Vermont Board of Nursing Review – July 2011
Reviewed by Sedation Certification – March 21, 2019
State Sedation Policy – Yes
Can RN’s give sedation? – Yes
Can RN’s give Propofol/Ketamine? – Under Certain Circumstances – Intubated/Ventilated

 

There are two Position Statements listed below.  The second one is specific for Propofol.

 

https://www.sec.state.vt.us/media/369398/PS-Role-of-the-Nurse-in-the-Administration-and-Monitoring-of-Moderate-Sedation.pdf

Vermont Board of Nursing
Position Statement
THE SCOPE OF PRACTICE FOR THE REGISTERED NURSE
(non-Certified Registered Nurse Anesthetist)
IN THE ADMINISTRATION AND MONITORING
OF MODERATE SEDATION FOR PROCEDURES
POSITION STATEMENT

Question:
What is the role of the Registered Nurse in the administration and monitoring of Moderate sedation for patient procedures?

Definitions:
Moderate sedation, as described by the American Society of Anesthesiologists, is produced by the administration of pharmacological agents to provide a tranquil state permitting cooperation and tolerance of diagnostic and therapeutic medical procedures. A patient under Moderate Sedation has a depressed level of consciousness but retains the ability to independently and continuously maintain a patent airway and to respond appropriately to physical stimulation and/or verbal command.

According to the American Society of Anesthesiologists the following describes the four levels of anesthesia:

Minimal sedation: Also known as anxiolysis. A drug-induced state during which the patient responds normally to verbal commands. Cognitive function and coordination may be impaired. Ventilatory and cardiovascular functions are unaffected.

Moderate sedation/analgesia (conscious sedation): A drug-induced depression of consciousness during which the patient responds purposefully to verbal command, either alone or accompanied by light tactile stimulation. No interventions are necessary to maintain a patent airway. Spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep sedation/analgesia: A drug-induced depression of consciousness during which the patient cannot be easily aroused, but responds purposefully* following repeated or painful stimulation. Independent ventilatory function may be impaired. The patient may require assistance to maintain a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General anesthesia: A drug-induced loss of consciousness during which the patient is not arousable, even to painful stimuli. The ability to maintain independent ventilatory function is often impaired. Assistance is often required in maintaining a patent airway. Positive pressure ventilation may be required due to depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

* Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

Background:

o Nursing practice has evolved to provide for registered nurses (non-CRNA) with skilled training to administer and monitor patients under procedural Moderate Sedation, which may occasionally progress to Deep Sedation for a short period of time.

o The Vermont State Board of Nursing does not maintain a listing of specific medications acceptable for administration by registered nurses (non-CRNA). When administering any medication, the nurse should be knowledgeable of and comply with acceptable state and federal laws, rules, regulations and guidelines pertaining to the medications utilized for sedation. These include but are not limited PS-Role of the Nurse in the Administration and Monitoring of Moderate Sedation 2011 0721 2 to: the U.S. Food and Drug Administration (FDA), U.S. Drug Enforcement Administration (DEA), the Pharmaceutical manufacturer’s guidelines and recommendation for personnel administering the medication, and the Vermont State Board of Nursing position statements.

o The healthcare institution, in conjunction with a multi-disciplinary healthcare team, is responsible for determining which levels of departmental personnel are appropriate to administer non-anesthetic agents for the sole purpose of Moderate Sedation. Medications with primary roles as anesthetics agents, such as Propofol, Ketamine, Etomidate, Methohexital, and Thiopental, administered for the purpose of Moderate Sedation present specific safety concerns in the hands of non-CRNAs and may not be appropriate agents for administration by the registered nurse (non-CRNA). These agents should be administered by skilled, trained anesthesia providers.

Position Statement which Reflects the Nurse’s Roles and Responsibilities:

It is within the scope of practice for a registered nurse (non-CRNA, certified registered nurse anesthetist) to administer non-anesthetic medications and to monitor patients in a state of Moderate Sedation as defined by the American Society of Anesthesiologists. The registered nurse (non-CRNA) must be specifically trained with demonstrated knowledge, skills, and ability in the clinical settings in which the nurse will practice.

