Opioid Safety: Sleep Apnea & Failure to Rescue Preventing Patient Harm with Continuous Respiratory Monitoring K. P. Rothfield, MD Chairman, Department of Anesthesiology

Disclosures  None

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Objectives  Review the mechanism, history & role of opioids in pain management  Discuss “pain as the fifth vital sign”  Focus on what makes Dilaudid different  Review best practices in opioid safety

Objectives  Define Failure to Rescue and Oversedation and Respiratory Depression (OSRD)  Discuss how OSRD places patients at risk  Examine the opportunities for both anesthesia providers to improve patient safety  Discuss the role of risk assessment & technology in decreasing ADEs

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What is OSRD?  Opioids and sedatives depress brain centers which control level of consciousness and respiratory drive  In vulnerable patients, this may lead to unconsciousness, respiratory arrest, and cardiac arrest  Adverse outcomes due to OSRD are on the rise nationally

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What Medications Cause OSRD? Groups of medications that have additive or potentiating effects:   Opioids: Morphine, Fentanyl, Dilaudid, Hydrocodone, Vicodin, Oxycodone   Antiemetics: Phenergan   Anxiolytics: Ativan   Antipruritics: Benadryl   Antitussives: some of these contain codeine (Robitussin AC/Robitussin DAC) or hydrocodone (Hycodan) 6

Opioids and Sedatives: Adverse Effects

 Depress medullary respiratory drive center  Decrease level of consciousness  Morbidity and mortality

What is Failure to Rescue? Definition: “ When caregivers fail to notice or respond when a patient is dying of preventable complications in a hospital”

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Morphine  A natural product of the poppy seed  Commercially available in 1827 from Merck  Hypodermic needle invented in 1857 during the American Civil War  Named for Morpheus, the Greek god of dreams

Morphine in World War II

Pain: The Fifth Vital Sign  2001 Joint Commission Standards  Patients’ right to appropriate assessment and management of pain  Screening and reassessment for pain  Educate patients & families about pain management

Unintended Consequences  Preoccupation with recorded pain scores in patient charts  Providers worrying about potential litigation if patient pain is not eliminated  Overzealous use of opioids

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Opioid Adverse Effects

 Depress medullary respiratory drive center  Decrease level of consciousness  Morbidity and mortality is rising  Dilaudid presents special risks

Dilaudid (Hydromorphone) is Different

 7-8 times more potent than Morphine  Similar side effect profile, despite rumors of superiority  More deadly because of its potency, and lack of universal appreciation of safe dosing guidelines  Available in Herculean concentrations  General lack of awareness of relative potency

Interventions: Dosing Education  1 mg of Dilaudid is equivalent to 7 mg   Age > 65 years and opioid naïve:

0.2 mg - 0.3 mg IV every 4 or 6 hrs  Age < 65 years and opioid naïve: 0.5 mg – 1 mg IV every 4 or 6 hrs  Discourage 1mg starting dose

CPOE  Force prescribers to consider dosing  Overrides remain an issue

Human Factors  High alert medication-use double check  Remove concentrations greater than 1mg/cc from patient care areas  Tall man lettering: HYDROmorphone  Use standard form/CPOE for PCA orders   Discourage continuous infusion via PCA   Use double checks and 200% accountability for pump changes and refills

Not For Procedural Sedation

 Dilaudid is an inappropriate agent for procedural sedation  Long half life increases risk of late onset respiratory depression

Reversal Agents  Regular pharmacy review of Naloxone ordering may provides insights into problems with Dilaudid and other opioids  The routine use of reversal agents to expedite care is not acceptable

Vulnerable Patients

 Obesity  Respiratory disease  Advanced age  Concomitant use of other opioids & sedatives  Obstructive sleep apnea  Postoperative patients 24

Identifying Patients at Risk

 STOP-BANG Questionnaire  Score of 3 or higher is a sensitive predictor of sleep apnea  Low specificity

STOP-BANG  Snoring  Tired during daytime  Observed to Obstruct  Pressure (hypertension)  BMI  Age over 50  Neck size  Gender (male)

Suspected Sleep Apnea: The STOP-BANG QUESTIONAIRRE   S (Snore) – Have you been told that you snore?   T (Tired) – Are you often tired during the day?   O (Obstructive) – Have you been told that you stop breathing during the night?   P (Pressure) – Do you have high blood pressure?   B (BMI) – Is the patient’s BMI (body mass index) greater than 35?   A (Age) – Is patient 50 years old or greater?   N (Neck) – Is patient’s neck circumference greater than17 inches for males or greater than 16 inches for females?   G (Gender) – Is patient male?

If yes to 3 or more means high likelihood of sleep apnea 27

Patterns of Respiratory Depression:

Lessons from Monitoring Technology

Progressive Hypoventilation  CO2 Narcosis  Progressive rise in CO2 and fall in O2 saturation  Occurs over minutes to hours  Often due to overdosing of narcotics or sedatives

Repetitive Airflow Reductions Followed by Apnea  “Arousal dependent survival” that occurs only during sleep.   Arousal failure secondary to medications  Apnea results in precipitous hypoxemia causing terminal arousal arrest.

ASA Sleep Apnea Guidelines  Centrally monitored pulse oximetry recommended  Not all patients with OSA  are admitted postop  Creates confusion and risk exposure

Why Are Postoperative Patients Vulnerable?  Mandatory supine position  Exposure to opioids, benzodiazepines and other anesthetic agents  Fatigue  Circadian rhythms

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Reducing the Risk of OSRD

 Identify vulnerable patients  Use respiratory monitoring

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Anesthesia Patient Safety Foundation 2011  “Continual electronic monitoring should be used on inpatients receiving postoperative opioids”  “Risk stratification was shown to be insufficient to eradicate postoperative opioid-induced respiratory depression”

Pulse Oximetry  Noninvasive  Inexpensive  Must be continuous and centrally monitored to be effective

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Masimo Patient SafetyNet  Reads through motion  Less alarm fatigue  Effective with wide alarm range (low 85%)

Anesthesia Patient Safety Foundation Recommendations 2011  Centrally monitored pulse oximetry monitoring recommended for all postop patients  Capnography for patients on oxygen  Nursing assessment of level of sedation is a critical component

Surveillance Capnography

 Recommended by ISMP  Expensive  Patient compliance & signal acquisition problematic

Masimo Respiratory Acoustic Monitoring

 Uses acoustic technology to listen to breathing  Integrates with pulse oximetry monitoring  May outperform capnography  More evidence needed

Limitations of Pulse Oximetry  Patients on supplemental oxygen may not desaturate until several minutes of apnea have occurred  The addition of capnography or other technology that accurately measures respiratory rate allows early detection of apnea

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Proposed CMS Quality Measure 3040: Appropriate Monitoring of Patients Receiving PCA

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Intermittent Bolus Dosing of Opioids Is Not Safer Than PCA

“Future technology developments may improve the ability to more effectively utilize continuous electronic monitoring of oxygenation and ventilation in the postoperative period. However, maintaining the status quo while awaiting newer technology is not acceptable”

Summary  In hindsight, most OSRD adverse events could have been predicted  Aggressive identification and monitoring of patients at risk is needed  Leveraging technology has the potential to improve outcomes

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