Advance for Nurses had published a number of articles written or sourced by the Physician-Patient Alliance for Health & Safety. As that publication winds down, we have archived a number of articles here.
Six Nursing Lessons
Nurse and mother reflects on the untimely death of her teenage son
by Pamela Parker, BSN, RN, CAPA
Posted on: July 13, 2015
On July 23, 2007, my 17-year old son Logan died after successfully undergoing routine surgery to correct his sleep apnea. As a recovery room nurse, I have often asked myself how this could have been prevented.
By writing these six lessons I learned, I hope that other loved ones may be saved, other families spared the agony of losing a cherished member.
Logan’s surgery was scheduled at a freestanding outpatient surgery center. It was scheduled for surgery to have his tonsils and uvula removed, and his septum and turbinates repaired – all of which is standard surgery to correct for sleep apnea in children.
Lesson #1 – All Patients Receiving Opioids Should be Assessed for Risk for Over-sedation and Respiratory Depression
Logan had been diagnosed with obstructive sleep apnea. It is imperative to not only screen every patient for sleep apnea, it is important to modify the care that we deliver based upon the patient’s risk.
In its recent Sentinel Event Alert #49 on “Safe Use of Opioids in Hospitals, The Joint Commission specified the characteristics of patients who are at risk.1
In an article by the Cleveland Clinic, Silvia Neme-Mercante, MD cautions:
Patients with sleep apnea who are undergoing any type of surgery are at an increased risk for developing respiratory and cardiovascular complications in the period following the surgery.2
Logan’s diagnosis of sleep apnea should have caused a modification in his treatment plan, however, no modification occurred. Although Logan had been diagnosed with sleep apnea, there are many instances of undiagnosed obstructive sleep apnea (OSA) – so much so that undiagnosed OSA has been described as an epidemic.
As Stavros G. Memtsoudis, M.D., Ph.D. and his colleagues at the Weill Medical College of Cornell University wrote:
The prevalence of OSA is estimated to be 25% among candidates for elective surgery and may be as high as 80% in high-risk populations such as patients undergoing bariatric surgery. Further complicating matters is a high prevalence of associated conditions such as obesity, hypoventilation syndrome, and chronic hypercapnia. Disturbingly, OSA remains undiagnosed in 80% of patients at the time of surgery, which means that many patients may unknowingly be placed at risk partially because of the untreated nature of their disease, and outcomes data for such patients are necessarily incomplete.3
Moreover, a study published in the British Journal of Anesthesia found that anesthetists and surgeons failed to identify a significant number of patients with pre-existing OSA and symptomatic undiagnosed OSA, before operation. 1
In addition to having sleep apnea, Logan was also opioid na??ve, another condition which The Joint Commission says is linked to a higher risk of over-sedation and respiratory compromise.
The National Comprehensive Cancer Network defines opioid naive patients as those “who are not chronically receiving opioid analgesic on a daily basis.” Consequently, because opioid naive patients are at greater risk for over-sedation and respiratory depression, The Joint Commission recommends taking “extra precautions with patients who are new to opioids or who are being restarted on opioids.” 1
All patients having surgery should have a pre-procedure assessment of their risk for oversedation and respiratory depression.
Lesson #2 – Clinicians Must Recognize the Signs of Respiratory Compromise
When we were allowed to see him, the first words that Logan said were “I made it!” and he gave us each a high five. His father and I each sat beside him on the right side of the bed and the nurse sat on the left side of the bed with the monitor on the left side of the bed. Logan had a few sips of sprite and a grape Popsicle.
During this time, Logan’s oxygen saturation monitor continued to alarm. The nurse would say “take a deep breath” occasionally and change the monitor’s probe on his finger to another finger.
The Pasero Opioid-induced Sedation Scale tells us what patient conditions are acceptable or unacceptable, and set forth the appropriate action to ensure patient safety. 5
Based on the Pasero Opioid-induced Sedation Scale, Logan was a 3. Changing the probe from one finger to another may have stopped the pulse oximeter alarm from going off, but it did not address the true problem. According to the Pasero Opioid-induced Sedation Scale, Logan’s condition was unacceptable. This required a “decrease opioid dose 25% to 50% or notify prescriber or anesthesiologist for orders; consider administering a non-sedating, opioid-sparing nonopioid, such as acetaminophen or an NSAID, if not contraindicated.”5
Lesson #3 – All Patients Receiving Opioids Should be Continuously Electronically Monitored
In Sentinel Event Alert #49 on “Safe Use of Opioids in Hospitals,” The Joint Commission identified respiratory depression is an identified patient safety issue and indicated that lack of knowledge about potency differences among opioids, improper prescribing and administration of multiple opioids and modalities of opioid administration (i.e., oral, parenteral and transdermal patches), and inadequate monitoring of patients on opioids.1
Moreover, recent CMS guidance recommends “at a minimum” that hospitals “have adequate provisions for immediate post-operative care, to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.” 6
When I looked at the pulse oximeter that was monitoring Logan, it did not display a waveform, as it usually does – it just displayed a number. Her solution to manage the annoying alarms – move the probe to another finger. The nurse said that his “color looks good,” so she thought that he was fine.
Was Logan monitored? Yes, he was monitored. But, was he monitored adequately? Definitely not!
In a recent video released by the Anesthesia Patient Safety Foundation (APSF) the APSF states that continuous electronic monitoring of oxygenation and ventilation, when combined with traditional nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment. 7
“It’s time for a change in how we monitor postoperative patients receiving opioids,” declared Dr. Robert Stoelting, president of the Anesthesia Patient Safety Foundation (APSF). “We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”8
Lesson #4 – Don’t Rely Upon Pulse Oximeters, Monitor with Capnography
Although Logan was monitored by a pulse oximeter, which is often used on patients, I know from my experience as a recovery room nurse that oximetry is a lagging indicator of respiratory compromise.
In his op-ed, “Preventable In-Hospital Cardiac Arrests?Are We Monitoring the Wrong Organ?”, Lakshmipathi Chelluri, MD, MPH, professor, Department of Critical Care Medicine, co-chair, P&T Committee, UPMC Presbyterian, University of Pittsburgh School of Medicine, asks a great question. He says:
Current respiratory monitoring systems available for prevention of secondary cardiac are pulse oximetry and capnography monitoring. Pulse oximetry measures the oxygenation of blood and is widely use. However, pulse oximetry is a lagging indicator to detect fatigue and respiratory compromise. Capnography measures the amount of carbon dioxide in exhaled breath and is a better indicator of the adequacy of ventilation of the patient. 9
I believe one of the most important lessons I learned is that increased CO2 can be lethal. Logan had received minimal IV narcotics as well as oral/liquid hydrocodone. His somnolence was caused from the increased CO2exacerbated by his sleep apnea. Additionally, the cardiomyopathy discovered during the autopsy was probably a result of the central and obstructive sleep apnea revealed in his sleep study. The cardiomyopathy is probably why his heart would not effectively restart . briefly restarting then quitting . however, I am getting ahead of myself in Logan’s story .
SEE ALSO: Earn CE: The Importance of Sleep
So, let’s take the extra step – let’s make sure our patients have enough oxygen and monitor them with pulse oximetry and let’s make sure enough they’re breathing out enough carbon dioxide with capnography. To do otherwise, risks our patients’ lives.
Lesson #5 – All Patients Should be Monitored for an Extended Period in an Unstimulated Environment Prior to Discharge
When we arrived home, he was very weak and sleepy when I helped him out of the car. He appeared to be weaker than when he walked at the surgery center. I helped him to the love seat in the living room and he wanted to watch a movie he had just received as a gift. I started the movie and he never woke up to see it play. He started to look very pale and I told him to take a deep breath.
Each successive time I woke him up, it was more challenging to awaken him because he was so somnolent. I was afraid to leave him and sat on the floor next to him and watched him closely. Because the popsicle had made his lips purple, I looked at his nail beds, ears and nose. The last time I woke him up, his eyes opened and looking past me, asked quietly, “Where’s mom?” I said, “Logan, I am mom! Take a deep breath.”
He said “Oh yeah,” took a couple of deep breaths and fell asleep.
I called a friend and coworker who lived close to assist me with taking him to the hospital.
Logan was clearly not ready for discharge. He was suffering from respiratory compromise and should have been monitored closely at the outpatient surgery center to make sure that he was no longer at risk.
Lesson #6 – Medical Interventions Shouldn’t be Based on Human Heroics, but on Process
As I was sitting next to Logan, I tried to wake him up and have him take a deep breath, but he did not respond. I rubbed his sternum very hard and still no response. I put my hand near his mouth and nose, and I felt soft breathing. After about three breaths, I felt no breathing at all. Moving the coffee table, I grabbed an arm and a leg and rolled him on the floor. He landed face down. I could not believe that he did not wake up. I rolled him on his back and gave him two rescue breaths. I called 911 to say Logan needed an ambulance. I checked for a pulse and he had a weak pulse.
I could not believe that he was not breathing. I remember 911 transferring me to another dispatch. I told them that I was doing rescue breathing and I needed to put the phone down. I screamed at him between breaths.
My friend knocked on the door. Seeing my face, she ran to us on the floor. She checked a pulse and found none. She began compressions and at one point she thought that air was going in his stomach. I pushed on his stomach, rolled him on his side, wiped the brown purple stuff coming out of his mouth and started rescue breathing again. We continued to reposition his head while I was rescue breathing.
The paramedics came rushing in and took over the rescue attempt. Going into the kitchen, I told a fireman about Logan’s medications. When I returned to the living room, Logan had been intubated and was on an IV. The paramedics were doing compressions and using an ambu bag. When the paramedics said “atropine” and “epinephrine,” I began to panic.
We followed the ambulance to the hospital where we were allowed into the trauma room. Although my mind was a blur, I later learned that Logan’s heart briefly restarted. The nurse said “Doctor, his heart rate is decreasing.” The doctor went to Logan’s side, came back to us and said that he wanted us to sit next to him and talk to him. My husband was on his left side and was sobbing and I was on his right side.
I screamed at Logan to try harder and hang on. I even promised to have him meet Peyton Manning if he would just try harder. I rubbed his face and arms, and told him how much I needed him and that I needed him to try hard.
The doctor came to us and said that he was very sorry but there was not anything they could do to make his heart start again. He said now was the time we would need to tell him goodbye. I screamed … then I composed myself and I told Logan “Now you are entering the Kingdom of Heaven.” I said I loved him and mentioned everyone that I could think of that loved him. I looked up at the nurse realized that she was about to stop giving him compressions. I then walked to the sink in the trauma room and threw up.
Medical interventions shouldn’t be based on human heroics – and, yet, that was the only avenue left to save Logan. Moreover, although individuals clearly play a role in any medical process, the Institute of Medicine report, “To Err is Human: Building a Safer Health System,” reminds us:
The majority of medical errors do not result from individual recklessness or the actions of a particular group – this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. 10
The healthcare process from Logan’s admission to discharge was flawed.
Can We Do Better?
Each healthcare provider needs to consider the risk of respiratory compromise when planning a patient’s care. This includes all clinicians involved in creating and implementing the plan – including surgeon, anesthesiologist, recovery room and med/surg nurses – and should entail frequency of respiratory assessment and the type of monitors being used. ETCO2 should be used on all patients who are at risk for increased carbon dioxide. Other considerations include minimal usage of medications that increase respiratory depression (such as, phenergan and benadryl). Additionally, the patient should receive full reversal medications by anesthesia at the end of the surgery. Clinicians must create a better plan for the at-risk patient.
I am a recovery room nurse and yet I couldn’t save him. After discharge, his deterioration was already rolling down too accelerated a path. Surely we can do better – screen our patients for risk, notice signs of deterioration in a timely manner, and intervene earlier.
I firmly believe that if the appropriate monitors had been used (specifically capnography) and additional and longer monitoring in an unstimulated environment, July 23, 2007 would have had a different ending.
CO2 narcosis can be deadly to our patients. What does that look like? What do we need to do in order to intervene for these patients who are at high risk or diagnosed OSA? After Logan’s death, my hospital learned from what happened to Logan and began screening patients for sleep apnea.
Logan’s death was prior to any knowledge that I had on CO2. Probably the nurse caring for him was also unaware of these dangers. The guidelines for respiratory depression have come after his death. Unfortunately it often takes a bad outcome to create a better process. Logan’s “bad outcome” was heart wrenching and devastating for our family. Now is the time for process improvement.
I hope that other nurses and healthcare facilities may also learn from Logan’s death.
Pamela Parker has been a registered nurse for almost 25 years. She is a recovery room nurse and works in the ambulatory procedure unit at a hospital in Indiana. In addition to providing patient care, Pamela is a clinical educator and provides bereavement support. To help others with the loss of loved ones, she writes a blog “Hope for Grieving Mothers” (http://www.holeheartedmamas.com/).
1. “Safe use of opioids in hospitals.” The Joint Commission Sentinel Alert Event. August 8, 2012. http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf
2. “Scheduled for Surgery? Here’s Why You Need Sleep Apnea Screening.” The Cleveland Clinic. May 11, 2015. http://health.clevelandclinic.org/2015/05/scheduled-for-surgery-heres-why-you-need-sleep-apnea-screening.
3. Memtsoudis, G. et al. “A Rude Awakening – The Perioperative Sleep Apnea Epidemic.” The New England Journal of Medicine. June 20, 2013. http://www.galleonpharma.com/wp-content/uploads/2013/06/NEJMp-sleep-apnea-epidemic.pdf
4. Singh, M. et al. “Proportion of surgical patients with undiagnosed obstructive sleep apnoea.” British Journal of Anaesthesia. October 2, 2012.http://bja.oxfordjournals.org/content/110/4/629.full
5. Pasero Opioid-induced Sedation Scale (POSS). Illinois Hospital Association.https://www.ihatoday.org/uploadDocs/1/paseroopioidscale.pdf
6. Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids. Centers for Medicare and Medicaid Services. March 3, 2014. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-14-15.html
7. Monitoring for OIVI Video. Anesthesia Patient Safety Foundation. http://apsf.org/resources/oivi/
8. Power, Sean. “PPAHS Joins Anesthesia Patient Safety Foundation in Call for a “Paradigm Shift” in Opioid Safety.” Physician-Patient Alliance for Health & Safety. February 19, 2014. http://ppahs.org/2014/02/ppahs-joins-anesthesia-patient-safety-foundation-in-call-for-a-paradigm-shift-in-opioid-safety/
9. Chelluri, Lakshmipathi. “Preventable In-Hospital Cardiac Arrests? Are We Monitoring the Wrong Organ?” Open Journal of Emergency Medicine. August 16, 2014. http://www.scirp.org/journal/PaperInformation.aspx?paperID=49206#.VBdZGktpnzQ
10. “To Err is Human. Building a Safer Health System. Institute of Medicine. November 1999. https://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf