Tools and Recommendations for Assessing the Risk of Over-Sedation and Respiratory Depression

Although there are benefits to the use of opioids for the management of pain, particularly with patients post-operatively, there are risks of over-sedation and respiratory depression, as The Joint Commission cautions in its Sentinel Event Alert “Safe use of opioids in hospitals”:

While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.

Assessing which patients are at risk of developing opioid-induced respiratory depression (OIRD) would be of benefit, as treatments could be altered or tailored to the particular patient to reduce the risk of opioid-related adverse events.

The Michigan Opioid Safety Score (MOSS) was “developed to incorporate patient risk, respiratory rate, and sedation into one bedside score that could be used to improve patient safety during inpatient opioid therapy. Scoring is based on a summation of risk data with objective bedside measures of over-sedation trumping a patient’s subjective reports of pain.”

Michigan Opioid Safety Score
Michigan Opioid Safety Score

In addition, the American Pain Society recently released clinical practice guidelines for post-surgical pain management:

“The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery,” said Roger Chou, MD, lead author and head of the Oregon Evidence-based Practice Center.

Chou said the key recommendation in the guideline, based on high-quality evidence, is wider use of a variety of analgesic medications and techniques.

“The guideline strongly advises use of multimodal anesthesia that target different mechanisms of actions in the peripheral and central nervous systems,” he said.

“Randomized trails have shown that multimodal anesthesia involving simultaneous use of combinations of several medications — acting on different pain receptors or administered through different techniques — are associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered by one technique.

These guidelines and assessment tool may help with optimizing pain therapy and determining which patients are at risk of OIRD.

Once opioids have been been administered, the Anesthesia Patient Safety Foundation (APSF) recommends continuous electronic monitoring of oxygenation and ventilation, which when combined with traditional nursing assessment and vigilance would greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment.

Ensuring the safety of patients receiving opioids stretches across the continuum of care – from patient assessment to treatment selection to monitoring once opioids have been administered.


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