Elsevier

Pain Management Nursing

Volume 12, Issue 3, September 2011, Pages 118-145.e10
Pain Management Nursing

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

https://doi.org/10.1016/j.pmn.2011.06.008Get rights and content

Abstract

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.

Section snippets

Background

Effective pain management is a priority of care and a patient right (Joint Commission, 2010). Advances in pain science justify the need for more aggressive pain therapies to reduce pain severity and the likelihood for both short- and long-term consequences of unrelieved pain (Basbaum, Bautista, Scherrer, & Julius, 2009; Carr & Goudas, 1999; Latremoliere and Woolf, 2009, Woolf and Salter, 2000). Multimodal analgesia, which combines analgesics with variable pharmacodynamics to target multiple

Methodology

For this review, the definition of “monitoring” is the practice of using nurse observations of sedation and respiration including but not limited to the use of sedation assessment scales and technologies to collect serial measurements to anticipate and recognize unintended advancing sedation or respiratory depression. There was early agreement among panel members that the search and appraisal of scientific literature and formulation of recommendations should focus primarily on adult

Statement of Conditions

This report is aligned with ASPMN’s mission and goals to promote optimal nursing care for people affected by pain through best nursing practices, education, standards, advocacy, and research. (http://aspmn.org/) The ASPMN Expert Consensus Panel on Monitoring for Opioid-Induced Sedation and Respiratory Depression recommendations serve as a guide for developing and implementing safe and effective plans of care, facilitating systems-level changes to support safe and effective patient care, and

Definition

Individual risks are defined as factors that predispose a person to unintended opioid-induced advancing sedation and respiratory depression. These factors include but are not limited to age, anatomic anomalies, physical characteristics, primary and comorbid medical conditions, psychologic states, and functional status. Identification of patients at risk for adverse events when opioid analgesics are administered for pain management is a critical consideration when developing plans of care to

Definition

Iatrogenic risks are defined as pain therapy–related variables, environmental factors, and circumstances in the hospital workplace that may predispose a patient to increased risk for unintended advancing sedation or respiratory depression. Methods of opioid administration and nurse practice variables, such as staffing and communication, are of greatest concern.

Search Strategies

Three separate searches of Medline and PubMed databases were performed to identify relevant publications in the past 20 years. Searches

Definition

For the present review, pharmacology is defined as pharmacologic agents that are administered for the treatment of pain in the acute care setting.

Search Strategies

Medline and the Cochrane Collaboration databases were searched for relevant publications of research with limits for age (>19 years), English language, and human studies from 1990 to year end 2009. MeSH terms used included: opioid, opioid analgesics, morphine, hydromorphone, fentanyl, oxycodone, respiratory depression, sedation, opioid-induced

Definition

The ASPMN’s definition of “monitoring” is the practice of using nurse observations including, but not limited to, the use of sedation assessment scales and technologies to collect serial measurements to anticipate and recognize advancing sedation or respiratory depression.

Search Strategies

A substantial review of the literature was conducted in PubMed and CINAHL to identify relevant research and clinical articles defining the practice of monitoring for patients receiving opioid analgesics for pain management.

Summary

To coincide with the mission of the ASPMN “to advance and promote optimal nursing care for people affected by pain by promoting best nursing practice,” clinical practice guidelines have been developed for monitoring patients at risk of advancing sedation and respiratory depression with opioid analgesia. This report has been executed with methodologies that include scientific rigor in the appraisal and summary of evidence and consensus building in the formulation of recommendations that focus on

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