Nurses administering propofol; OR temperature and humidity; OR internet use; OR cleaning; approved skin markers

AORN Journal, Nov, 2004 by Debra T. Moore

QUESTION: Some physicians at our facility are requesting a change in the moderate sedation policy. They want circulating nurses to administer propofol for moderate sedation. If changing the policy is not possible, the surgeon wants to administer the propofol and have a nurse monitor the patient. Many nurses are concerned about this practice as it relates to patient safety. Does AORN have a recommendation to address this issue?

ANSWER: Propofol should be administered only by people trained in the administration of general anesthesia. According to the April 14, 2004, joint statement from the American Association for Nurse Anesthetists (AANA) and the American Society of Anesthesiologists (ASA),

   ... propofol should be administered
   only by persons trained in the
   administration of general anesthesia,
   who are not simultaneously
   involved in the surgical or diagnostic
   procedure." (1)

This position is based on the unpredictability of a patient's reaction to propofol, the potential for rapid and profound changes in the depth of sedation, and the lack of a reversal agent (ie, antagonist) for propofol. The AANA and ASA joint statement makes it clear that the practitioner performing the procedure should not be the practitioner administering propofol.

According to Beverly Phillips, MD, chairwoman of ASA's Ambulatory Surgical Care Committee and professor of anesthesiology at Harvard Medical School, Boston, having RNs administer propofol is a patient safety issue. (2) The ASA cautions practitioners about a rapid and profound decrease in cardiorespiratory function and level of consciousness that could culminate in general anesthesia. (3) In addition, a patient's airway, can become obstructed quickly during administration of propofol, and personnel who are not anesthesia care providers often fail to recognize the obstruction until the patient experiences profound oxygen desaturation.

Unlike other medications used during moderate sedation (eg, midazolam, morphine), the effects of propofol cannot be reversed. (4) The company that manufactures propofol provides product information warning that propofol is for general anesthesia or monitored anesthesia care sedation and should be administered only by practitioners trained in the administration of general anesthesia. The manufacturer also warns that the practitioner administering propofol should not be involved in the procedure. (5) As with all medications, it is essential that the product literature for propofol be consulted and directions for its use followed.

Facilities accredited by the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) should be aware that the AAAASF's standards regarding the administration of propofol have changed. The standards now require that only certified RN anesthetists or anesthesiologists administer propofol. (6)

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards regarding moderate sedation require that a sufficient number of qualified staff members, in addition to the person performing the procedure, be available in the OR to monitor the patient. 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. (7,8) Only those qualified to manage a patient undergoing general anesthesia should administer propofol because of the potential for rapid and unpredictable changes in the depth of sedation.

There is controversy in the health care arena regarding nurse administration of propofol. Thirteen states prohibit the administration of propofol by an RN. (9) Perioperative RNs should be aware of their state's practice rules and regulations regarding administration of propofol, and monitoring of patients' moderate sedation. Nurses can contact their state board of nursing for more information.

QUESTION: I work in the Southern United States, and it often is difficult to control temperature and humidity in the OR. What are AORN's recommendations for environmental controls (eg, humidity, temperature) in the OR? Are there different environmental factors for the postanesthesia care unit (PACU) and sterile storage areas?

ANSWER: The standards for humidity and temperature are published by the American Institute of Architects (AIA) Committee on Architecture for Health and the US Department of Health and Human Services (Table 1). (10) The Centers for Disease Control and Prevention's 1999 publication, Guidelines for Prevention of Surgical Wound Infections, also supports AIA standards.

Maintaining relative humidity in the OR is difficult in many locations throughout the United States. To maintain the recommended range, special centralized units may be needed. To maintain humidity at a constant level within the recommended range, specialized units should be self-regulating. Single room units (eg, floor coolers, fans) are not recommended because these units create air turbulence and may disperse bacteria and dust into the controlled environment.