It is not within the registered nurse’s (non-CRNA) scope of practice to administer an anesthetic agent for any level of sedation as described by the American Society of Anesthesiologists. It is also not within the scope of practice for the registered nurse (non-CRNA) to administer medications for the purpose of deep sedation or general anesthesia.

• This position statement applies for the purpose of procedural Moderate Sedation administered by the registered nurse (non-CRNA). It does not apply to the administration of pharmacological agents by the registered nurse (non-CRNA) practicing in an acute care setting where the patient may require emergent intubation, is intubated, requires mechanical ventilator breathing support, and/or is being continuously hemodynamically monitored. (See Vermont State Board of Nursing position statement on the administration of Propofol in critical care setting).

Clinical Nursing Administration, Management and Monitoring:

The Vermont State Board of Nursing believes that in order to be responsive to the needs and safeguard the life and health of patients, registered nurses must be accountable and responsible for Moderate Sedation. Moderate Sedation care will be delivered in such a manner to ensure that the patient will receive safe and effective nursing care management.

1. The health care facility will have in place an education and training mechanism for the registered nurse (non-CRNA) to demonstrate clinical competency for the practice of Moderate Sedation. The registered nurse (non-CRNA) shall have documented education beyond the basic nursing education, and annually demonstrated competency to include:

Medication Competency:

A. Knowledge of anatomy, physiology, pharmacology, medication dosing titration, cardiac arrhythmia recognition and complications related to Moderate Sedation and medications.
B. Knowledge of the Moderate Sedation medication reversal agents, their dosing and the physiological effects.
C. Ability to anticipate and recognize potential complications of moderate sedation in relationship to the type of medication being administered, and demonstrate appropriate interventions in compliance with standards of practice, emergency protocols and guidelines.

Physiological Knowledge Competency:

A. Knowledge and skills to perform and evaluate pre- procedure baseline, intra procedure, and post procedure clinical assessment of the patient undergoing Moderate Sedation.
B. Ability to assess total patient care requirements during Moderate Sedation and recovery. Physiologic measurements should include, but not be limited to, respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and patient’s level of consciousness.
C. Ability to recognize the potential physiological complications of each type of medication being administered.
D. Knowledge and skills to assess and intervene in the event of complications or undesired outcomes and the ability to institute nursing interventions in compliance with orders (including standing orders) or institutional protocols or guidelines.
E. Knowledge of age-specific considerations and co-morbidities in regard to assessment parameters, potential complications, and appropriate intervention according to institutional protocols and guidelines.

Airway Management Competency:

A. Knowledge of the principles of oxygen delivery, respiratory physiology, transport and uptake, and the ability to use oxygen delivery devices. This would include rescuing a patient that may progress to deep sedation and beyond.
B. Skill in airway management resuscitation, i.e. opening airway, head tilt, chin lift, use of bag valve mask device, oral and nasal airway establishment in emergency situational procedures.

Professional Accountability Competency:

A. Knowledge of the legal ramifications of administering moderate sedation and/or monitoring patients receiving Moderate Sedation, including the RN’s responsibility and liability in the event of an untoward reaction or life-threatening complications.
B. Understanding of concepts relating to Advanced Cardiac Life Support (ACLS).
C. Application of principles of accurate documentation in providing a comprehensive description of patient responses and outcomes. The current recommendation for documentation of patient under continuous Moderate Sedation monitoring is every 5 minutes.
D. Knowledge of State law and institutional policy regarding the registered nurse (nonCRNA) administration of agents for Moderate Sedation.

2. The RN managing the care of patients receiving Moderate Sedation has no other responsibilities that would compromise continuous monitoring.
3. A qualified anesthetist provider or physician selects and orders the medications to achieve Moderate Sedation before, during and after the planned procedure.
4. Guidelines for patient monitoring, drug administration, and dealing with potential complications or emergency situations are available and have been developed in accordance with recognized and accepted standards of anesthesia practice.
5. Provisions are in place for the immediate availability of personnel who are experts in airway management, emergency intubation and advanced CPR, if complications arise.
6. While the registered nurse (non-CRNA) who administers sedation is acting on a specific medical order for a specific client, the registered nurse has the right and obligation to refuse to administer and/or continue to administer medication(s) to clients with significant medical conditions or amounts that may induce deep sedation and/or loss of consciousness.

