Monitoring for opioid-induced advancing sedation and respiratory depression: ASPMN membership survey of current practice

Predicting opioid-induced oversedation in hospitalised patients: a multicentre observational study

OBJECTIVES

Opioid-induced respiratory depression (OIRD) and oversedation are rare but potentially devastating adverse events in hospitalised patients. We investigated which features predict an individual patient's risk of OIRD or oversedation; and developed a risk stratification tool that can be used to aid point-of-care clinical decision-making.

DESIGN

Retrospective observational study.

SETTING

Twelve acute care hospitals in a large not-for-profit integrated delivery system.

PARTICIPANTS

All inpatients ≥18 years admitted between 1 July 2016 and 30 June 2018 who received an opioid during their stay (163 190 unique hospitalisations).

MAIN OUTCOME MEASURES

The primary outcome was occurrence of sedation or respiratory depression severe enough that emergent reversal with naloxone was required, as determined from medical record review; if naloxone reversal was unsuccessful or if there was no evidence of hypoxic encephalopathy or death due to oversedation, it was not considered an oversedation event.

RESULTS

Age, sex, body mass index, chronic obstructive pulmonary disease, concurrent sedating medication, renal insufficiency, liver insufficiency, opioid naïvety, sleep apnoea and surgery were significantly associated with risk of oversedation. The strongest predictor was concurrent administration of another sedating medication (adjusted HR, 95% CI=3.88, 2.48 to 6.06); the most common such medications were benzodiazepines (29%), antidepressants (22%) and gamma-aminobutyric acid analogue (14.7%). The c-statistic for the final model was 0.755. The 24-point Oversedation Risk Criteria (ORC) score developed from the model stratifies patients as high (>20%, ≥21 points), moderate (11%-20%, 10-20 points) and low risk (≤10%, <10 points).

CONCLUSIONS

The ORC risk score identifies patients at high risk for OIRD or oversedation from routinely collected data, enabling targeted monitoring for early detection and intervention. It can also be applied to preventive strategies-for example, clinical decision support offered when concurrent prescriptions for opioids and other sedating medications are entered that shows how the chosen combination impacts the patient's risk.

A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse

BACKGROUND

Nursing brings a unique lens to care of patients with pain and opioid misuse.

AIMS

This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care.

DESIGN

The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.

DATA SOURCES

Using combined key terms ("opioid misuse," "pain," "nursing") in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites.

ANALYSIS METHOD

Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature.

RESULTS

Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108).

CONCLUSION

Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse.

IMPLICATIONS FOR NURSING

This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.

Implementing a Clinical Practice Guideline on Opioid-Induced Advancing Sedation and Respiratory Depression

BACKGROUND

Opioid-induced respiratory depression (OIRD) is a serious adverse reaction associated with opioid administration.

LOCAL PROBLEM

The purpose of this quality improvement study was to evaluate the impact of implementing a clinical practice guideline for OIRD in a medical-surgical setting lacking standardized monitoring techniques and reporting criteria for patients receiving opioid analgesia.

METHODS

An American Society for Pain Management Nursing protocol was implemented in 4 medical/surgical units. The impact on OIRD-related nurse knowledge, documentation, and opioid-related rapid response calls was measured pre- and postimplementation.

RESULTS

Nurse OIRD-related knowledge significantly increased. The number of naloxone administrations associated with prior intravenous opioid analgesic administration did not significantly change. However, there was a significant decrease in the postimplementation number of respiratory distress-related rapid response calls.

CONCLUSIONS

Implementation of the American Society for Pain Management Nursing guidelines had a positive impact on knowledge, documentation, early intervention of OIRD, and the number of opioid-related rapid response calls.

Opioid-Induced Sedation and Respiratory Depression: Are Sedation Scales Enough to Prevent Adverse Drug Events Postoperatively?

OBJECTIVES

Nurses who care for hospitalized patients are responsible for ensuring adequate pain management is provided in a safe manner. The clinical challenge is balancing the effective control of the patient's pain with the side effects of administering opioids. The aim of this literature review is to explore the evidence on how nurses assess for opioid-induced sedation and advancing respiratory depression and how they integrate those data in their critical thinking skills when deciding to administer opioids for pain.

DESIGN

A matrix method was used to guide the review and synthesis of the evidence. Tables with column headings (citation, purpose of study, design/measurements, outcomes, and results) were constructed to record data extracted from each study.

DATA SOURCES

Primary source research articles were examined using the MESH terms sedation, sedation scale, respiratory depression, opioid, pain, pain assessment, adverse events, naloxone and postoperative.

REVIEW/ANALYSIS METHODS

Original studies such as retrospective case-control studies and descriptive studies were included. The final studies that met the inclusion criteria and were independently reviewed by the authors. The two main areas of interest were the evidence for how nurses assess for advancing sedation and excessive respiratory depression and how nurses integrate their assessment data in their critical thinking skills when deciding to administer opioids for pain.

