Texas

15.8 Role of the Nurse in Moderate Sedation

• 1. The practice of the registered nurse who holds licensure as an advanced practice registered nurse in the role and population focus of nurse anesthetist (CRNA) functioning within his/her authorized scope of practice;
  2. The registered nurse practicing in an acute care setting, such as critical care, where the patient in question is intubated, receiving mechanical ventilatory support, and continuously monitored by the patient care RN; or
  3. Adjunct or off label use of low dose agents for pain management or other indications.

Role of the LVN

The administration of pharmacologic agents via intravenous or other routes for the purpose of achieving moderate sedation requires mastery of complex nursing knowledge, advanced skills, and the ability to make independent nursing judgments during an unstable and unpredictable period for the patient.  It is the opinion of the Board that the one-year vocational nursing program does not provide the Licensed Vocational Nurse (LVN) with the educational foundation to assure patient safety for optimal anesthesia care inclusive of both the administration of pharmacologic agents intended to induce moderate sedation and/or assessment and monitoring of the patient receiving moderate (conscious) sedation.

In alignment with 22 TAC §217.11, Standards of Nursing Practice, Board Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice, and Board Position Statement 15.10, Continuing Education: Limitations for Expanding Scope of Nursing Practice, the Board also maintains that continuing education that falls short of achieving licensure as a registered nurse would be insufficient to assure vocational nurse competency and patient safety with regard to both medication administration and patient monitoring associated with moderate sedation.

Though the Board cannot dictate physician practice, it is the Board’s position that a LVN cannot administer medications or monitor patients receiving moderate sedation as a delegated medical act.

Role of the RN or non-CRNA Advanced Practice Registered Nurse

Though optimal anesthesia care is best provided by qualified certified registered nurse anesthetists (CRNAs) or anesthesiologists, the Board recognizes that the demand in the practice setting necessitates provision of moderate sedation by registered nurses and non-CRNA advanced practice registered nurses in certain practice situations.

All licensed nurses practicing in Texas are required to “know and comply” with the Nursing Practice Act (NPA) and Board Rules. 22 TAC §217.11(1)(B) requires the nurse to “promote a safe environment for clients and others.” This standard establishes the nurse’s duty to the patient/client, which supersedes any physician order or any facility policy. This “duty” to the patient requires the nurse to use informed professional judgment when choosing to assist or engage in a given procedure. [See Position Statement 15.14, Duty of a Nurse in Any Practice Setting].

As the NPA and Board rules are not prescriptive to specific tasks a nurse may or may not perform, a RN or non-CRNA advanced practice registered nurse should consider evidence-based practice guidelines put forth by professional organizations with clinical expertise in the administration of pharmacologic agents used for sedation/anesthesia as well as advanced airway management and cardiovascular support.  A number of professional specialty organizations have well-defined standards and recommendations for ongoing nursing education and competency assessment related to administration and monitoring of patients receiving moderate sedation.

These organizations include the American Association of Nurse Anesthetists (AANA)¹, the American Nurses Association (ANA)², the Association of periOperative Registered Nurses (AORN)³, and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).⁴ Statements published by the American Society of Anesthesiologists (ASA) also support the positions of the above nursing organizations.⁵  The Board advises the nurse use caution in applying moderate sedation standards of any individual or specialty group who are not also experts in the field of advanced airway management/anesthesia. The Board encourages the use of the BON’s Scope of Practice Decision-Making Model (DMM)

Employing institutions should develop policies and procedures to guide the RN or non-CRNA advanced practice registered nurse in administration of medications and patient monitoring associated with moderate sedation. Policies and procedures should include but not be limited to:

• Performance of a pre-sedation health assessment by the individual ordering the sedation and the RN or non-CRNA advanced practice registered nurse administering the sedation;
• Guidelines for patient monitoring, drug administration, and a plan for managing potential complications or emergency situations developed in accordance with currently accepted standards of practice;
• Accessibility of emergency equipment and supplies;
• Documentation and monitoring of the level of sedation and physiologic measurements (e.g. blood pressure, oxygen saturation, cardiac rate and rhythm); and
• Documentation/evidence of initial education and training and ongoing competence of the RN or non-CRNA advanced practice registered nurse administering and/or monitoring patients receiving moderate sedation

