Saturday, March 25, 2017

By: AMFS Nursing Expert

Nurses need to know the difference, as it can be life or death. Did the patient aspirate because they are over sedated and the nurse doesn’t properly evaluate a patient who is on Dilauded? Arguments have be made that there is no sedation scale for nurses on a medical unit because Dilauded is not a sedative.  Dilauded has sedative properties and has been attributed to many errors.  Sedation scales are typically used in PACU and procedural areas where patients are receiving conscious sedation.  However, if a patient is administered Dilauded on a medical unit, nurses are not exempt from monitoring its side effects.  Factors that raise patients’ risk of harm from opioid-induced respiratory depression include age (i.e., 65 years of age or older), diseases affecting the respiratory (e.g., asthma, chronic obstructive pulmonary disease) or cardiovascular systems, concomitant use of respiratory-function depressants other than opioids, opioid-naïve patients who are overweight, and patients with sleep disorders (e.g., sleep apnea).

Best practice when reviewing a chart would be to look for documentation that nurses have assessed the patient after every intervention of administration of Dilauded; arousability, vital signs, possibly pulse oximetry.  Medical units only require routine once a shift vital signs. However, that is not generally applicable for interventions.  Joint Commission, common sense prevails, after each intervention a nurse is required to re-assess their patient.  Nursing practice for re-assessment is based on what the intervention is.

The lack of knowledge about HYDROmorphone potency and the difference in potency between morphine and HYDROmorphone has led to serious medication errors.  In the case of Dilaudid, an apparent lack of understanding by some physicians and nurses of what represents a safe dose have complicated overdosing.  For example, Dilaudid 1–4 mg IV is a common order, but it is actually equivalent to 8–32 mg of morphine.[1] In 2003 Lexi-Comp revised dosing recommendations based on advice from clinical experts.  For opiate-naïve patients, the intravenous dose was reduced from 1–2 mg q 2–4 hours to 0.2–0.6 mg q 2–3 hours.[2] It is important for health care providers to be familiar with current dosing guidelines.  Routine monitoring of vital signs by nursing staff may fail to recognize early signs of respiratory depression.  Bradypnea is a poor predictor of desaturation and may be a late or absent finding,[3] and pulse oximetry may not be an accurate monitoring tool for patients.  When pain is ameliorated and the patient falls asleep, he or she may slip unnoticed into respiratory depression and apnea.  Nurses must be cautious when a patient is eating and experiences vomiting, while sedated.  This is a risk for aspiration and is why NPO before surgery is indicated.  Opiates have sedative properties.

The terms opioid naive and opioid tolerant are now clinically accepted and widely used, especially in the area of pain management.  The NCCN uses the US Food and Drug Administration (FDA) definitions for these characteristics.  Nurses in all areas need to address this in the nursing admission assessment.  Just because a patient had Dilauded or morphine 6 months ago, one time for surgery does not make them opiate tolerant.

Opioid tolerant: patients who are taking for 1 week or longer at least:

  • 60 mg oral morphine/day;
  • 25 µg transdermal fentanyl/hour;
  • 30 mg oral oxycodone/day;
  • 8 mg oral hydromorphone/day;
  • 25 mg oral oxymorphone/day; or
  • An equianalgesic dose of any other opioid.

Opioid naive: patients who do not meet the above definition of opioid tolerant, and who have not taken opioid doses at least as much as those listed above for 1 week or longer. The NCCN v.2010 pain management algorithms also supply simpler definitions for these terms:

  • Opioid naive: patients who are not chronically receiving opioid analgesics on a daily basis; and
  • Opioid tolerant: patients who are chronically receiving opioid analgesics on a daily basis. 

CASE STUDY SCENARIO

A physician orders 2mg Dilauded IVP Q 2-3 hour’s prn for pain, not IM, not in a PCA, but through an existing IV and Zofran Q6 hours for nausea.  General diet, routine labs and a diagnostic work up from the ED was normal.  What’s wrong with this order?  Has there been an assessment of the patient’s opiate tolerance? If not, then “BEWARE”, as the patient can aspirate from respiratory depression when vomiting, or can simply die from over sedation.

Nurse A on a medical unit has 2 years of experience and has given Dilaudid previously. There is an automated medication dispensing system that houses Dilauded 1mg, 2mg, and 4mg in pre-filled syringes.  Mrs. Ward is a female patient, 46 years old, 5’6” and 180lbs.  She was admitted for severe low back pain.  Her past medical history includes hypertension and a TAH (total abdominal hysterectomy) 2 years ago, otherwise no health problems noted.  Her nursing admission history assessment revealed no previous or current illicit drug or alcohol history.  Her current medications were listed as vivelle dot, lisonpril and multi-vitamins.  At the time of her TAH she received Dilauded through a PCA pump, tolerated this well and was discharged home after an uneventful hospitalization.  She denies any current narcotic/opiate use.

Nurse A is working a 7pm-7am shift and has 8 medical patients on a 32-bed unit. Mrs. Ward was admitted at 18:45 for new onset headache.  There is one CNA assigned for the unit.  Routine vital signs are ordered and taken at beginning of each shift.

19:00 initial vital signs revealed blood pressure 140/84, pulse rate 72, respirations of 18 and a pain score of 10 with nausea and vomiting.  Mrs. Ward received 2mg IV Dilauded at 20:00 and zofran for nausea.  Nurse A documents pain remains a 10 after 15-30 minutes and a response documented as “poor”.  No other vital signs documented, no other interventions noted. Mrs. Ward is awake, alert and orientated and is eating.

