Nurses have been given the green light to perform procedural sedation of patients using propofol provided they work under a strict set of guidelines released by the Australian and New Zealand College of Anaesthetists.

It follows a declaration by the college that while the practice cannot be deemed completely safe, models of propofol sedation by non-anaesthetists are already widespread and “may be acceptable” with appropriate training, personnel and support systems.

The first update to the official guidance (link here) since 2014, the document’s publication follows more than 12 months of consultation involving 29 colleges and specialty groups across Australia and New Zealand.

Labelled PG09(G), it is now being introduced as a six-month pilot, allowing ANZCA to gather feedback before a finalised document is published later this year.

Other key changes include:

• Updated definitions for minimal, moderate and deep sedation, plus specific wording excluding deep sedation from the guidance given the risks of progression to general anaesthesia.
• Specific guidance addressing paediatric sedation
• A shift in focus from the seditionist’s profession to their competency, with an expectation that practitioners achieve and demonstrate competency with their targeted depth, plus one level deeper, in case of unintentionally exceeding the targeted depth.

“Medical practitioners from many disciplines, nurses, dentists and dental specialists administer sedative/hypnotic medications,” a background paper released alongside the guideline states.

“The purpose of PG09(G) is to optimise patient care in the management of procedural sedation by all sedationists.”

The document goes on to state there is little evidence of a significant difference in outcomes when propofol is used for minimal or moderate sedation by anaesthetists compared to other medical practitioners and dentists.

Nevertheless, the guideline goes on to say that as the administration of any medication carries a risk of adverse events, it would be inappropriate to consider and technique “safe”.

As a result, the guideline says the drug should only be used for procedural sedation by non-anaesthetists under an agreed set of principles including:

• Where propofol is administered by the proceduralist who also assumes the role of sedationist, the presence of two additional staff members is essential, one of whom, the assisting practitioner, has the requisite skills and competencies.
• Use of propofol by non-anaesthetist practitioners is acceptable only if the requisite number of staff with the applicable skills and competencies is present, or if targeting only minimal sedation.
• It is essential that non-anaesthetist practitioners who wish to administer propofol sedation are trained in sedation consistent with the competencies outlined by ANZCA.

Nevertheless, the Gastroenterological Society of Australia (GESA) has stressed that endoscopist-directed, nurse-administered propofol sedation should only be performed in hospitals where medical emergency teams are available to respond in the rare event that resuscitation is required.

It has also made clear it does not advise the practice in facilities without immediate access to emergency response teams.

Another major change to the guidance relates to the discharge of patients, stressing this should be authorised by the practitioner responsible for managing sedation or another qualified practitioner working within their scope of practice.

“Patients should be escorted and discharged into the care of a responsible adult to whom written instructions should be given,” the guideline says.

“If despite reasonable efforts, a responsible adult is not available for discharge supervision, the practitioner responsible for managing sedation may exercise their judgement in deciding on post-sedation supervision and mode of transport (excluding driving or public transport) to their discharge destination.”

“A carer at home may not be essential if the practitioner managing sedation, having administered only agents with rapid offset of action, assesses the patient to have made a good recovery after a brief or minimally invasive procedure with a low risk of adverse events.”