1. Legal Implications of Unwanted Sedation in the PACU: Mitigating Risks and Improving Patient Safety Myrna Mamaril, MS, RN, NEA-BC, CPAN, CAPA, FAAN

2. Conflict of Interest: I have nothing to disclose

3. National Opioid Crisis
2015 there were 33,091 deaths in the United States (US) due to opioids (CDC, 2016)
2016 more than 64,000 overdose deaths with 175 deaths/day (Kramer, 2019)
In addition, the economic burden of opioid epidemic reached 95 billion dollars in 2016 with $21.4 billion spent on treating substance use patients (Castellucci, 2017)
This national toll has renewed scrutiny in the media and in the halls of government, as citizens everywhere are demanding a public response that will bring the crisis under control

4. Objectives Discuss the different levels of unwanted sedation
Describe three variable that influence unwanted sedation from opioids
Analyze when the PACU nurse determines it is safe to discharge patients to home or transport patients to an inpatient unit when they have been administered opioids during their recovery.

5. Case Study
PACU RN admitted 52 yr old knee scope in the Same Day PACU and immediately gave Dilaudid 2 mg IV…. No Doctor’s Order
20 minutes later discharged to car with wife.
Wife stops at CVS to get prescription filled
When she went back to car, she discovered her husband slumped over, Unarousable, and making weird gurgling sounds
Screams and runs into CVS to have them call for help

6. EP Lab Nurses Arrives with Patient Unannounced in PACU
41 yr old female successful ablation with 2 cc of Fentanyl and 10 mg of Versed
Not monitored, no oxygen delivery unresponsive, grayish color
No orders (no medical direction for care)
Admission oxygen saturation 84%;
Report from transport RNs – we need go – this patient really needs the PACU can’t stay other patients to do EP studies.

7. Case Study
66 year old male who had an L3, L4- S1 fusion in PACU 90 minutes; 100 mcg Fentanyl, 2 mg Dilaudid – last dose given at 10 minutes ago in PACU
Report called to inpatient unit; bed not ready;
10 minutes later patient having back spasms and medicated with 25 mg Valium IV (per floor order); notified bed ready
Transported to inpatient unit

8. Unwanted Sedation
Postanesthesia care nurses should always be vigilant in assessing the potential for postoperative opioid- induced respiratory depression.
1. Inadequate gas exchange
2. Demand for oxygen exceeds supply
3. failure of lungs to remove carbon dioxide

9. Additive Effect of Opioids
What do we know about specific opioids?
Morphine – End metabolites
Meperidine (Demerol)?
Fentanyl – times more potent than morphine
Hydromorphone (Dilaudid) 5-7 times more potent than morphine

10. Morphine Sulfate Onset: <1 minute Peak: 20 minutes
Titrated to effect
Alteration in pain perception and emotional response
Myocardial function is preserved
Causes histamine release
Slight hypotension
Onset: <1 minute
Peak: 20 minutes
Duration: 1 to 4 hours
Dose: 1 to 10 mg titrated
Watch for hypersensitivity

11. Fentanyl Citrate (Sublimaze)
Short duration of action
Stored in fat and muscle tissue
When released from tissue may have delayed respiratory depression
Onset: 1 to 3 minutes
Duration: 30 to 60 minutes
Dose: adult: to 2g/kg titrated
Watch for apnea and chest wall rigidity

12. Hydromorphone (Dilaudid)
Onset: minutes
Duration: hours
More potent than morphine: 7 to 1
Morphine 10 = hydromorphone 1.5
Not for ICP or  respiratory function
Good for pain and sedation
Alters perception and emotional response to pain
Short half-life
No metabolites
Good in renal insufficiency

13. Propofol (Diprivan) Non-barbiturate, hypnotic
Midazolam acts synergistically: may reduce propofol by 50%
Emergence is rapid
Duration of single dose is 3 to 8 minutes (dose- dependent)
Decreases cerebral perfusion, cerebral blood flow and ICP
IV Push or Continuous IV drip