Use of Specific Pharmacologic Agents

It is up to facilities and physicians to determine specific pharmacologic agents to be used to induce moderate sedation. The Board advises the RN or non-CRNA advanced practice registered nurse use caution, however, when deciding whether s/he has the competency to administer the specific pharmacologic agents ordered by the physician. What is within the scope of practice for one RN is not necessarily within the scope of practice for another RN. (See references to 22 TAC §217.11 & Scope of Practice Decision-Making Model (DMM) above). With regard to this issue, the Board recommends the RN also take into consideration:

1. Availability of and knowledge regarding the administration of reversal agents for the pharmacologic agents used; and
2. If reversal agents do not exist for the pharmacologic agents used or the criteria outlined in (1) above are not met, then the nurse must consider his/her individual knowledge, skills, and abilities to rescue a patient from un-intended deep sedation/anesthesia using advanced life support airway management equipment and techniques.

RNs or non-CRNA Advanced Practice Registered Nurses Administering Propofol, Ketamine, or Other Anesthetic Agents to Non-Intubated Patients

Of concern to the Board is the growing number of inquiries related to RNs and non-CRNA advanced practice registered nurses administering Propofol, Ketamine, or other drugs commonly used for anesthesia purposes to non-intubated patients for the purpose of moderate sedation in a variety of patient care settings. It is critical for any RN who chooses to engage in moderate sedation to appreciate the differences between moderate sedation and deep sedation/anesthesia.

Moderate Sedation versus Deep Sedation Anesthesia

According to the professional literature, “moderate sedation” is defined as a medication-induced, medically controlled state of depressed consciousness. Included in the literature from various professional organizations is the caveat that, while under moderate sedation, the patient at all times retains the ability to independently and continuously maintain a patent airway and cardiovascular function, and is able to respond meaningfully and purposefully to verbal commands, with or without light physical stimulation. Reflex withdrawal to physical stimulation is not considered a purposeful response. Loss of consciousness for patients undergoing moderate sedation should not be the goal and thus pharmacologic agents used should render this result unlikely. If the patient requires painful or repeated stimulation for arousal and/or airway maintenance, this is considered deep sedation.

In a state of deep sedation, the patient’s level of consciousness is depressed, and the patient is likely to require assistance to maintain a patent airway. Deep sedation occurring in a patient who is not appropriately monitored and/or who does not have appropriate airway support may result in a life-threatening emergency for the patient.  This is not consistent with the concept of moderate sedation as defined in this position statement or the professional literature and is generally considered to be beyond the scope of practice of the RN.

Although Propofol is classified as a sedative/hypnotic/anesthetic, according to the FDA product information, it is intended for use as an anesthetic agent or for maintaining sedation of an intubated, mechanically ventilated patient. The product information brochure for Propofol further includes a warning that “only persons trained to administer general anesthesia and not involved in the conduct of the surgical/diagnostic procedure should administer Propofol for purposes of general anesthesia or for monitored anesthesia care/sedation.” The clinical effects for patients receiving anesthetic agents such as Propofol may vary widely within a negligible dose range. Though reportedly “short-acting”, it is also noteworthy that there are no reversal agents for Propofol.

As the US Food and Drug Administration (FDA) approves computer-assisted personalized sedation systems, a nurse is encouraged to use the Scope of Practice Decision-Making Model (DMM) to reach a sound decision whether to engage in nursing practice utilizing such a device in accordance with the US FDA approval requirements. US FDA approval requirements for computer-assisted personalized sedation systems include requirements for completion of training in addition to safety requirements, such as the immediate availability of anesthesia providers. A nurse is required to complete training prior to using any computer-assisted personalized sedation system and is encouraged to retain proof of training.

The patient receiving anesthetic agents is at increased risk for loss of consciousness and/or normal protective reflexes, regardless of who is administering this medication. The loss of consciousness and/or protective reflexes may indicate progression into deep sedation and this is not consistent with the concept of moderate sedation outlined in the professional literature.

Though the RN or non-CRNA advanced practice registered nurse may have completed continuing education in advanced cardiac life support (ACLS) and practiced techniques during the training program, this process does not ensure ongoing expertise in airway management and emergency intubation. The American Heart Association (AHA)⁶ has identified factors that contribute to misplacement of the endotracheal tube during resuscitation including: “inadequate training, lack of experience” and patient characteristics such as physiology and movement. It is also important to note that no continuing education program, including ACLS programs, will ensure that the RN or non-CRNA advanced practice registered nurse has the knowledge, skills and abilities to rescue a patient from deep sedation or general anesthesia.  Furthermore, it is the joint position of the AANA and ASA that, “because sedation is a continuum, it is not always possible to predict how an individual patient will respond.”  These organizations state only qualified anesthesia providers who are trained in the administration of general anesthesia should administer anesthetic agents, including induction agents.

Therefore, it is the position of the Board that the administration of anesthetic agents (e.g. propofol, methohexital, ketamine, and etomidate) is outside the scope of practice for RNs and non-CRNA advanced practice registered nurses except in the following situations:

• when assisting in the physical presence of a CRNA or anesthesiologist (the CRNA or anesthesiologist may direct the RN to administer anesthetic agents in conjunction with the CRNA or anesthesiologist intubating or otherwise managing the patient’s airway)
• when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist)
• when administering these medications to patients who are intubated and mechanically ventilated in critical care settings
• when assisting an individual with current competence in advanced airway management, including emergency intubation procedures
• when utilizing a US FDA approved computer-assisted personalized sedation system in accordance with the US FDA approval requirements, where appropriate safety requirements are met (such as immediate availability of anesthesia providers) after completing appropriate training.

While the physician or other health care provider performing the procedure may possess the necessary knowledge, skills and abilities to rescue a patient from deep sedation and general anesthesia, it is not prudent to presume this physician will be able to leave the surgical site or abandon the procedure to assist in rescuing the patient.  In the case of an appropriately licensed practitioner performing a procedure that can be safely abandoned to rescue or intubate the patient, the RN may administer the anesthetic agent when directed. In this instance, the RN is responsible for accepting the assignment and for knowing the rationale, effects, and correctly administering the medication [22 TAC §217.11 (1)(T) & (1)(C)].

The Board again stresses that the nurse’s duty to assure patient safety [22 TAC §217.11(1)(B)] is an independent obligation under his/her professional licensure that supersedes any physician order or facility policy.⁷ It is important to note that the nurse’s duty to the patient obligates him/her to decline orders for medications or doses of medications that have the potential to cause the patient to reach a deeper level of sedation or anesthesia.  The nurse’s duty is outlined in detail in Board Position Statement 15.14, Duty of a Nurse In Any Practice Setting.

Recommended Reference Document:  The American Association of Nurse Anesthetists developed an informational advisory document in 2016 to guide policy development for the safe administration of procedural sedation by a non-anesthesia sedation team in a hospital, ambulatory surgical center, or office setting.¹ The anesthetic agents Ketamine and Propofol are both mentioned within the document in the context of procedural sedation.

References¹ The American Association of Nurse Anesthetists. (2016). Non-anesthesia Provider Procedural Sedation and Analgesia: Policy Considerations. Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/non-anesthesia-provider-procedural-sedation-and-analgesia.pdf?sfvrsn=670049b1_

² American Nurses Association. (2008). Procedural Sedation Consensus Statement. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/procedural-sedation-consensus-statement

³ The Association of periOperative Registered Nurses. (2017). Patient Care Guidelines: Care of the Patient Receiving Moderate Sedation Analgesia. Retrieved from https://aornguidelines.org/guidelines/content?sectionid=173733727&view=book.

⁴ Association of Women’s Health, Obstetric and Neonatal Nurses. (2020). Role of the registered nurse in the care of the pregnant woman receiving analgesia and anesthesia by catheter techniques. Retrieved from http://www.jognn.org/article/S0884-2175(20)30012-5/fulltext

⁵ American Association of Nurse Anesthetists and American Society of Anesthesiologists. (2013) AANA–ASA Joint Position Statement Regarding Propofol Administration. Retrieved fromhttps://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/aana-asa-propofol-joint-ps.pdf?sfvrsn=f80049b1_2

⁶ American Heart Association (2020). American Heart Association CPR & ECC guidelines. Retrieved from https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/

⁷ Lunsford v. BNE,  648 S.W. 391, (Tex. App–Austin 1983)

Additional ResourcesTexas Board of Nursing. (2012). Nurses on guard- best practices in patient safety: Off-label administration of Ketamine for pain management by a nurse. Texas Board of Nursing Bulletin, 43(4), 5-6.

Texas Board of Nursing. (2017). FAQ: Off Label Use of Medication.

(Board Action 01/1992; Revised: 01/2003; 01/2004; 01/2006; 01/2007; 01/2009; 01/2012; 01/2013; 01/2014; 01/2016; 01/2017; 01/2018; 01/2019; 01/2020; 01/2021)
(Reviewed: 01/2008; 01/2010; 01/2011; 01/2015)