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To the Editor:

I read the position paper supporting nurse-administered propofol sedation (NAPS) which was coissued by the American Association for the Study of Liver Diseases (AASLD) and other societies.1 Currently, the package insert states “the drug should be administered only by persons trained in the administration of general anesthesia”. By this definition, registered nurses would not qualify. In fact, NAPS is illegal in more than a dozen states, including my own.

Most endoscopy centers use a nurse to administer moderate sedation with midazolam. The problem with propofol is that it was designed for use beyond moderate sedation, specifically, deep sedation and general anesthesia. In fact, the U.S. Food and Drug Adminstration (FDA) has reports of hundreds of patients who have died as a result of propofol administration. This is likely an underestimation and also does not include those who encountered peril but survived.

The American Society of Anesthesiologists (ASA) practice guidelines state: “Even if moderate sedation is intended, patients receiving propofol should receive care consistent with that required for deep sedation”.2 In a position statement, the ASA feels that because of the significant risk that patients who receive deep sedation may enter a state of general anesthesia, privileges to administer deep sedation should be granted only to practitioners who are qualified to administer general anesthesia.3 The American Association for Accreditation of Ambulatory Surgical Facilities specifically prohibits NAPS.4

The Joint Commission on Accreditation of Healthcare Organizations standards regarding sedation require that the person administering the medication and monitoring the patient must be able to manage the patient at whatever level of anesthesia is achieved, even if that level was unintended.5, 6 This may pose a problem for hospitals if their “standard” for the operating room (where endoscopy is sometimes performed) is that propofol be administered exclusively by certified registered nurse anesthestists, yet allows NAPS in the endoscopy area.

Most of the studies referenced in this position paper involve retrospective data. In the prospective study by Rex et al., ASA class III patients were excluded.7 The AASLD position paper discusses NAPS in low-risk patients. Endoscopy related to liver disease mainly centers around patients with cirrhosis and varices. Are these patients low risk? Should there be prospective trials with our patient population prior to the AASLD endorsing this position?

The wording of the package insert warning approved by the FDA, the ASA's position against NAPS, and roughly 25% of states with laws against NAPS pose a formidable legal hurdle if an adverse event were encountered. What if the ASA collects data on the safety of anesthesiologists supervising registered nurses performing endoscopy? Will our society be as quick to accept their perspective?

References

  1. Top of page
  • 1
    Vargo JJ, Cohen LB, Rex DK, Kwo PY. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. HEPATOLOGY 2009; 50: 16831689.
  • 2
    American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96: 10041017.
  • 3
    American Society of Anesthesiologists. ASA Statement on granting privileges to nonanesthesiologist practitioners for personally administering deep sedation or supervising deep sedation by individuals who are not anesthesia professionals. http://www.asahq.org/publicationsAndServices/standards/40.pdf. Accessed December 2009.
  • 4
    American Association for Accreditation of Ambulatory Surgery Facilities. AAAASF procedural standards and checklist for accreditation of ambulatory facilities. http://www.aaaasf.org/pub/AAAASF%20Procedural%20Standards%20Version%201%20FINAL.pdf. Accessed December 2009.
  • 5
    Joint Commission on Accreditation of Healthcare Organizations. Standards for the administration of moderate or deep anesthesia, pc13.20. In: 2004 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2003: pc41pc43.
  • 6
    Joint Commission on Accreditation of Healthcare Organizations. Moderate sedation medication and patient monitoring. http://www.jointcommission.org/AccreditationPrograms/AmbulatoryCare/Standards/09_FAQs/PC/Moderate_Sedation_Medication.htm. Accessed December 2009.
  • 7
    Rex DK, Overley C, Kinser K, Coates M, Lee A, Goodwine BW, et al. Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases. Am J Gastroenterol 2002; 97: 11591163.

David Frank Dies M.D.*, * GastroIntestinal Specialists, The Liver Center, Shreveport, LA.