room.

 26. Ephedrine is readily available in the room and a triple check is made that the epinephrine is not given by mistake.

 27. Atropine is readily available in the room.

 28. A crash cart is present in the room.

 29. As little time as possible is spent with the patient in the supine position and all three team members, the physician, sedation nurse, an endoscopic technician, should be in agreement that it is safe to move the patient to this position for scope advantage.  As soon as the cecum is reached with this maneuver, the patient is turned back into the safer left lateral decubitus position.  [This is good practice with traditional sedation as well, and is not distinct to propofol sedation.]

 30. The ULENA will be ACLS certified and possess excellent upper airway management skills equivalent to an excellent recovery room nurse.

 31. The patient is to bring his or her inhalers, if any, and use them in timing prior to the procedure so that the lungs are in tip-top pharmacologic shape.

 32. Patients are allowed to sip juice as soon as they can decide which juice they want, frequently within two minutes of termination of the procedure, as long as they are not experiencing pain from gas distention from colonoscopy or nausea.

 33. Some patients can leave within as little at ten minutes.  To leave this early, they have to have a perfect Aldrete score and satisfy a nurse's whims otherwise.

 34. There are occasional people who have nausea or gas distention after an endoscopic procedure, more commonly after colonoscopy than upper endoscopy.  If the symptoms are excessive, injection for nausea or for pain is given by a standing order by the nurse, who then subsequently reports if to the doctor.  To receive such a medication, a person is usually quite awake and alert.  Lesser degrees of discomfort from gas distention (since propofol wears off so quickly) can be treated with tincture of time, nursing attention, and simethecone (more or less as a placebo).  Fortunately, significant gas distention with discomfort is seen in only about 3% of people and we may be able to reduce this to less than 1% with a more dedicated effort at suctioning air upon retrieval and at the termination of the exam.  Perhaps particularly susceptible are the people with a lot of diverticulosis and spasm of the left colon.

 35. The ULENA will complete the Diprivan competency evaluation, fulfill the competency criteria, and fulfill the checklist for continued Diprivan competency.

 36. Overall, the goal is to choose the proper and safe level of sedation for each patient in regards what is being done for the patient with the strong commitment to painless exams, 100% amnesia, and yet using the least amount of medication.  We have found that even if people groan or talk, even making a complete sentence that is grammatically correct, they will not remember what they said, the endoscopic experience at all, and there will be a greater sense of the painless rendering by the team administering sedation.  The range of sedation goes from anxiolysis in the preprocedural arena, to levels consistent with light traditional sedation, to deeper levels, but always with the goal in mind of being "two minutes away from sipping juice."  In our experience, some of our anesthesiology colleagues have given too much medicine and too fast, although in general they have done a fair to good job and have been very supportive.  Thus, we will emphasize great attentiveness to the patient's needs and practice careful decision making with every small incremental dose that is given.

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