To the Editor,

We are the Assistant Administrator and Medical Director of the Wichita Falls Endoscopy Center. We read the column by Daniel and Schmelzer (2009) in the July-August issue of Gastroenterology Nursing journal regarding meperidine usage for endoscopic sedation. We wholeheartedly endorse your conclusion that there is no rationale for the continued use of meperidine for routine endoscopic sedation. We would, however, like to comment on an issue that we have been dealing with for quite some time.

In the article, the authors stated that "in Texas, only anesthesia providers (anesthesiologist and certified registered nurse anesthetists) may administer propofol." We believe that it is not entirely true and the statement is incomplete. There are exceptions to registered nurses (RNs) being able to administer propofol, and one of the exceptions is assisting individuals with current competence in advanced airway management. See Position Statement 15.8: "The Role of the Nurse in Moderate Sedation, Texas Board of Nurse Examiners," which does not promote, but does not prohibit nurses from choosing to do this.

Therefore, it is the position of the Board that the administration of anesthetic agents (e.g., propofol, methohexital, ketamine, and etomidate) is outside the scope of practice for RNs and non-CRNA (certified registered nurse anesthetist) advanced practice RNs except in the following situations:

* When assisting in the physical presence of a CRNA or anesthesiologist.

* When administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e., when functioning as a student nurse anesthetist).

* When administering these medications to patients who are intubated and mechanically ventilated in critical care settings.

* When assisting an individual with current competence in advanced airway management, including emergency intubation procedures.

Gastroenterologists at our facility have been using physician-directed propofol sedation (PDPS) to provide moderate sedation for our outpatient endoscopy patients since July 2006. To date, we have sedated more than 17,000 patients without incident. This issue was addressed during our 2007 accreditation survey. The surveyor noted our use of PDPS; we successfully supported our policy and received a 3-year accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC). We contacted the Texas Board of Nurse Examiners by e-mail and were given a response the next day that included the following statement: "Nothing in that position statement prevents any RN from making the decision to administer propofol to a non-intubated patient during an endoscopy procedure."

All of the standard endoscopic sedatives carry the potential for crossover to deep sedation and respiratory arrest. Anyone providing endoscopic sedation should be prepared for and capable of managing that potential occurrence. In our opinion, the availability of reversal agents for some drugs does not change that requirement and has the potential to give one a false sense of security. We believe that PDPS for moderate endoscopic sedation can be done safely and in our experience offers significant advantages in both physician and patient satisfaction. Gastroenterology sedation continues to develop, and nurses and physicians must choose wisely and proceed cautiously as developments occur.

Sincerely,

Jana Beasley, RN

Charles Thueson, MD

Jana Beasley and Charles Thueson are from Wichita Falls Endoscopy Center, Wichita Falls, Texas.

Correspondence to: Jana Beasley, RN, Wichita Falls Endoscopy Center, Wichita Falls, TX 76301 ([email protected]).