14. Propofol (Diprivan) Rapid and emergence No analgesia
Onset: 15 – 45 seconds
Duration: 5 – 10 minutes
No analgesia
No cumulative effects
Less N & V
Dose dependent respiratory (rate, depth) & circulatory (BP, CO, SVR) depression
Incidence of apnea greater than thiopental

15. Midazolam (Versed) Hypnotic, anticonvulsant, muscle relaxant
3X as potent as diazepam
Rapid onset, peak in 10 to 30 minutes, duration 1 to 4 hrs
Decrease in BP, SVR
Increase in HR
Used premed, endo, induction, intraop as adjunct to inhalation
Sedation with regional
Reduction in anxiety and profound amnesia
Use with caution in MI, COPD
No effect on ICP
Decrease dose in elderly

16. ASPAN Standards
Sedation can occur at any time during opioid administration, however it can be more pronounced at the beginning and with subsequent increases in opioid dosing (p80)
Level of opioid-induced sedation varies among patients, and influenced by doses, route of administration, patient’s age, opioid tolerance, current medical condition and comorbidities (p80)
ASPAN, (2019) Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements, Cherry Hill, NJ: ASPAN.

17. ASPAN Standards
“It takes less opioid to produce sedation than to produce respiratory depression, which explains why increased sedation is commonly seen before the development of life- threatening respiratory depression.” (p80)
The opioids that are mainly used in the postanesthesia care unit (PACU) are morphine, hydromorphone (Dilaudid) and fentanyl
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN.

18. 2019-2020 ASPAN Standards Background
In 2001, the Joint Commission established assessment standards for pain management.
There was a clinical emphasis for nurses to be the aggressive in managing pain and as a 5th vital sign.
Today, there is a new knowledge of the consequences of opioid use in the postanesthesia patient and the prevention of unwanted sedation.
TJC is moving from pain scales to functional outcome. TJC published a 2016 article to dispute the 5th VS as belonging to them.
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN.

19. 2001 The Joint Commission Established Standard
Pain Management is a patient right
Aggressive pain treatment suing opioids for post operative pain
However over this past 10 years opioid only interventions have contributed to increased adverse events (excessive sedation and life- threatening respiratory depression
Opioid adverse effects: dose-related
Emphasis today is on multimodal analgesia
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN.

20. Purpose of PR11
Promote identification of patients at high risk for opioid-induced sedation and respiratory depression before administration of opioid analgesics
Enhance the assessment of sedation during opioid administration as a means of preventing life-threatening respiratory depression
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN.

21. Let’s examine the risk factors of unwanted sedation

22. Recommendations for Assessing and Screening Patients
Individual Patient Risk Factors
Pre-existing pulmonary disease
Known or suspected sleep-disordered breathing
Anatomic or airway abnormalities
Comorbidities
ASA status greater than 2
Obese or morbidly obese

23. Individual Patient Risk Factors
Aged older than 55 years of age
Preexisting pulmonary disease
Chronic obstructive pulmonary disease (COPD)
Known or suspected sleep-disordered breathing
Obstructive sleep apnea; predictors for OSA
Central sleep apnea (medical conditions affect lung and heart; Medications depress CNS; >65 yrs of age

24. Individual Patient Risk Factors
Anatomic airway abnormalities
Congenital
Difficult Airway
Comorbidities
Systemic disease
Renal or hepatic impairment
Preexisting cardiopulmonary disease
Dysrhythmias
Diabetes mellitus
Coronary artery disease
Hypertension

25. Individual Patient Risk Factors
ASA Status greater than ASA II
Definition of ASA Physical Classification
Obese or morbidly obese

26. Type of Anesthesia
General anesthesia increases risk for postoperative pulmonary complications
Sedation?
Regional?

27. Type of Surgical Procedure
Independent risk factor for postoperative respiratory failure
This is identified by signs and symptoms that include shallow breathing, rapid shallow respirations, hypoventilation, hypercapnia, and decreased breath sounds

28. Surgical Procedures Aortic aneurysm repair (11 x higher risk)
Thoracic surgery (5.9 x higher risk)
Vascular surgery (3.4 x higher risk)
Upper abdomen (3.3 x higher risk)
Neurosurgery (2.9 x higher risk)
Neck surgery ( 2.1 x higher risk)
Bariatric surgery
Length (time) of surgery
Emergency surgery
Length (size) of incision

29. Iatrogenic Risks Neuraxial therapy Parenteral opioid administration
Patient controlled analgesia – opioids
PCA with basal rate (continuous infusion)
Older patient using PCA
Type of surgery with PCA use
Unauthorized use of PCA (e.g. “proxy”
Rapid dose escalation with opioids
Co-administration of medications with opioids (e.g. benzodiazepines, antihistamines)

30. Other Predictors Timing as a predictor First 24 hours after surgery
Between 11pm and 7 am
Quiet, less stimulating patient environments
Poor handoff communication
Staffing factors that increase risk
Practice environment
Lack of pain team or pain service oversight

31. Assess for Unwanted Sedation
Patient assessment data should be used to determine location of patient Phase I or Phase II level of care; staffing levels; consistent, systematic interpretation of patient trends in sedation and respiratory status during opioid administration
Implementation of sedation assessment scales promotes safety during opioid administration

32. Sedation Scales Pasero Opioid-Induced Sedation Scale (POSS)
Richmond Agitation and Sedation Scale (RASS)
Inova Sedation Scale
Moline-Roberts Pharmacologic Scale
Aldrete Scoring System
Ramsay/Modified Ramsay
Sedation Agitation Scale

33. Determine Appropriate Patient Monitoring during Opioid Administration
Hospital policies and procedures
Use valid and reliable sedation scale to assess unwanted sedation
Determine frequency, nature, duration, and intensity of monitoring based on individual and iatrogenic risks and response to opioid therapy
Assess sedation during wakefulness and sleep

34. More Vigilant Monitoring When at Risk for Adverse Events
Peak of medication effect
During first 24 hours after surgery
After increase in dose of opioid
Coinciding with aggressive titration of opioids
Recent or rapid change in end-organ function
When switching from one opioid to another or one route of administration to another
Within first 6 hours after anesthesia
During the hours of 11pm to 7 am

35. Determine Technology-Supported Monitoring
Based on individual and iatrogenic risk factors
Measure end-tidal carbon dioxide (ETCO2 and capnography) can be useful indicator for respiratory depression in high risk patients
Hospital policies should define patient selection criteria for monitoring
Patients with signs and symptoms of respiratory
Depression, poor respiratory effort, snoring, desaturation –be aroused immediately take deep breaths!

36. Develop Hospital Policies/Procedures related to Opioid Administration
Define nursing assessment, documentation and communication of opioid-induced sedation and respiratory depression
Ensure provision of appropriate resources to facilitate risk assessment for opioid-induced sedation and respiratory depression
Clarify hospital position on hospital use of home equipment

37. Develop Hospital Policies/Procedures related to Opioid Administration
Define concurrent administration of opioids and adjunct agents (e.g. ketamine, clonidine and dexmedetomidine), guidelines for patient monitoring for unwanted sedation and safe medication administration
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN

38. Develop Prevention of Unwanted Sedation Educational Programs
Content should include: opioid-induced unintended advancing sedation and respiratory depression; opioid-sparing, multimodal principles
Identification of individual and iatrogenic factors for patient receiving opioids
Evidenced-based assessment criteria and tools for assessing risks
Pharmacologic factors that contribute to unwanted sedation and respiratory depression
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN

39. Perform Individualized Discharge Assessment of Postop Inpatient
Do not transfer patients between levels of care near the peak effect of the opioid administration
Handoff communication
Communicate all pertinent patient individual and iatrogenic risk factors across all transitions of care from prehospital to discharge
Inform the receiving nurse of the patient’s tolerance of opioid administration by reporting assessment findings
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN.