Health Care Facility Administration, Management, Monitoring and Key Practice Elements for Moderate Sedation:

Health Care facility policy and plan for Registered Nurse (non-CRNA) sedation practice shall include:

• The health care facility will have in place an education and training mechanism for the registered nurse (non-CRNA) to demonstrate clinical competency for the practice of Moderate Sedation. Review and reaffirmation of the registered nurse competency to manage patients receiving Moderate Sedation shall occur and shall be documented annually.

• The healthcare facility must determine which medications are appropriate for the nurse to safely administer, based on the nurse’s education, competency, current standards of practice, clinical resources, quality assurance monitoring, and the facility’s policies and procedures.

• While the provider performing the procedure may possess the necessary knowledge, skill set and abilities to rescue the patient from Deep sedation and General Anesthesia, it is not prudent to presume they will be able to leave the surgical site or abandon the procedure to assist in rescuing the patient under Moderate Sedation care.

References/Citations:

1. Kost, Michael. Moderate Sedation/Analgesia. 2nd edition, February 2004
2. American Society of Anesthesiologists. Guidelines for Sedation and Analgesia by Non Anesthesiologists. (2002)
3. American Association of Critical Care Nurses (AACN). (2002). Sedation Guideline. Retrieved 7/12/11 at http://www.aacn.org

Date of Initial acceptance: June 2005

Revised: July 2011

Revised (Date)

This opinion is subject to change as changes in nursing practice occur


 

https://www.sec.state.vt.us/media/369404/PS-Role-of-the-Nurse-in-the-Administration-of-Propofol.pdf

 

Vermont Board of Nursing
Position Statement
REGISTERED NURSES’ ROLE IN THE ADMINISTRATION OF PROPOFOL (DIPRIVAN)
Question: Is the administration of Propofol within the scope of practice of the Registered Nurse?
Definitions:
Sedation and analgesia: a medically controlled state of depressed consciousness that allows protective
reflexes to be maintained. The patient retains the ability to independently maintain his or her airway and
to respond purposefully to verbal commands and/or tactile stimulation. The American Society of
Anesthesiologists (ASA) Task Force on Sedation and Analgesia has developed Practice Guidelines for
Sedation and Analgesia by Non-Anesthesiologists which states “sedation and analgesia describes a state
that allows patients to tolerate unpleasant procedures while maintaining adequate cardio-respiratory
function and the ability to respond purposefully to verbal command and tactile stimulation.”
The Task Force concluded that the term sedation and analgesia more accurately defines this therapeutic
goal than does the more commonly used but imprecise term of ‘conscious sedation.’ Those patients
whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than
encompassed by sedation/analgesia. This level of sedation is more accurately described as deep
sedation which is not within the scope of practice of the Registered Nurse.
Propofol: an intravenous preparation, classified as a sedative/hypnotic according to the manufacturer’s
product information. It is intended for use as an anesthetic agent or for the purpose of maintaining
sedation of an intubated, mechanically ventilated patient.
Critical Care setting: an intensive care unit, emergency department or other specialized care area in
which a credentialed provider in airway management is immediately available.
Background:
According to The American Society of Anesthesiologists (ASA), the standard definition for the four levels
of sedation and anesthesia are:
Minimal sedation: Also known as anxiolysis. A drug-induced state during which the patient responds
normally to verbal commands. Cognitive function and coordination may be impaired. Ventilatory and
cardiovascular functions are unaffected.
Moderate sedation/analgesia (conscious sedation): A drug-induced depression of consciousness
during which the patient responds purposefully to verbal command, either alone or accompanied by light
tactile stimulation. No interventions are necessary to maintain a patent airway. Spontaneous ventilation
is adequate. Cardiovascular function is usually maintained.
Deep sedation/analgesia: A drug-induced depression of consciousness during which the patient cannot
be easily aroused, but responds purposefully* following repeated or painful stimulation. Independent
ventilatory function may be impaired. The patient may require assistance to maintain a patent airway.
Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
General anesthesia: A drug-induced loss of consciousness during which the patient is not arousable,
even to painful stimuli. The ability to maintain independent ventilatory function is often impaired.
Assistance is often required in maintaining a patent airway. Positive pressure ventilation may be required
due to depressed spontaneous ventilation or drug-induced depression of neuromuscular function.
Cardiovascular function may be impaired.
* Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.
PS-Role of the Registered Nurse in the Administration of Propofol – Combined – 2011 0721
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1. Sedation and analgesia may easily be converted to deep sedation and the loss of consciousness
because of the agents used and the physical status and drug sensitivities of the individual patient. The
administration of sedation and analgesia requires constant monitoring of the patient and ability of the
administrator to respond immediately to any adverse reaction or complication. Vigilance and the ability to
recognize and intervene if complications or undesired outcomes arise are essential requirements for
administrators of sedation and analgesia.
2. 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 lifethreatening 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 considered to be beyond the scope
of practice of the RN.
3. Although Propofol is classified as a sedative/hypnotic, according to the manufacturer’s product
information, it is intended for use as an anesthetic agent or for the purpose of 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 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 noteworthy that there are no reversal agents for Propofol.
4. Although 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.
5. It should be stressed that the registered nurse’s duty to assure patient safety is an independent
obligation under his/her professional licensure that supersedes any physician order or facility policy. 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.
6. The patient receiving anesthetic agents, such as Propofol, is at increased risk for loss of
consciousness and/or abnormal protective airway reflexes, regardless of who is administering this
medication. The provider of this agent, in the non-intubated procedure setting, should retain extensive
training in the administration of anesthetic agents and advanced airway management. Again, this is not
consistent with the concept of moderate sedation outlined in the professional literature.
Position Statement which Reflects Nurse’s Roles and Responsibilities in the Administration of
intravenous Propofol for Critical Care Sedation, on Patients that Require Intubation and
Mechanical Ventilation:
Nurse’s Responsibilities and Requirements Relating to the Intubated/Mechanically Ventilated
Patient
Given that the following criteria are met, it is within the scope of practice for the RN to administer
intravenous Propofol to the intubated, mechanically ventilated patient in continuous and bolus dosing, for
ongoing sedation/analgesia within the Critical Care setting.
Exception: The Registered Nurse may administer Propofol to the non-intubated patient for the purpose of
rapid sequence intubation when the clinical presentation of impending respiratory failure is imminent. This
will be done in the presence of, and under the direction of, a provider credentialed to manage a patient in
this level of critical physical acuity.
PS-Role of the Registered Nurse in the Administration of Propofol – Combined – 2011 0721
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Knowledge and Skills
It is the expectation that the following knowledge and skills are gained and demonstrated prior to
administration of intravenous Propofol. Evidence of education, training, experience, and ongoing
competency appropriate to the responsibilities, treatment provided, and the patient/population served
should be maintained in personnel files and/or individual portfolios. The Registered Nurse must possess
knowledge and the ability to apply it during the administration of intravenous Propofol for critical care
sedation, on patients that require intubation, and mechanical ventilation.
Qualifications
1. The Registered Nurse is allowed by state law and institutional policy to administer sedation.
2. The health care facility shall have in place an educational/credentialing mechanism which includes a
process for evaluating and documenting the individual’s competency relating to the management of
patients receiving intravenous Propofol sedation. Evaluation and documentation should occur on a
periodic basis.
A. Management & Monitoring
The Registered Nurse managing and monitoring the care of patients receiving intravenous Propofol
sedation is able to:
a. Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia
recognition, and complications related to intravenous Propofol sedation.
b. Assess the total patient care requirements before and during the administration of intravenous
Propofol sedation, including the recovery phase.
c. Understand the principles of oxygen delivery, transport and uptake, respiratory physiology, as
well as understand and use oxygen delivery devices, including mechanical ventilation.
d. Recognize potential complications of sedation with intravenous Propofol administration.
e. Posses the competency to assess, diagnose, and if complications occur, and institute appropriate
interventions in compliance with orders or institutional protocols.
f. Demonstrate competency, through Advanced Cardiopulmonary Life Support (ACLS) and/or
Pediatric Advanced Life Support (PALS), in airway management and resuscitation appropriate to
the age of the patient.
g. Understand the legal ramifications of providing this care.
B. Practice Setting
It is not the Board’s role to develop policy for the individual practice settings. However, any nurse who is
going to administer sedating or anesthetic agents for the purposes expressed in this position statement
has the responsibility to ensure that the following criteria are met prior to participating in sedation for the
intubated, mechanically ventilated patient.
1. Written administrative policies and protocols are readily available and medically approved. These
policies and protocols should be consistent with currently accepted practice, and include (but not be
limited to) information on patient selection criteria, patient monitoring, definitions of levels of sedation,
drug administration, and directions for dealing with potential complications or emergency situations; and
2. Written risk management and quality improvement plan in place and reviewed on a periodic basis.
3. An emergency cart must be immediately accessible to every location where sedation is
administered. This cart must include emergency resuscitative drugs, airway and ventilatory adjunct
equipment, defibrillator, and a source for administration of 100% oxygen. A positive pressure breathing
device, oxygen, suction, and appropriate airways must be placed in each room where sedation is
administered.
4. Back-up personnel who are experts in airway management, emergency intubations, and advanced
cardiopulmonary resuscitation must be immediately available on site.
PS-Role of the Registered Nurse in the Administration of Propofol – Combined – 2011 0721
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5. A qualified professional capable of managing complications must be present in the facility.
Position Statement which reflects Nurses’ Roles and Responsibilities in the Administration of
Propofol for Moderate Sedation/Analgesia in Non-intubated Patients:
It is not within the scope of practice of the registered nurse (RN) who is not a Certified Registered Nurse
Anesthetist (CRNA) to administer agents used primarily as anesthetics for moderate and deep sedation,
including Propofol, in accordance with the American Association of Nurse Anesthetists – American
Society of Anesthesiologists Joint Statement Regarding Propofol Administration (2004). This would
include the non-intubated patient undergoing procedures, including but not limited to, invasive cardiology,
invasive radiology, endoscopic gastro-intestinal procedures, Invasive bronchoscope and emergent
procedures.
It is not within the scope of practice of the RN who is not a Certified Registered Nurse Anesthetist
(CRNA) to manage deep sedation or general anesthesia.
References/Citations:
1. American Association of Critical-Care Nurses (AACN). Sedation Guideline with Propofol. AACN
Vol.1, No 21 Pg. 9. Retrieved 8/09, from http://www.aacn.org
2. American Association of Nurse Anesthetists (AANA). (2003). Considerations for policy guidelines
for registered nurses engaged in the administration of sedation and analgesia. Retrieved 8/11/05,
from http://www.aana.com
3. American Association of Nurse Anesthetists (AANA), & American Society of Anesthesiologists (ASA).
AANA-ASA Joint Statement Regarding Propofol Administration. American Society of
Anesthesiologists. Retrieved 8/9/2005, written 2004
from http://www.asahq.org/news/propofolstatement.htm
4. American Association of Critical-Care Nurses (AACN). Sedation Guideline. AACN Website. Retrieved
8/18/05, from http://www.aacn.org
5. Reeves, S. T., Havidich, J. E., & Tobin, D. P. Conscious Sedation of Children
With Propofol Is Anything but Conscious. Pediatrics. 2004; 114: p74-76, Retrieved 8/11/05, from
http://www.pediatrics.org
6. Institute for Safe Medication Practices. ISMP medication Safety Alert. Propofol sedation who should
administer? Nov.3rd 2005. website http://www.ismp.org
7. Physician’s Desk reference. www.PDR.net Propofol (Diprivan) Abraxis Mfg.
Date of Initial acceptance: May 2007
Revised: July 2011
Revised (Date)
Revised (Date)
Reviewed (Date)
This opinion is subject to change as changes in nursing practice occur.