PSA-PANA Joint Statement on the Administration of Propofol to Unintubated Patients

There has been a dramatic increase in the use of the anesthetic induction agent propofol to provide anesthesia and amnesia during medical procedures of short duration, such as electrophysiologic and endoscopic interventions. The substitution of deep sedation, or a general anesthetic of short duration, with propofol for the traditional “conscious sedation” has increased both patient satisfaction and the efficiency of the centers performing these procedures.

Conscious sedation is defined by Pennsylvania Nursing Board regulations as “a minimally depressed level of consciousness in which the patient retains the ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal commands." No interventions are required to maintain a patent airway, spontaneous ventilation is usually adequate, and cardiovascular function is usually maintained during conscious sedation. Board of Nursing Regulations permit, and physicians have safely used, registered nurses who are not CRNAs to administer conscious sedation. The primary patient monitoring required during conscious sedation is to ensure that the patient remains capable of responding to verbal commands. Specialized training in how to maintain the airway, assist with ventilation, and/or maintain circulation should rarely be needed.

Propofol is an agent that is capable of rapidly inducing general anesthesia for short periods of time and is therefore capable of interfering with airway patency and spontaneous ventilation. Due to the potential for rapid, profound changes in anesthetic depth and the lack of antagonist medications, agents such as propofol require special attention. The package insert for this drug states:

For general anesthesia… 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.
For sedation of intubated, mechanically ventilated adult patients in the Intensive Care Unit (ICU), [propofol] should be administered only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management.”

State Board of Nursing Regulations do not permit registered nurses, who are not CRNAs, to administer deep sedation or general anesthesia.

The Pennsylvania Society of Anesthesiologists believes that when propofol is utilized as either an anesthetic agent or as an agent utilized to achieve sedation in a nonintubated patient, it should be administered by a practitioner with training and experience in the management of general anesthesia, credentialed by the facility and permitted by state law to administer general anesthesia. This practitioner may not simultaneously be performing the medical or surgical procedure.