23:00 Mrs. Ward has episodes of emesis and pain 10/10 and receives additional 2 mg Dilauded IVP.  Repeat pain assessment is documented as “good”, no time noted, no score, no vital signs.

02:00 Mrs. Ward complains of increased back pain 10/10 and is given 2mg IVP Dilauded. Response is documented as “good” as evidenced as “sleeping”.  No time noted, no vital signs noted.  In fact, the only set of vital signs is at 23:00, the start of the night shift.

05:00 CNA was passing water and Nurse A documents (post expiration) at 07:42 for a 05:00 note “patient sleeping as evidenced by snoring”.

07:00 patient found unresponsive, cold, mottled and triple zero.  A code is called and unsuccessful resuscitation attempted.  Patient pronounced at 07:15. Did the patient aspirate or overdose?

Let’s start with the orders.  The Joint Commissions medication management standards as it speaks to “PRN” orders.  Medication management Standard MM.04.01.01 for medication orders state they need to be clear and accurate[4].  Nurses are accountable for safe practice and following the hospitals policy and using critical thinking skills when taking orders that are out of the recommended parameters.  They must know starting dosages for “opiate naïve” patients.  Is the patient “opiate naïve” by definition?  If not certain, ask the patient, look at the history.  Is 2mg an appropriate dose to start with in an opiate naive patient?  Nurses should look it up in the hospital’s formulary, current nursing drug books, or call the pharmacy.  Pharmacy and nursing must work hand in hand, should not accept opiate orders without knowing if the patient is “opiate naïve or tolerant” before dispensing.  These “stop gaps” help to prevent medication errors that result in bad outcomes.

Quality pain management begins with an affirmation by clinicians that patients should have access to the best pain relief that can safely be provided (APS, 2004)[5]. The most effective treatment for all pain is a multimodal and balanced approach that combines both pharmacologic and non-pharmacologic strategies. The orders for pain management should generally include other treatment modalities.  Nurses may suggest to the physician to add ibuprofen, and even consult with the pain management service in the hospital if there is one. Additionally, it is essential that most analgesics be started at a low dose and gradually titrated to pain relief with close monitoring of side effects.  This approach is particularly true when opioid analgesics are used for acute pain.  The recommended starting dosage of Dilauded in opiate naïve patients is .2-.6 mg IVP [6].   

Monitoring a patient’s response and any adverse effects is critical for obtaining a safe outcome. Equally important is accurate documentation of these events.  Documenting after a shift ends will always come into question if there is a bad outcome.  PACU units have a standardized sedation scale used to determine depth of sedation, arousability, and determination of intervention[7] if needed.  Medical surgical units can and should be using a similar scale for all patients receiving opiates.  This patient was also obese; the nurse documented after her shift her 05:00 assessment that revealed the patient was snoring; this can be an ominous sign.  Nurses should note arousability.  Peeking in the room is not an acceptable standard of care for assessment-re-assessment.  The nurse must make an assessment and not from the hallway. Patients do need to sleep, but also must be checked if they are easily arousable and often.

What happened to blood pressure? Dilauded causes hypotension.  There were no documented vital signs in the medical records since 23:00.  What about skin color, temperature, and depth of respirations?  Documenting a response to pain medication when using opiates needs to be complete and not in a one-word sentence (i.e. “good”).

Times are not optional in documentation.  The medical records tell the story.  It is the book for each health care provider to work from.  In fact, the Academy of Medical-Surgical Nurses 2008 Position Statement on Medication Errors quote, “Only the nurse is responsible for the final review process before the medication is administered.”[8]

Pasero - McCaffery Opioid-induced Sedation Scale

S = Sleep, easy to arouse
Acceptable: No action necessary; supplemental opioid may be given if needed.

1 = Awake and alert
Acceptable: No action necessary; supplemental opioid may be given if needed.

2 = Slightly drowsy, easily aroused
Acceptable: No action necessary; supplemental opioid may be given if needed.

3 = Frequently drowsy, arousable, drifts off to sleep during conversation

Unacceptable: Decrease opioid dose by 25–50 percent. Administer acetaminophen or an NSAID, if not contraindicated, to control pain; monitor sedation and respiratory status closely until sedation level is less than 3.

4 = Somnolent, minimal or no response to physical stimulation

Unacceptable: Stop opioid. Notify anesthesia provider; very slowly administer dilute IV naloxone (0.4 mg naloxone in 10 mL saline; 0.5 mL over 2-minute period); administer acetaminophen or an NSAID, if not contraindicated, to control pain; monitor sedation and respiratory status closely until sedation level is less than 3. 

REFERENCES 

  1. Institute for Safe Medication Practices, Medication Safety Alert.          www.ismp.org/Newsletters/acutecare/archives/July02.asp#july24. July 24, 2002.
  2. Institute for Safe Medication Practices, Medication Safety Alert.
  3. www.ismp.org/Newsletters/acutecare/archives/Oct02.asp#Oct30. October 30, 2002
  4. Overdyk FJ, Carter R, Maddox RR, Callura J, Herrin AE, Henriquez C. Continuous 
  5. FDA
  6. Joint Commission Medication Standard Manual. 2012. Standard MM.04.01.01
  7. APS American Pain Society. 2004
  8.  http://www.drugs.com/mtm/hydromorphone.html Drugs.com
  9. American Academy medical Surgical Nurses.
  10. Source: Pasero C. Acute pain service: policy and procedure guideline manual. Los Angeles, CA: Academy Medical Systems, 1994; Pasero C, Portenoy RK, McCaffery M. Opioid analgesics, In: McCaffery M, Pasero C. Pain: clinical manual. 2nd ed. St. Louis, MO: Mosby; 1999. p. 161-29