Joyce S. Willens, PhD, RN, BC Villanova University
54
American Society for Pain Management Nursing: Evidence Based Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression Joyce S. Willens, PhD, RN, BC Villanova University
Joyce S. Willens, PhD, RN, BC Villanova University
Joyce S. Willens, PhD, RN, BC Villanova University
Slide 2
History of EBG Existed in clinical practice for decades Called
Practice Guidelines Practice Policies Clinical Policies Clinical
Algorithms Position Statements
Slide 3
History Movement began in US in the mid 1980s National
Institute of Health came under pressure from policy makers to
provide formal system of assessing new medical developments Evolved
into NIH Consensus Development
Slide 4
Experience with EB Guidelines AHCPR- 1992 Reviewed pain
literature All neuraxial opioid studies
Slide 5
Experience with EB Guidelines APS - 1994 Reviewed ALL
literature for these guidelines
Slide 6
Sickle Cell Pain Guidelines Computer data bases used to search
literature beginning in 1965 Key words pain and sickle cell anemia
Inclusion criteria were: Research articles including assessment and
measurement Pain guidelines and management articles
Slide 7
Presented State of the Art Cardiology conference 2000 Tel Aviv,
Israel
Slide 8
Presentation given in Tel Aviv Israel in 1990
Slide 9
Clinical Practice Guidelines Systematically developed
statements to assist practitioner and patient decisions about
appropriate health care for specific clinical conditions (Institute
of Medicine).
Slide 10
Process Developed levels of scientific evidence Developed
strength and consistency of evidence A- type 1 or consistent
findings from multiple study types B evidence of types II, III, or
IV but findings are inconsistent
Slide 11
Currently -Identify the Problem Began with noticing > use of
naloxone Tracking by nurses and pharmacists Commonality IV PCA
Incidence of sudden onset life-threatening respiratory event with
IV opioid analgesia is 3.6 per 10,000 adults
Slide 12
Comprehensive Literature Review There were no universally
accepted guidelines to direct effective and safe assessment and
monitoring practices. Research has not firmly established that
measuring SpO2 and capnography (ETCO2) prevents mortality
Slide 13
ASPMN Expert Consensus Panel Led by Donna Jarzyna, MS, RN-BC,
CNS-BC Carla R. Jungquist, PhD, RN-C, FNP Chris Pasero, MD, RN-BC,
FAAN Allison Nisbet, MSN, RN, CPHON, AOCNS, CNS-BC Linda Oakes,
MSN, RN-BC, CCNS Susan J. Dempsey, MN,RN-BC, CNS Diane Santangelo,
MS, RN, ANP-C Rosemary C. Polomano, PhD, RN, FAAN Convened in April
2008
Slide 14
Monitoring Defined practice of using the nurse observations of
sedation and respiration including but not limited to the use of
sedation assessment scales and technologies to collect serial
measurement to anticipate and recognize unintended advancing
sedation or respiratory depression.
Slide 15
Step 1 Panel members independently searched electronic
databases Medline PubMed Cumulative Index to Nursing and Allied
Health Literature (CINAHL) Cochrane Library
Slide 16
Relevant Publications Data based articles Case reports Clinical
Reviews commentaries and editorials Terms opioid induced sedation
and respiratory depression > 50 citations were on black board
for review Tele conferences were held to discuss the readings
Slide 17
Step 2 17 articles of varying quality were selected Each panel
member independently rated at least 3 articles Scope of content
Overall quality Adequacy of references Evidence of research
synthesis Confirmation of existing evidence and research Relevance
to practice
Slide 18
Cohens Kappa Statistic Calculated percent agreement 0.72- 1.00
High degree of concordance among raters
Slide 19
Consensus on categories for evidence Individual Patient Risks
Iatrogenic Risks Pharmacology Monitoring
Slide 20
Literature Included Meta-analysis Systematic reviews Randomized
controlled trials (RCT) Clinical Trials Prospective observational
studies Retrospective reviews Secondary analyses
Slide 21
Opinion Based Data Survey members to conduct practice analysis
Use of monitoring when pt receiving opioids On-line survey January
2009-end of February These results have been published in 2011
Conducted the survey again in 2013 Published in September issue
2014
Slide 22
ASA Grading System Originally used by an ASA taskforce for
their report on operating room fires Class I Normally healthy Class
II- Patient with mild systemic disease Class III- Patient with
severe systemic disease Class IV- Patient with severe systemic
disease that is a threat to life Class V- Morbid patient who is not
expected to survive without the surgery Class VI- A declared brain-
dead patient for organ removal
Slide 23
Strength of Evidence and Benefit Risk Ratio ACC/AHA Taskforce
on Practice Guidelines (2010) Class I. Evidence and/or general
agreement that a given treatment is useful and effective
Benefit>>> Risk Class II. Conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of
treatment
Slide 24
Strength of Evidence and Benefit Risk Ratio Class II.
