Introduction

Non-anesthesiologist administered propofol (NAAP) describes the administration of propofol by a registered nurse under the direction of a physician, or by a physician or nurse other than an anesthesia professional. A level of moderate-to-deep sedation is targeted with NAAP, using propofol either alone or in combination with one or more other agents. Recommendations issued in 2004 by the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy specify that “physician-nurse teams administering propofol should possess the training and skills necessary to rescue patients from severe respiratory depression.”

Propofol represents an option for patients undergoing sedation for gastrointestinal endoscopy; when optimally administered, it may offer more rapid cognitive and functional recovery. Currently, propofol is off-label for use by non-anesthesiologists, which has raised safety and liability questions for nurses, gastroenterologists and facilities. To date, two models have emerged for use of propofol by non-anesthesiologists during endoscopic sedation: Nurse-administered propofol sedation (NAPS) and Gastroenterologist-directed propofol.

Nurse-administered propofol sedation (NAPS)

NAPS involves the administration of propofol by a registered nurse under the supervision of an endoscopist. The nurse's sole responsibility during the procedure is for the administration of propofol through physician ordered titration and patient monitoring. The goal is to anticipate the portions of the endoscopy that may be more painful or stimulating, and administer propofol to achieve a deeper level of sedation while monitoring for airway obstruction, as well as respiratory rate and other vital signs. With NAPS, propofol is used as a monotherapy for moderate to deep sedation. NAPS was the initial model for non-anesthesiologist administered propofol.

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Gastroenterologist-directed propofol

In Gastroenterologist-directed propofol, propofol is combined with small doses of other medications such as a benzodiazepine and an opioid to achieve sedation (see Combination Propofol). The physician and nurse share dosing responsibility. The advantage of this approach is that the analgesic synergism is greater than the hypnotic synergism, which theoretically extends propofol’s therapeutic window and helps to mitigate the risk of deep sedation.

Advantages and disadvantages of propofol

Propofol is used as an alternative to standard benzodiazepine and opioid-based regimens for a variety of reasons. Advantages of propofol over traditional agents include ultra-short onset of action of approximately 30-60 seconds (through rapid redistribution throughout the entire body) with peak effect in one to three minutes, short half-life, minimal risk of nausea, and short recovery time. For example, among patients who had previously received a combination of midazolam and meperidine for colonoscopy, 85% preferred propofol sedation.

However, some characteristics of propofol can make it difficult to use for moderate sedation. As the drug has no analgesic effects, patients may experience agitation, confusion, and withdrawal from painful stimuli when under moderate sedation. Because propofol has a relative narrow therapeutic range, it must be titrated carefully to achieve moderate sedation without inadvertently inducing deeper levels of sedation. Patients can quickly slip from moderate to deep sedation risking life-threatening respiratory depression. Unlike opioids and benzodiazepines, propofol cannot be quickly pharmacologically reversed. There is no antagonist for propofol, so patients experiencing overdose will need assistance with ventilation until spontaneous ventilation resumes. Propofol can also cause a drop in blood pressure and heart rate. Additionally, propofol is vulnerable to microbial contamination and once drawn up should be used within a few hours.

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Controversies Surrounding Non-anesthesiologist Administered Propofol

The use of propofol by non-anesthesiologists is off-label. The current package insert notes that for general anesthesia or monitored anesthesia care (MAC) sedation, propofol should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.

However, there is a body of literature that has demonstrated the safety and efficacy of gastroenterologists and registered nurses administering propofol sedation for gastrointestinal endoscopic procedures. To date, there have been over 450,000 patient experiences worldwide with gastroenterologist-directed administration of propofol and NAPS. From the data available for all patients in these series, there were four (4) occurrences of endotracheal intubation, one (1) neurological injury and three (3) deaths. The deaths occurred in patients with an advanced ASA classification including metastatic malignancy and cardiomyopathy. Practitioners administering propofol need to be prepared to manage adverse events, such as laryngospasm, prolonged apnea, aspiration requiring hospitalization, and hypoxemia requiring airway management, especially in patients with an advanced ASA physiologic classification. Sedation-related complications appear to decrease with advanced experience-level (≥ 100 NAPS procedures). (Citations of studies regarding nurse-administered propofol sedation are available in the bibliography and associated links.)

