Opioid Safety, Position Statement, Respiratory Compromise

Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring PPAHS Position Statement on Continuous Monitoring

The following is a position statement published by PPAHS. If you would prefer to view our statement as a PDF, please click here.

Much of the public attention has been focused on the harm caused by prescription use and abuse of opioids. However, there is another facet that must be focused on: opioid-induced respiratory depression in clinical settings. This includes patients undergoing moderate and conscious sedation, or recovering from procedures and managing pain using a patient-controlled analgesia (PCA) pump, particularly those during the postoperative period. Read More

Must Reads, Patient Safety

5 Most Viewed Healthcare Posts in 2015

The 5 most viewed healthcare posts on the Physician-Patient Alliance for Health & Safety (PPAHS) blog were from previous years. Although we would like to think that these posts were just great articles – in fact, they had more views in 2015 than any other post, including those posted this year – sadly we think that it just shows that the patient safety issues discussed still remain.

The Google trends analysis of “opioids” (shown below) demonstrates, for example, an increase in interest from 2005 until now:

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Opioid Safety, Respiratory Compromise

Hypoxemia in the PACU: Most Episodes Occur After 30 Minutes from Admission

By Sean Power, Community Manager, Physician-Patient Alliance for Health & Safety

Is reliance on pulse oximetry to detect hypoxemia related to opioid-induced respiratory depression the best practice to identify patients at risk?

Toby N Weingarten, MD, Associate Professor of Anesthesiology, Mayo Clinic, Rochester, MN, raises this question by calling attention to an analysis by Epstein et. al.,[1] which found that, contrary to expectations, most episodes of hypoxemia—abnormally low concentrations of oxygen in the blood—take place after 30 minutes from admission to the postanesthesia care unit (PACU). He notes that the administration of opioids was greater in patients who experienced hypoxemia than those who did not.

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Opioid Safety, Respiratory Compromise

Failure to Effectively Monitor Postoperative Patients May Lead to Brain Injury or Death

ECRI Institute recently released its report, “Top Ten Technology Hazards for 2016”, which noted that failure to effectively monitor postoperative patients for opioid-induced respiratory depression can lead to brain injury or death.

This concern of ECRI is yet another call for improved safety measures for patient’s receiving opioids.

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Opioid Safety

Protecting Post-Operative Obese Patients

This post originally appeared on Advance for Nurses. As that publication winds down, we have archived it here.

Nurses should be vigilant against obstructive sleep apnea

By Maureen F. Cooney, DNP, FNP-BC and Denise Sullivan, MSN, ANP-BC
Posted on: April 29, 2015

One in three U.S. adults (34.9% or 78.6 million) are obese, and from a health perspective, the odds are stacked against them.  Along with being at a higher risk for heart disease, stroke and type 2 Diabetes, they are far more likely to suffer life-threatening respiratory compromise-particularly obstructed sleep apnea (OSA)-while receiving post-operative opioids.

Even more alarming:

  • OSA occurs in 40% of obese female and 50% of obese males
  • Incidences of OSA increase in proportion to patients’ levels of obesity
  • The prevalence of OSA in patients deemed as extremely or morbidly obese is more than 77%

SEE ALSO: Treatment of Obesity

Obesity, opioids and OSA are a “deadly trio” that can alter the airway tone of obese patients; lead to chronic hypoventilation with mild hypercarbia when patients are resting before surgery; and increase the risk for aspiration and acute airway obstruction after extubation.  In fact, airway obstruction and death have been reported in obese patients treated with only minimal doses of opioids.

Vigilance in All Phases of Treatment

  • Although obese patients are most at risk for OSA after surgery, their pain management plans should incorporate all phases of their treatment.  Keeping that perspective in mind, caregivers should:
  • Identify an anesthesiologist with special interest in anesthetic care and pain management to serve as interdepartmental liaison
  • Adopt “opioid sparing strategies” whenever possible
  • Avoid opioids in combination with sedatives
  • Continually monitor obese patients — no matter what dosage of opioids are used in their treatment

To help protect the safety of obese patients at every stage of treatment, we offer the following tips and recommendations.

 

PRE-OP RECOMMENDATIONS

  • Conduct an anesthesiology consult at least one day prior to surgery
  • Assess the patients for sleep apnea-polysomnography
  • Instruct the patient to quit smoking at least six weeks before surgery

INTEROPERATIVE TIPS

  • Use regional blocks as a sole anesthetic technique
  • Use intraoperative capnography for monitoring of respiration
  • Place patients in a non-supine posture during extubation and recovery
  • Resume use of positive airway pressure device

POST-OPERATIVE/MONITORING RECOMMENDATIONS

  • Use pulse oximetry for every patient with clinically significant obesity and/or if OSA was suspected during assessment
  • Set alarms for less than 90% saturation for 10 seconds
  • Treatment postop hypoxemia with early nasal intermittent positive pressure ventilation (NIPPV)
  • Don’t rely entirely on intermittent “spot checks” of oxygenation (pulse oximetry) and ventilation (nursing assessment) to recognize indications of drug-induced respiratory depression in the postoperative period
  • Continuously monitor oxygenation and  ventilation of all obese patients receiving opioids postoperatively should be used
  • Use capnography in patients requiring supplemental oxygen

Because they face an increased risk of suffering life-threatening OSA while receiving post-surgical opioids, obese patients should always be continuously monitored. Continuous electronic monitoring of obese patients is among the key ways that caregivers can protect obese patients from OSA-and steer clear of the potentially high costs of litigation and extended hospital stays that can result from OSA.

Maureen F. Cooney, DNP, FNP-BC, is a nurse practitioner in pain management at Westchester Medical Center, Valhalla, NY. Denise Sullivan, MSN, ANP-BC, is a nurse practitioner in pain management at Jacobi Medical Center, Bronx, NY.

Opioid Safety, Respiratory Compromise

Top 10 Opioid Safety Articles in 2014

Of the more than 125 articles we posted in 2014, below are 10 of the most read and most discussed articles on opioid safety (order is by publication date).

As you read through these articles, please ask yourself – has a new standard of care been established requiring continuous electronic monitoring by hospitals of all patients receiving opioids? Read More

Opioid Safety, Practices & Tips, Respiratory Compromise

“Keep It On” Campaign: 8 Tips for Ensuring Children are Monitored Safely

By Lynn Razzano RN, MSN, ONCC Clinical Nurse Consultant for PPAHS

The Physician-Patient Alliance for Health & Safety was recently contacted by a mother whose one-year-old baby boy tragically passed away. The boy suffered from leukemia, had a successful bone marrow transplant, and had received fentanyl and methadone. Although monitored with a pulse oximeter, his nurses had difficulty keeping the monitor on his finger (they had used tape), which caused the oximeter to false alarm frequently and the alarms to be turned down. Read More

Respiratory Compromise

What Does New CMS Guidance on Monitoring Post-Operative Patients Receiving Opioids Mean for Hospital Practice?

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

[This article first appeared in Patient Safety & Quality Healthcare. To read the full article, please click here.]

In its guidance, “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids,” CMS explains the reason behind the issue for this guidance:

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Opioid Safety, Respiratory Compromise

The Good and Bad News for Patients Receiving Opioids: Physician-Patient Alliance Presents Survey Results at International Anesthesia Research Society Annual Conference

At the International Anesthesia Research Society annual conference, which took place May 17-20, 2014, the Physician-Patient Alliance for Health & Safety presented results from the first national survey of patient-controlled analgesia (PCA) practice. The survey results showed good news and bad news for patients receiving opioids. Read More