Administration of propofol; infectious waste disposal; Aspergillus; portable humidifiers in the OR - Clinical Issues

AORN Journal,  Oct, 2003  by Joan Blanchard

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QUESTION: Intravenous conscious sedation is being used more frequently at our facility. The nurses monitoring these patients are being asked by physicians to administer propofol on an increasing basis. Is this something we should be doing?

ANSWER: Propofol is considered an anesthetic medication; therefore, it should be administered only by those who have the appropriate anesthesia credentials. According to the Physicians Desk Reference:

   For general anesthesia of 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.
   Patients should be continuously
   monitored, and facilities for maintenance
   of a patent airway, artificial
   ventilation, and oxygen enrichment
   and circulatory resuscitation must
   be immediately available. (1 (p664))

Propofol produces significant cardiac depression in the usual induction doses. The effects are more pronounced than those seen with equivalent doses of thiopental, midazolam, or etomidate. Respiratory depression, even more prominent than that seen with thiopental, has been reported with induction doses of propofol. Residual medication is eliminated via the liver, and hepatic elimination can be prolonged in patients with liver disease.

Propofol's pharmaceutical activity can be influenced by age. Older patients require lower doses, whereas children require higher doses because of their increased distribution volume based on body weight (ie, children can have a higher rate of clearance).

The effects of propofol administration are unpredictable. Propofol can accumulate with prolonged infusion. (2) Standard protocols are difficult to develop because propofol is a short-acting medication. Some patients respond to minimal dosages, and others require massive amounts of the medication to achieve procedural sedation. Airway management can be extremely demanding, and rapid intubation may be required. Propofol has no known reversal medications. (3) Artificial ventilation, resuscitation, or both may be required if a patient experiences respiratory compromise or arrest.

Only six state boards of nursing in the United States have issued either a declaratory statement or an advisory opinion that administration to and/or monitoring of patients receiving propofol for procedural sedation is within a nurse's scope of practice. Twelve states have issued either a declaratory statement or an advisory opinion that administration to and/or monitoring of patients with propofol or other anesthetic agents is beyond the scope of practice for RNs other than certified RN anesthetists. No rulings have been issued in the remaining 32 states. (3)

Propofol is a highly effective, rapid-acting anesthetic medication that can have serious adverse effects. Sedation occurs on a continuum from minimal sedation through moderate sedation to deep sedation to anesthesia. Patients may slip unavoidably into a deeper level of sedation/analgesia than desired (Table 1). (3,4) Individuals administering to and/or monitoring patients undergoing moderate or deep sedation or anesthesia should have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved either intentionally or unintentionally. Additionally, anyone permitted to administer moderate sedation should be qualified to revive patients from deep sedation, manage a compromised airway, and provide adequate oxygenation and ventilation. (5) As with all medications, the produce literature for propofol should be consulted and directions for use followed carefully. Individual state regulatory agencies should be consulted for scope of practice questions.

QUESTION: We have been instructed to put all regulated waste into red bags for special handling and disposal and have been doing this for some time. We recently hired two new staff members with experience at other facilities, and they are questioning some of the items we put into bags. Exactly what goes into regulated waste, and how should it be handled after it is placed into the red bag? Should we be concerned about how it is disposed?

ANSWER: All regulated waste should be placed in red bags, including liquid or semi-liquid blood or other potentially infectious materials, such as

* contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed,

* items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling,

* contaminated sharps, and

* pathological and microbiological wastes containing blood or other potentially infectious materials. (6)

All red bags should be transported to a secured area in the facility designated for hazardous waste. The bags are placed in this area for storage until it is time for transportation to the waste management processing plant or facility. Hazardous waste must be packaged according to guidelines published by the US Department of Transportation so that it may be transported safely. Transportation guidelines require that packages or containers must