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Patient care and monitoring during use of propofol

A joint statement issued in 2004 by the American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy outlines the following criteria for gastroendoscopic sedation using propofol:

Patients should receive care consistent with deep sedation. Personnel should be capable of rescuing the patient from general anesthesia and/or severe respiratory depression.

A designated individual, other than the endoscopist, should be present to monitor the patient throughout the procedure and should be able to recognize and assist in the management of complications.

Physician-nurse teams administering propofol should possess the training and skills necessary to rescue patients from severe respiratory depression. The optimal type and duration of training for nurses to competently administer propofol is unknown.

A joint position statement issued in 2004 by the American Society of Gastrointestinal Endoscopy, and the Society of Gastroenterology Nurses and Associates specifies the following duties for the GI nurse:

The nurse prepares and administers sedation medications under the direct order and supervision of the physician according to the predetermined medication plan. The physician may also administer medications to the patient.

The nurse monitors the patient's vital signs, comfort and clinical status and records these data prior to, at intervals during, and following the procedure.

For deep sedation, the registered nurse performing the patient monitoring should have no other responsibilities.

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Policies

Gastroenterology societies have lobbied to have state regulatory boards approve nurse-administered propofol sedation, and have petitioned the FDA to revise the the propofol labeling that currently states, "Only those persons trained in the administration of general anesthesia should administer the drug." Currently, state laws or nursing practice acts in 24 states forbid the practice of nurse-administered propofol (see State Regulations). In states where the practice is permitted, specific requirements regarding the training and credentialing of persons administering propofol may vary from facility to facility.

At each endoscopy suite, an interdisciplinary team should establish policies and practice guidelines for the administration of propofol. The American Society of Anesthesiologists and the American Association of Nurse Anesthetists state that only persons trained in the administration of general anesthesia, who are not simultaneously involved in the procedures, should administer propofol. Because regulations governing sedation administration by nursing personnel vary from state to state, it is important for nurses and physicians to understand state licensure, state nurse practice acts, and individual institutional policies (See State Regulations).

If the facility chooses to support nurse-administered propofol sedation, the circumstances and required education and mentorship that must be accomplished need to be specified beforehand, as well as competencies that must be met periodically, such as ACLS certification. A continuous monitoring process needs to be established (e.g., vital signs, oxygen saturation, ECG, and possibly capnography). Equipment must be readily accessible at the point of care to maintain a patent airway, provide oxygen, intubate, ventilate, and offer circulatory resuscitation.

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Sources

A Joint Statement of a Working Group from the American College of Gastroenterology (ACG), the American Gatroenterological Association (AGA) and the American Society for Gastrointestinal Endoscopy (ASGE). Recommendations on the Administration of Sedation for the Performance of Endoscopic Procedures. 2004.

Aisenberg J, Cohen LB. Sedation in endoscopic practice. Gastrointest Endoscopy Clin N Am. 2006;16:695-708.

ASGE/SGNA. Joint Position Statement: Role of GI Registered Nurses in the Management of Patients Undergoing Sedated Procedures. 2004.

Chen SC, Rex DK. Review article: registered nurse-administered propofol sedation for endoscopy. Aliment Pharmacol Ther. 2004;19:147-155.

Cohen LB, Delegge MH, Aisenberg J, Brill JV, Inadomi JM, et al. AGA Institute review of endoscopic sedation. Gastroenterology. 2007 Aug;133(2):675-701.

Deenadayalu VP, Eid EF, Goff JS, Walker JA, Cohen LB, et al. Non-anesthesiologist administered propofol sedation for endoscopic procedures: A worldwide safety review. Gastrointest Endosc 2008;67:AB107.

Fatima H, DeWitt J, LeBlanc J, Sherman S, McGreevy K, Imperiale TF. Nurse-administered propofol sedation for upper endoscopic ultrasonography. Am J Gastroenterol. 2008 Jul;103(7):1649-56.

Iravani, M. On computers, nurses, and propofol: further evidence for the jury? Gastrointestinal Endoscopy. 2008; 68 (3):510-511.

Rex DK et al. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology. 2005 Nov;129(5):1384-91.

Sieg A. Propofol sedation in outpatient colonoscopy by trained practice nurses supervised by the gastroenterologist: a prospective evaluation of over 3000 cases. Z Gastroenterol. 2007 Aug;45(8):697-701

Tohda G, Higashi S, Wakahara S, Morikawa M, Sakumoto H, Kane T. Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists. Endoscopy. 2006 Apr;38(4):360-7

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Last Updated June 12, 2009