Conflicting evidence and/or a divergence of opinion about the
usefulness/efficacy of treatment Class IIa-. Weight of
evidence/opinion is in favor of usefulness Benefit >>Risk
Class IIb. Usefulness/efficacy is less well established by the
evidence Benefit > Risk
Slide 25
Strength of Evidence and Benefit Risk Ratio Class III.
Conditions for which there is evidence and/or general agreement
that the treatment is not useful and in some cases may be harmful
Risk > Benefit ACCF/AHA Taskforce on Practice Guidelines.
Methodology Manual for ACCF/AHA Guideline Writing Committees
http://my.americanherat.org.idc/groups/ahamahpubli
c/@wcm/@sop/documents/downloadable//ic,_319826 /pdf
Slide 26
Statement of Conditions Aligned with ASPMN mission and goals
Serves as a guide for developing and implementing safe and
effective plans of care Facilitates systems-level changes Applies
scientifically derived and consensus based among panel members No
pharmaceutical involvement
Slide 27
Individual Risks Factors that predispose a person to unintended
opioid- induced advancing sedation and respiratory depression Not
limited to Age Anatomic anomalies Physical characteristics Primary
and comorbid medical condition Psychologic states Functional
status
Sleep disordered Breathing Factors that predispose a person to
unintended opioid- induced advancing sedation and respiratory
depression.
Slide 30
Sleep Disordered Breathing Keywords: sleep apnea- 7,647
citations Risk factors- 436,675 citations Combined with the word
and 1639 citations 91 were deemed relevant
Slide 31
Postoperative Pulmonary Complications Postoperative
complications 11,861 citations Risks 180,339 citations Combined
using and- 521 citations 68 were deemed relevant
Slide 32
Other Categories Iatrogenic Risks with Pain Treatment
Modalities Supplemental Opioids with Peripheral Local Anesthetic
Agents Parenteral, Subcutaneous, and Patient Controlled Analgesia
Coadministration of Antihistamines Coadministration of
Benzodiazepines
Slide 33
Other Categories Timing as a Predictor for Opioid-Induced
Sedation and Respiratory Depression Categories B-1 and B-2 Evidence
Communication Not much in literature Support for SBAR
Slide 34
Categories Pharmacology- pharmacologic agents that are
administered for the treatment of pain in the acute care setting
Comparison of Opioid Analgesics Category C-2 NS difference in
respiratory depression between opioids Acetaminophen- Category A-1
Evidence NSAIDs Category A-1 Evidence
Categories Patient Monitoring Practices Opioid Induced Sedation
Sedation Scales Opioid-induced Respiratory Depression Technology
Supported Monitoring Use of pulse oximetry Use of capnography
Slide 37
After Each Category Recommendation Statements for each category
Statements for each category Should, is recommended, is indicated,
is useful/effective/beneficial Unknown/unclear/uncertain/not well
established Recommendations for Education Implementation
Strategies
Slide 38
Finished Document Sent out for external review by 10 experts
Pain Management Nurses Pharm D Anesthesiologists
Slide 39
Presentations Jungquist, C.R. & Willens, J.S. Preventing
adverse events secondary to opioid-induced advancing sedation and
respiratory depression in adult hospitalized patients: Evidence to
bedside- American Pain Society-Honolulu, HI May 2012
Slide 40
Presentations Jungquist, C.R. & Willens, J.S. Preventing
adverse events secondary to opioid-induced advancing sedation and
respiratory depression in adult hospitalized patients: Evidence to
bedside- American Society for Pain Management Nursing- Baltimore,
MD September 2012
Slide 41
Monitoring for Opioid Induced Sedation and Respiratory
Depression- 2 nd survey 2013 Asked whether their hospital was
practicing 4 safety procedures Written guidelines for assessment
after opioid initiation or titration Double- check of PCA when
