West Virginia Board of Nursing Review – October 22, 2010
Reviewed by Sedation Certification – March 21, 2019
State Sedation Policy – Yes
Can RN’s give sedation? – Yes
Can RN’s give Propofol/Ketamine? – Under Certain Circumstances – Intubated/Ventilated
ADMINISTRATION OF ANESTHETIC AGENTS
REVISED OCTOBER 22, 2010
West Virginia Board of Examiners for Registered Nurses
In accordance with West Virginia Code Chapter 30, Article 1, Section 15, that provides that:
In any case where it is lawful for a duly licensed physician or dentist practicing medicine or dentistry under the laws of this state to administer anesthetics, such anesthetics may lawfully be given and administered by any person (a) who has been licensed to practice registered professional nursing under this article, and (b) who holds a diploma or certificate evidencing his or her successful completion of the educational program of a school of anesthesia duly accredited by the American association of nurse anesthetists: Provided, that such anesthesia is administered by such person in the presence and under the supervision of such physician or dentist.
The West Virginia Board of Examiners for Registered Professional Nurses (Board) has determined that it is not within the scope of practice for a registered professional nurse who is not a Certified Registered Nurse Anesthesist (CRNA) to administer medications classified as anesthetics such as ketamine, propofol, etomidate, sodium thipental, methohexital, nitrous oxide and neuromuscular blocking agents (paralytics), except under very specific circumstances. These specific circumstances include:
1. The administration of a continuous infusion of an anesthetic agent or neuromuscular blocking agent (paralytic) for a patient who is intubated and ventilated in the acute care setting. The administration of an anesthetic agent or neuromuscular blocking agent (paralytic) is for the purposes of maintaining comfort, stable oxygenation and ventilation, and a viable airway. In this case a CRNA or licensed physician qualified in the administration of anesthetics must administer the first dose of the anesthetic or neuromuscular blocking (paralytic) agent and determine the continuous infusion dosage. Dose titrations and boluses of subsequent anesthetic agents or neuromuscular blocking agents (paralytics) to be administered to the intubated and ventilated patient may be implemented by the registered professional nurse (RN) based upon specific orders or protocols signed by a qualified licensed physician.
2. RAPID SEQUENCE INTUBATION- (RSI) is defined as a technique in which a potent sedative or induction agent is administered virtually simultaneously with a paralyzing dose of a neuromuscular blocking agent to facilitate tracheal intubation. The technique includes specific protection against aspiration of gastric contents, provides excellent access to the airway for intubation, and permits pharmacologic control of adverse responses to illness, injury, and the intubation itself.
RN Role in RSI:
In-depth knowledge of anatomy, physiology, pharmacology, patient assessment and emergency procedures is necessary for the registered nurse (RN) to accept responsibility for administering medications and monitoring clients receiving IV sedation for RSI.
A. Medications for RSI may be administered by an RN in the presence of a physician or advanced practice RN credentialed in emergency airway management and cardiovascular support.
B. A physician or advanced practice RN ordering the sedation should be present at the time the sedation is administered in order to participate in the procedure and in the response to any emergency.
C. Medications for RSI during pre-hospital and/or inter-facility transport may be administered by an RN at the direction of a physician or advanced practice RN credentialed in emergency airway management and cardiovascular support.
D. Age-appropriate resources (i.e., equipment – pulse oximeter and cardiac monitors), emergency resuscitation equipment and medications, as well as personnel qualified to provide necessary emergency measures, such as intubation and airway management, must be readily available during IV sedation for RSI procedures.
E. RN may accept the responsibility for the care of patients receiving l.V.
sedation for RSI if she/he has the appropriate knowledge, skills, and validated competency and is in a practice setting that provides the necessary resources to assure patient safety. This management may include administration of medications, monitoring the patient for intended and untoward responses to the medication and her/his level of consciousness throughout the procedure, and implementing emergency activities, e.g. suction, oxygen, and defibrillation, if required.
F. RN who accepts responsibility of monitoring status of the patient cannot assume other responsibilities such as performing a procedure which would leave the client unattended, thereby jeopardizing the safety of the client. (For example, while endotracheal intubation is within the scope of practice for the RN, a single RN could not be simultaneously responsible for both the medication administration/monitoring activities and the intubation itself.)
G. Patient stability must be assessed by the RN prior to transferring responsibility for patient care to a nurse not competent in the administration/monitoring of sedation agents.
H. The RN must assure that written policies and procedures for the RN to administer intravenous sedation for RSI are currently in place by the employing agency. This includes listing specific drugs and dosages approved by the facility for use in these situations.
I. Mechanisms to assure the RN knowledge and competency requirements are met and maintained.
3. The administration of Ketamine, as prescribed by a licensed physician as a palliative care intervention for pain management in an acute care setting is within the scope of practice of the RN.
In all circumstances provided above, it is expected that the RN has appropriate emergency equipment and personnel competent in emergency resuscitation immediately available and possesses the current knowledge and skill to apply this intervention in practice. This includes but is not limited to the RN who possesses current knowledge of pharmacology for this type of drug including drug actions side effects and contraindications, and assessment skills and in the case of palliative care, knowledge of end of life care including pain management at the end of life.
Given the level of independent assessment, decision-making, and evaluation required for the safe care of the client receiving RSI nursing management of these patients cannot be delegated to a Licensed Practical Nurse by the Registered Professional Nurse.