RESULTS

Results indicated a lack of evidence examining the relationships among sedation, respiratory depression, and adverse events and the overall impact of managing these variables on patients' pain.

CONCLUSIONS

This review revealed a lack of evidence between how nurses assess for opioid induced advancing sedation and excessive respiratory depression, and the impact, including the adverse events associate with acute pain management.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Sedation scales: Do they capture the concept of opioid-induced sedation?

AIM

The purpose of this study was to explore the concept of opioid-induced sedation and how nurses define and measure sedation in the hospital setting.

BACKGROUND

Opioid medications are the primary treatment for acute pain in the postoperative setting. One of the most serious side effects of opioid therapy is excessive sedation and respiratory depression. Nurses have the responsibility of providing effective pain management, while keeping the patient safe from adverse sedation and respiratory depression. Thus, the assessment of sedation becomes an integral part of the nurses' responsibilities.

REVIEW METHOD

A review of the literature on the concept of opioid-induced sedation, and how it is measured by nurses in the hospital setting was performed using the Walker and Avant's (2011) framework.

RESULTS

Sedation is an ambiguous concept that challenges nurse's critical thinking skills. The linear sedation scales can assist with the measurement of sedation, but may lack sensitivity and specificity in detecting the small changes on the continuum of levels of consciousness. Additionally, the scales may not capture the entire aspects of the concept of sedation.

CONCLUSIONS

Sedation, as defined by the linear sedation scales is limiting nurses' appreciation of the small changes in level of cognition as well as consciousness that occurs as an adverse and potentially dangerous side effect of opioid medications used for acute pain management. Through developing a better understanding of sedation as a clinical concept, nurses may enhance their clinical skillset in safer postoperative pain management. Additionally, linear sedation scales could be further developed to better capture all aspects of sedation.

The common meanings and shared practices of sedation assessment in the context of managing patients with an opioid: A phenomenological study

AIMS AND OBJECTIVES

To examine the common meanings of opioid-induced sedation and shared practices in the context of post-operative pain management in expert Post-Anesthesia Care Unit nurses during patient's pain management with opioids.

BACKGROUND

Within the clinical setting, linear pain and sedation scales are not enough to support clinical judgement with acute pain management. Because sedation measurement rests along a fluctuating continuum, it is possible for a patient to be sedated and then shift to increasing alertness, and then to drift back to a sedated state. This potential for acute clinical transition can be challenging to nurses of all levels, even for expert nurses.

DESIGN

Interpretive phenomenology.

METHODS

Twenty expert Post-Anesthetic Care Unit nurses, with more than 7 years of nursing experience, participated in qualitative interviews regarding their lived experiences. Interviews were analysed using a modified seven-stage process for interpretation by Diekelmann, Allen and Tanner. The manuscript was developed utilising the COREQ guidelines for reporting qualitative studies.

RESULTS

Four themes identified through the participant's stories were recognising every patient is different, engaging in iterative knowing, walking a fine line, and looking beyond and anticipating. This study identified a constitutive pattern of interpreting sedation by integrating practical understanding and anticipating beyond.

CONCLUSIONS

This study indicates a deeper complexity in the way opioid-induced sedation is assessed and balanced with pain management by nurses in the Post-Anesthetic Care Unit.

RELEVANCE TO PRACTICE

Nurses in the study adapted their practices around pain management with opioids, in response to their patient's level of sedation; incorporating practices such as giving small, incremental doses and changing the drug. Nurses valued the importance of having "eyeballs on everybody" and being ready to meet the needs of their patient. They appreciate the time to watch and wait for their patient to respond, to better judge the result of their interventions.

Addressing Safe Opioid Monitoring Practices Using an Interprofessional Approach

OBJECTIVE

The aims of the project are to increase knowledge related to opioids and improve adherence to evidence-based interventions for sedation monitoring and assessment in adult inpatients receiving opioids for pain through delivery of an interprofessional online program.

BACKGROUND

Preventable opioid-induced respiratory depression is a patient safety risk in hospitals. Sedation and respiratory assessment and monitoring guidelines and tools are available to improve practice.

METHODS

An interprofessional team identified organization-specific drivers of opioid-induced sedation and respiratory depression using process improvement methodology, developed interventions, and evaluated clinician opioid knowledge and documentation practice.

RESULTS

Opioid knowledge survey responses improved after the interventions. Audits showing improved appropriate documentation by RNs of the correct sedation scale were performed over 2 separate 3-month periods.

CONCLUSIONS

Clinicians demonstrated increased knowledge about newly adopted sedation and monitoring practices targeted to prevent opioid-induced respiratory depression.