The Obese Surgical Patient: A Need for a Strong Multimodal Analgesia Approach

Chris Pasero, MS, RN-BC


March 20, 2014

Considering Respiratory Depression in Pain Management

Another essential consideration in the care of patients with risk factors for respiratory depression is the assurance that the patient is admitted to a clinical unit that is capable of providing adequate monitoring. Continuous capnography (end- tidal carbon dioxide [ETCO2]) and pulse oximetry (O2 saturation) are recommended for patients with multiple high- risk factors for respiratory depression.[1,2] This is particularly important when iatrogenic risk factors, such as sedating general anesthesia and opioids, are introduced.

Risk is further elevated when adverse effects occur and are treated with sedating drugs.[1,2] This underscores the importance of initiating pain treatment with a multimodal approach that incorporates a strong nonopioid foundation, so that the lowest opioid dose possible is administered, and assessing risk frequently throughout hospitalization to ensure that appropriate monitoring is implemented.

Increased sedation precedes respiratory depression, which serves as the rationale for current recommendations for nurses to systematically assess sedation levels in patients receiving sedating medications, such as opioids.[1,2,6,20] Table 3 shows a sedation scale commonly used in patients during opioid pain management.

Table 3. Pasero Opioid Sedation Scale (POSS) With Interventions

Appropriate action is given in italics at each level of sedation.

S = Sleep, easy to arouse
Acceptable; no action necessary; may increase opioid dose if needed

1 = Awake and alert
Acceptable; no action necessary; may increase opioid dose if needed

2 = Slightly drowsy, easily aroused
Acceptable; no action necessary; may increase opioid dose if needed

3 = Frequently drowsy, arousable, drifts off to sleep during conversation
Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at < 3 and respiratory status is satisfactory; reduce opioid dose by 25%-50% a or notify primary b or anesthesia provider for orders; consider administering a nonsedating, opioid-sparing nonopioid, such as acetaminophen or a NSAID, if not contraindicated; ask patient to take deep breaths every 15-30 minutes.

4 = Somnolent, minimal or no response to verbal and physical stimulation
Unacceptable; stop opioid; consider administering naloxone c,d; stay with patient, stimulate, and support respiration as indicated by patient status; call rapid response team (code blue) if indicated; notify primary b or anesthesia provider; monitor respiratory status and sedation level closely until sedation level is stable at < 3 and respiratory status is satisfactory.

a Opioid analgesic orders or a hospital protocol should include the expectation that a nurse will reduce the opioid dose if a patient is excessively sedated.
b For example, the physician, nurse practitioner, advanced practice nurse, or physician assistant responsible for the pain management prescription.
c For adults experiencing respiratory depression, give 0.5 mL dilute naloxone (Narcan, 0.4 mg/10mL normal saline) IV very slowly over 2 min; repeat based on patient's response (titrate to effect). If sedation and respiratory depression occurs during administration of transdermal fentanyl, remove the patch; if naloxone is necessary, treatment will be needed for a prolonged period, and the typical approach involves a naloxone infusion (see text). Patient must be monitored closely for at least 24 hours after discontinuation of the transdermal fentanyl.
dHospital protocols should include the expectation that a nurse will administer naloxone to any patient suspected of having life-threatening opioid-induced sedation and respiratory depression.

Copyright 1994, Chris Pasero. As cited in Pasero C, McCaffery M, eds. Pain Assessment and Pharmacologic Management. St. Louis: Mosby/Elsevier; 2011:510. Used with permission.

The scale includes interventions that have been shown to facilitate nursing decision-making surrounding opioid administration.[21,22] For example, nurses can avert life-threatening respiratory depression by promptly reducing opioid doses when advancing unwanted sedation is detected (eg, a POSS score of 3). In such cases, sedation level and respiratory status must be closely monitored until the patient is more awake and alert (POSS score < 3).[2,20]

Finally, the development of a multimodal pain treatment plan that helps patients achieve their functional goals is critical. It is essential that the patient in this scenario is alert and comfortable enough to deep- breathe, get out of bed, and ambulate early and frequently. Pain control that allows her to progressively increase the distance she can ambulate will be a determining factor in reducing the incidence of postoperative complications.[23] Ultimately, her ability to achieve established functional recovery outcomes will have an impact on her length of hospital stay and associated cost of care.[24,25,26]


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