initiating, titrating or inserting new PCA Two person check of
epidural drug/programing as above Bar code medication
administration
Slide 42
Monitoring for Opioid Induced Sedation and Respiratory
Depression- 2 nd survey 2013 ASPMN members invited via email June
2013 noted 102 hospitals responded Practice changes over time
Written guidelines for assessment after opioid initiation/titration
86% 2013 vs. 90% in 2009 Double check of PCA program, initiation,
titrating or hanging new bag 96% vs 96% 2 person check of epidural
drugs/programming 80% vs. 86% Bar code med administration 65% vs
30%
Slide 43
Pulse Oximetry Monitoring 28% of institutions represented in
this survey use continuous pulse oximetry 2% reported they did not
know their institutions practices or do not use electronic
monitoring at all Over the last 4 years the use of pulse ox has
increased The use of end tidal CO2 monitoring has increased from 2%
to 11%
Slide 44
Sedation Scales All institutions reported using some type of
sedation scale 90% of nurses endorsed assigning numbers to a level
of sedation Results of the survey indicate that changes in practice
are occurring Frequency of screening for high risk-OSA Authorized
agent controlled analgesia Criteria for defining respiratory
depression Hired or trained a expert pain nurse Initiated or
refined order sets for PCA Changed from intermittent to continuous
pulse ox monitoring Implemented use of sedation scale
Slide 45
Pasero Opioid-Induced Sedation Scale with Interventions S=
Sleep; easy to arouseNo action necessary 1. Awake and alertNo
action necessary may > opioid 2. Slightly drowsy, easily arouse
No action necessary may > 3. Frequently drowsy, arousable,
drifts off to sleep during conversation- Unacceptable- monitor resp
and sedation levels < opioid dose 25 -50% Consider
administration of opioid-sparing nonopioid 4. Somnolent, minimal or
no response to verbal or physical stim Unacceptable; stop opioid;
consider administering naloxone
Slide 46
Respiratory Assessment More than measuring rate for 30 -60
seconds Depth and regularity of respirations Notice trends Listen
to sound of patients respiration Snoring indicates airway
obstruction Decrease dose 25%- 50% Consider continuous ETCO2
monitoring
Slide 47
Clinical Signs of OSA Frequent, loud snoring Neck circumference
> 17 man- 16 woman BMI of 35 kg/m2 or more
Slide 48
Slide 49
Physical Exam Awake, alert, oriented Appears quite ill and
uncomfortable One episode of emesis VS 98.2, 85, 18, 148/88 Pain
intensity rating 10 on a 0 to 10 scale
Slide 50
Chronology of Treatment Admitted to ER at 5:37 PM 5:50 PM given
hydromorphone 1 mg IV 6:19 PM same 6:40 PM evaluated by MD 6:50 PM
hydromorphone 1 mg IV 7:21 PM fentanyl 100 mcg IV 7:25 PM fentanyl
100 mcg IV 7:30 PM fentanyl 50 mcg IV- Pain 10/10 7:40 PM fentanyl
25 mcg IV
Slide 51
Chronology of Treatment 10:00 PM promethazine 12.5 mg IV and
MSO4 5mg IV 10:25 PM Respiratory therapist called for BIPAP PMH of
multiple apneic episodes after analgesia 10:30 PM placed on BIPAP
11:15 PM promethazine 12.5 plus MSO4 5mg IV Next day 00:15 AM
Desaturation noted BIPAP reapplied
Slide 52
Medical Floor 2:10 AM PCA is begun 9:50 AM emesis- zophran
given - pain 10/10 11:17 AM MD consult- awake, alert & oriented
Pain consultation NP PCA changed to 2 mg MSO4 per dose every 15
minutes with no dose limit 4:00 PM alert and oriented Pt chart for
SPO2 left blank 5:45-9:37 PM multiple blanks on pt record
Slide 53
9:37 lorazepam 1 mg IV given for agitation and anxiety Removing
BIPAP mask, climbing out of bed NOTE THE MD WAS NOT CALLED PRIOR TO
ADMINISTRATION OF LORAZEPAM 10:33 PM Code Blue called 10:54 Narcan
0.8 mg IV Pulseless electrical activity Revived but never regained
consciousness Died a year later
Slide 54
Did not have ETCO2 monitoring on the floor NEVER did an
arterial blood gas analysis Settled out of court