40. Case Study
PACU RN admitted 52 yr old knee scope in the Same Day PACU and immediately gave Dilaudid 2 mg IV…. No Doctor’s Order
20 minutes later discharged to car with wife.
Wife stops at CVS to get prescription filled
When she went back to car, she discovered her husband slumped over, Unarousable, and making weird gurgling sounds
Screams and runs into CVS to have them call for help

41. EP Lab Nurses Arrives with Patient Unannounced in PACU
41 yr old female successful ablation with 2 cc of Fentanyl and 10 mg of Versed
Not monitored, no oxygen delivery unresponsive, grayish color
No orders (no medical direction for care)
Admission oxygen saturation 84%;
Report from transport RNs – we need go – this patient really needs the PACU can’t stay other patients to do EP studies.

42. Case Study
66 year old male who had an L3, L4- S1 fusion in PACU 90 minutes; 100 mcg Fentanyl, 2 mg Dilaudid – last dose given at 10 minutes ago in PACU
Report called to inpatient unit; bed not ready;
10 minutes later patient having back spasms and medicated with 25 mg Valium IV (per floor order); notified bed ready
Transported to inpatient unit

43. Case Study
PACU RN is called in at 0300 for a 28 y/o obese male who had emergency lap cholecystectomy and arrives in the PACU moaning and states his pain is so bad he thinks he is dying.
Anesthesia provider reports that the patient had Fentanyl 350 mcg during the case and comments the patient has a low tolerance for pain
PACU RN medicates: Fentanyl 25 mcg IV q 5 min x 4
concurrently with Dilaudid 0.2 mg IV q 5 min x 5
PACU RN calls report to inpatient receiving
Transfers the patient to inpatient bed at 0345

44. Case Study 69 year old male undergoing a total knee reconstruction
Farmer from rural Ohio
Admitted to PACU is severe pain at 0945; screaming; Acute pain service notified after 200 mcg Fentanyl and pain score 10/10
Pain Med changed to Morphine 10 mg IV stat; PCA 6 mg q 5 minutes with additional Morphine 5 mg for breakthrough pain
Discharged criteria met at 1330 with a total of 57 mg Morphine; Patient alert pain 8/10;

45. Unwanted Sedation
Postanesthesia care nurses should always be vigilant in assessing the potential for postoperative opioid-induced respiratory depression.
1. Inadequate gas exchange
2. Demand for oxygen exceeds supply
3. failure of lungs to remove carbon dioxide
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN

46. Additive Effect of Opioids
Morphine – End metabolites
Fentanyl – times more potent than morphine
Hydromophone (Dilaudid) 5-7 times more potent than morphine
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN

47. PACU nurse’s duty to advocate for safe transfer or safe discharge.
Practice Recommendation 6: Safe Transfer of Care: Handoff and Transportation The perianesthesia nurse is responsible for the safe transition of care of patients between care providers. The perianesthesia nurse uses the appropriate process for communication handoff. The perianesthesia nurse will also determine the mode of transportation to ensure safe transfer of care.

48. Handoff of Safe Care Inform the receiving nurse of:
1. The patient history of opioid use, such as naivety or tolerance (Junquist & Card, 2017)
2. Total amounts and time of opioids given
3  The need for rescue medications
4. Patients tolerance of opioid administration

49. Perform Individualized Discharge Assessment of Postop Inpatient
Do not transfer patients between levels of care near the peak effect of the opioid administration
Handoff communication
Communicate all pertinent patient individual and iatrogenic risk factors across all transitions of care from prehospital to discharge
Inform the receiving nurse of the patient’s tolerance of opioid administration by reporting assessment findings
ASPAN, (2019) Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive Statements,
Cherry Hill, NJ: ASPAN.

50. ASPAN Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements