American Society for Pain Management Nursing: Evidence
Download
Report
Transcript American Society for Pain Management Nursing: Evidence
Joyce S. Willens, PhD, RN, BC
Villanova University
History of EBG
Existed in clinical practice for decades
Called Practice Guidelines
Practice Policies
Clinical Policies
Clinical Algorithms
Position Statements
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
Experience with EB Guidelines
Reviewed pain
literature
All neuraxial opioid
studies
AHCPR- 1992
Experience with EB Guidelines
Reviewed ALL
literature for these
guidelines
APS - 1994
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
Presented “State of the Art”
Cardiology conference
2000
Tel Aviv, Israel
Presentation given in Tel Aviv Israel in 1990
Clinical Practice Guidelines
Systematically developed statements to
assist practitioner and patient decisions
about appropriate health care for specific
clinical conditions (Institute of Medicine).
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
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
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
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
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.
Step 1
Panel members independently searched electronic
databases
Medline
PubMed
Cumulative Index to Nursing and Allied Health
Literature (CINAHL)
Cochrane Library
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
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
Cohen’s Kappa Statistic
Calculated percent agreement
0.72- 1.00
High degree of concordance among raters
Consensus on categories for
evidence
Individual Patient Risks
Iatrogenic Risks
Pharmacology
Monitoring
Literature Included
Meta-analysis
Systematic reviews
Randomized controlled trials (RCT)
Clinical Trials
Prospective observational studies
Retrospective reviews
Secondary analyses
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
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
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
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
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
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
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
Patient Risk Factors
Two categories
Sleep disordered breathing – B-1 evidence
Postoperative pulmonary complications
B-1 evidence
Sleep disordered Breathing
Factors that predispose a person to unintended opioid-
induced advancing sedation and respiratory
depression.
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
Postoperative Pulmonary
Complications
Postoperative complications
11,861 citations
Risks
180,339 citations
Combined using and- 521 citations
68 were deemed relevant
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
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
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
Anticonvulsants – Category A-1 Evidence for Sedation
Antidepressants- Category D- Insufficient Evidence
Clonidine- Category C-2 Evidence
Ketamine-Category C-2 Evidence
Dexmedetomidine- Category C-2 Evidence
Categories
Patient Monitoring Practices
Opioid –Induced Sedation
Sedation Scales
Opioid-induced Respiratory Depression
Technology Supported Monitoring
Use of pulse oximetry
Use of capnography
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
Finished Document
Sent out for external review by 10 experts
Pain Management Nurses
Pharm D
Anesthesiologists
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
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
Monitoring for Opioid Induced
Sedation and Respiratory
Depression- 2nd 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
Monitoring for Opioid Induced Sedation and Respiratory
Depression- 2nd 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%
Pulse Oximetry Monitoring
28% of institutions represented in this survey use
continuous pulse oximetry
2% reported they did not know their institution’s
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%
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
Pasero Opioid-Induced Sedation
Scale with Interventions
S= Sleep; easy to arouse
action necessary
No
1. Awake and alert
No 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
Respiratory Assessment
More than measuring rate for 30 -60 seconds
Depth and regularity of respirations
Notice trends
Listen to sound of patient’s respiration
Snoring indicates airway obstruction
Decrease dose 25%- 50%
Consider continuous ETCO2 monitoring
Clinical Signs of OSA
Frequent, loud snoring
Neck circumference > 17” man- 16” woman
BMI of 35 kg/m2 or more
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
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
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
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
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
Did not have ETCO2 monitoring on the floor
NEVER did an arterial blood gas analysis
Settled out of court