American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression

University Medical Center, Tucson, Arizona 85724, USA.
Pain management nursing: official journal of the American Society of Pain Management Nurses (Impact Factor: 1.53). 09/2011; 12(3):118-145.e10. DOI: 10.1016/j.pmn.2011.06.008
Source: PubMed


As the complexity of analgesic therapies increases, priorities of care must be established to balance aggressive pain management with measures to prevent or minimize adverse events and to ensure high quality and safe care. Opioid analgesia remains the primary pharmacologic intervention for managing pain in hospitalized patients. Unintended advancing sedation and respiratory depression are two of the most serious opioid-related adverse events. Multiple factors, including opioid dosage, route of administration, duration of therapy, patient-specific factors, and desired goals of therapy, can influence the occurrence of these adverse events. Furthermore, there is an urgent need to educate all members of the health care team about the dangers and potential attributes of administration of sedating medications concomitant with opioid analgesia and the importance of initiating rational multimodal analgesic plans to help avoid adverse events. Nurses play an important role in: 1) identifying patients at risk for unintended advancing sedation and respiratory depression from opioid therapy; 2) implementing plans of care to assess and monitor patients; and 3) intervening to prevent the worsening of adverse events. Despite the frequency of opioid-induced sedation, there are no universally accepted guidelines to direct effective and safe assessment and monitoring practices for patients receiving opioid analgesia. Moreover, there is a paucity of information and no consensus about the benefits of technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy. To date, there have not been any randomized clinical trials to establish the value of technologic monitoring in preventing adverse respiratory events. Additionally, the use of technology-supported monitoring is costly, with far-reaching implications for hospital and nursing practices. As a result, there are considerable variations in screening for risk and monitoring practices. All of these factors prompted the American Society for Pain Management Nursing to approve the formation of an expert consensus panel to examine the scientific basis and state of practice for assessment and monitoring practices for adult hospitalized patients receiving opioid analgesics for pain control and to propose recommendations for patient care, education, and systems-level changes that promote quality care and patient safety.

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    • "Iatrogenesis is the development of complications directly related to receiving treatment. Iatrogenic factors during opioid administration are environmental and pain therapy-related circumstances in the hospital workplace that predispose a patient to increased risk of unintended advancing sedation and respiratory depression (Jarzyna et al., 2011). Specific areas of focus are opioid delivery modality, coadministration of sedating drugs, timing and environment, communication, nurse staffing and education, and monitoring practices (see Table 3). "
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    ABSTRACT: Background: Adverse events related to opioid-induced unintended advancing sedation and respiratory depression in hospitalized patients are occurring with increased frequency, and these adverse events can have a negative impact on quality and cost outcomes. Aim: The goal of this paper is to inform nurses on best practices for preventing opioid-induced advancing sedation and respiratory depression, and to inform nurse leaders on implementation strategies to guide change in policies and practice. Methods: This paper presents an evidenced-based systematic approach for organizations to use in implementing strategies to reduce adverse events secondary to opioid-induced advancing sedation and respiratory depression in the hospitalized adult patient. Results: An action-oriented framework was developed based on the authors' experiences, strategies recommended by the Institute for Healthcare Improvement (IHI), the National Association of Healthcare Quality (NAHQ), and expert consensus-based best monitoring practices. Linking Evidence to Action: Nurse executives and nurse managers assume accountability for ensuring that patient care is aligned with the best evidence, practices, and regulatory mandates. The framework presented in this paper can help prevent opioid-induced advancing sedation and respiratory depression, and assist nurse leaders in implementation strategies to guide policies and practice.
    Full-text · Article · Sep 2014 · Worldviews on Evidence-Based Nursing
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    • "There are several studies evaluating the availability and utilization of capnography in EDs and ICUs [10] [11] [12] [13] [14]. Despite the increasing literature base for capnography and its incorporation into national guidelines, capnography is not being used to its full potential [6] [7] [8] [9]. However, it is not due to lack of its physical presence on the unit (its adoption) but to a failure of incorporation into clinical practice (its implementation) [24]. "
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    ABSTRACT: Purpose: Although capnography is being incorporated into clinical guidelines, it is not used to its full potential. We investigated reasons for limited implementation of capnography in acute care areas and explored facilitators and barriers to its implementation. Methods: A purposeful sample of physicians and nurses in emergency departments and intensive care units participated in semistructured interviews. Grounded theory, iterative data analysis, and the constant comparative method were used to analyze the data to inductively generate ideas and build theories. Results: Nineteen providers were interviewed from 5 hospitals. Six themes were identified: variability in use of capnography among acute care units, availability and accessibility of capnography equipment, the evidence behind capnography use, the impact of capnography on patient care, personal experiences impacting use of capnography, and variable knowledge about capnography. Barriers and facilitators to use were found within each theme. Conclusions: We observed varied responsiveness to capnography and identified factors that work to foster or discourage its use. These data can guide future implementation strategies. A deliberate strategy to foster utilization, mitigate barriers, and broadly accelerate implementation has the potential to profoundly impact use of capnography in acute care areas with the goal of improving patient care.
    Full-text · Article · Jun 2014 · Journal of Critical Care
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    • "Since the 2009 survey, several new monitoring technologies have been introduced into the health care market. Additionally, in 2011 the ASPMN published its consensus report on opioid monitoring summarizing evidence in support of aggressive patient monitoring and educational programs for nurses to promote quality and safe patient care (Jarzyna et al., 2011). "
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    ABSTRACT: Adverse events secondary to opioid-induced advancing sedation and respiratory depression continue to occur during hospitalizations despite efforts to increase awareness and clinical practice guidelines to address prevention strategies. In 2009, ASPMN surveyed membership on current practices surrounding this topic. ASPMN clinical practice guidelines were then published in 2011. In winter of 2013, ASPMN membership was again surveyed to assess progress in preventing adverse events. This is a report of the follow-up membership survey. In general, monitoring practices are slowly improving over time, but there are many facilities that have not instituted best practices for avoiding adverse events.
    Full-text · Article · Mar 2014 · Pain management nursing: official journal of the American Society of Pain Management Nurses
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