Evaluation of a Standardized Sedation Assessment for Opioid Administration in the Post Anesthesia Care Unit

The impact of opioid-related sedation progressing to respiratory depression in the Post Anesthesia Care Unit (PACU) can be extensive; however, there is a paucity of research on the subject of standardized assessment tools to prevent adverse events. The purposes of this study were: (1) to measure the efficacy of a standardized method of assessing sedation and administering opioids for pain management via the Pasero Opioid-Induced Sedation Scale (POSS) with interventions in the PACU; (2) to increase PACU nurses’ confidence in assessing sedation associated with opioid administration for pain management and in the quality of care provided in their clinical area; and (3) to facilitate PACU and postoperative clinical unit nurses’ communications during patient handoffs regarding safe opioid administration. A quasi-experimental design was used to evaluate the POSS protocol. Two PACUs and six nursing units receiving postsurgical patients in a Midwestern inner-city hospital served as the setting for this research. Medical records were surveyed for outcome data to evaluate the efficacy of the care protocol in two patient cohorts before and after implementation of the POSS protocol. Nurses completed a written survey to identify changes in satisfaction with nurse-to-nurse communication, perceptions of quality of care, and confidence with opioid administration. The final sample included 842 PACU patients and 67 nurses from the PACU and clinical units. The intervention did not significantly change PACU length of stay or amount of administered opioids and patients were noted to be more alert at time of discharge from the PACU. Nurses reported increased perceptions of quality of care and confidence in opioid administration. The findings from this study support the use of the POSS Scale with interventions in the PACU care protocols.     

Does Neurofunction Monitoring Enhance Nursing Confidence and Comfort?

Despite advances in the science of sedation and pain assessment, few studies have examined the impact of various assessment tools on nursing confidence. This study examines how bispectral index monitoring impacts nursing confidence in the assessment and comfort in medication administration based on that assessment. In this prospective observational Quality Improvement project, nurses using bispectral index (BIS) and the Richmond Agitation Sedation Scale (RASS) were randomly selected to complete a self-assessment survey intended to measure their personal confidence and comfort regarding care they were providing for a specific patient on the day the survey was completed. From 110 nurse surveys, nurses had higher confidence assessing pain and sedation when BIS monitor was used in concert with RASS assessments for patients with neuromuscular blockade agents. There was no different in confidence in- nor comfort with- sedation and pain assessments for patients not receiving neuromuscular blockade agents.     

The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care

Aims and objectives: To evaluate the concurrent validity and reliability of the behavioural COMFORT and a modified version of the FLACC scale for assessment of pain and sedation in intubated and ventilated children and to evaluate the construct validity of the FLACC scale for assessment of pain. Background: Few instruments are available for assessment of pain/sedation in paediatric intensive care. Design: A prospective observational study was performed postoperatively in 40 children aged 0–10 years. Methods: Two trained nurses observed the child simultaneously and assessing COMFORT behavioural (COMFORT‐B) and FLACC scores. In comparison, two bedside nurses concurrently scored pain using an observational visual analogue scale (VAS_obs) and sedation using the Nurse Interpretation of Sedation (NIS) score: oversedated, adequately or insufficient sedated. In 20 additional patients, one nurse assessed FLACC scores before and after analgesics. Results: The majority of patients were <1 year. A moderate but significant correlation was found between each scale and both sedation and VAS_obs. COMFORT‐B differentiated better than FLACC between the three sedation levels. For those assessed to be in pain (VAS_obs > 3), both COMFORT‐B and FLACC scores were significantly different compared with VAS_obs < 3. The interrater reliability was high for COMFORT‐B and FLACC (kappa 0·71 and 0·63, respectively). For bedside nurses’ assessment of pain, the interrater reliability was high (kappa 0·63) but low for the level of sedation (kappa 0·20). After administration of analgesics, the FLACC median score decreased significantly from 5 to 0. Conclusions: The COMFORT‐B scale was a more reliable measure of children’s sedation than bedside subjective assessment and gives more substantial information about sedation than the FLACC scale. Concurrent validity for assessment of pain was supported for both scales. The modified FLACC showed construct validity for measuring pain. Relevance to clinical practice: The use of validated scales may improve the assessment and management of pain and sedation in intubated children.     

Entropy correlates with Richmond Agitation Sedation Scale in mechanically ventilated critically ill patients

Sedation is routinely used in intensive care units. However due to absence of objective scoring systems like Bispectral Index and entropy our ability to regulate the degree of sedation is limited. This deficiency is further highlighted by the fact that agitation scores used in intensive care units (ICU) have no role in paralyzed patients. The present study compares entropy as a sedation scoring modality with Richmond Agitation Sedation Scale (RASS) in mechanically ventilated, critically ill patients in an ICU. Twenty-seven, mechanically ventilated, critically ill patients of either sex, 16–65 years of age, were studied over a period of 24 h. They received a standard sedation regimen consisting of a bolus dose of propofol 0.5 mg/kg and fentanyl 1 μg/kg followed by infusions of propofol and fentanyl ranging from 1.5 to 5 mg/kg/h and 0.5 to 2.0 μg/kg/h, respectively. Clinically relevant values of RASS for optimal ICU sedation (between 0 and ?3) in non-paralyzed patients were compared to corresponding entropy values, to find if any significant correlation exists between the two. These entropy measurements were obtained using the Datex-Ohmeda-M-Entropy? module. This module is presently not approved by Food and Drug Administration (FDA) for monitoring sedation in ICU. A total of 527 readings were obtained. There was a statistically significant correlation between the state entropy (SE) and RASS [Spearman’s rho/r_s = 0.334, p < 0.0001]; response entropy (RE) and RASS [Spearman’s rho/r_s = 0.341, p < 0.0001]). For adequate sedation as judged by a RASS value of 0 to ?3, the mean SE was 57.86 ± 16.50 and RE was 67.75 ± 15.65. The present study illustrates that entropy correlates with RASS (between scores 0 and ?3) when assessing the level of sedation in mechanically ventilated critically ill patients.     

Sedation assessment in critically ill adults: 2001-2004 update

OBJECTIVE: To review recently published literature on the validity and reliability of sedation assessment tools in critically ill adults and evaluate the potential advantages and disadvantages of each. DATA SOURCES: A computerized search of MEDLINE and PubMed (2001-May 2004) was conducted. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools used in adult intensive care units (ICUs) were identified. DATA SYNTHESIS: Six subjective and 3 objective assessment tools were identified. Four subjective assessment tools have reliability and 4 have validity data published that were not previously available. There are reliability data to further support the use of the previously published Motor Activity Assessment Scale. Additional reliability data exist for the Ramsay Scale and Glasgow Coma Scale. Conflicting evidence is available with the use of the Bispectral Index monitor in the ICU. Recently, the Patient State Index and Auditory Evoked Potentials were introduced for objective monitoring in critically ill patients. CONCLUSIONS: Increasing data on sedation assessment were published over the last few years, probably in response to supporting evidence that goal-driven sedation therapy improves patient outcomes. Reliability and/or validity testing exists for many of these scales. Several useful tools are available to guide sedation therapy in critically ill patients.     

Use of the Oucher Numeric and the Word Graphic Scale in children aged 9–14 years with post‐operative pain

? The construct validity and clinical applicability of two self‐report scales, the Oucher Numeric and the Word Graphic Scales, were examined in this study. Construct validity was tested on the assumption that pain declines following the administration of analgesia. ? Eighty‐one children aged between nine and 14 years with post‐operative pain used the two scales before and for each of the 4 hours following the administration of analgesia, to report their intensity of pain. The method used for testing construct validity was a replication of the study conducted by 3 ; Children’s pain perception before and after analgesia: a study of instrument construct validity and related issues. Journal of Pediatric Nursing 3 (1), 11–23) to test the construct validity of the Oucher Scale. Construct validity was supported for both the scales. ? Twenty‐eight nurses who administered the scales and the parents of 45 children who had observed their children use the scales, commented on the usefulness of the scales in assessment of pain during hospitalization. ? A majority of children and nurses preferred the Oucher Numeric, whereas the Word Graphic Scale was preferred by a majority of the parents. ? Preference of scale was based on its ease of use and whether the child preferred to use numbers or words to describe the intensity of pain. ? A majority of the children and nurses and all parents believed that a self‐report scale was useful for assessment and communication of children’s pain following surgery.     

肾移植患者术后疼痛及与镇静舒适的相关性

目的调查肾移植患者术后的疼痛情况,并探讨其与镇静、舒适间的相关性。方法 2013年5-11月,采用便利抽样法选抽取在某综合性三级甲等医院泌尿外科行肾移植手术的患者76例,采用0~10数字疼痛强度量表(numerical rating scale,NRS)、Ramsay镇静评分、舒适状况量表(general comfort questionnaire,GCQ)及手术后疼痛管理记录单对其进行问卷调查,并分析其相关性。结果 76例肾移植患者中,有43例术后发生中重度疼痛,不同透析史、居住地、文化程度和宗教信仰患者中重度疼痛的发生次数差异有统计学意义(P0.05);不同镇静状况下患者术后中重度疼痛的发生情况差异无统计学意义(P0.05),镇静得分与疼痛得分无显著相关(P0.05);患者舒适得分为65~111分,平均(79.72±8.30)分,不同舒适状况下患者术后中重度疼痛发生情况的差异无统计学意义(P0.05),舒适得分与中重度疼痛之间呈负相关(r=-0.295,P=0.018)。结论肾移植患者术后大多存在中重度疼痛,护理人员可根据患者情况采取针对性的护理措施,以减轻患者疼痛,提高护理质量。     

Appropriateness and Reliability Testing of the Modified Richmond Agitation-Sedation Scale in Spanish Patients With Advanced Cancer

ContextA tool to quantify agitation severity and sedation level in patients with advanced cancer is needed.ObjectivesTo test the appropriateness and reliability of the Richmond Agitation-Sedation Scale (RASS) in Spanish patients with advanced cancer.MethodsThe original RASS was translated into Spanish according to the standard guidelines. Face validity was assessed by members of the palliative care team, and interrater reliability was assessed, using a weighted kappa, from observations of patients admitted to the palliative care unit. The association between scores of the RASS, Ramsay Sedation Scale, and Glasgow Coma Scale was evaluated using Spearman's ρ.ResultsThree hundred twenty-two observations were performed in 156 patients: 116 observations were performed for delirious patients, 76 observations for sedated patients, and 130 observations for patients admitted for other symptom control. The weighted kappa values were practically equal to or greater than 0.90 between nurses and nurses and physicians. The agreement level between observers for each RASS score was roughly 90%. The correlation between the RASS and the Ramsay and Glasgow Scale values was analyzed for 196 observations recorded in 80 patients. The sedation scale of the RASS had a strong correlation with both the Ramsay (Spearman's ρ, ?0.89; P < 0.001) and the Glasgow Coma Scales (Spearman's ρ, 0.85; P < 0.001).ConclusionThese data support the use of the RASS in Spanish patients with advanced cancer.     

"Between the fixed and the changing": examining and comparing reliability and validity of 3 sedation-agitation measuring scales.

The goal of the study was to compare the reliability and validity of 3 Sedation Agitation Scale. Two nurses and a physician conducted 130 observations simultaneously. They found an excellent interrater reliability in the Richmond Agitation Sedation Scale (r>0.86), and high correlations between the Richmond Agitation Sedation Scale and the Sedation Agitation Scale and Visual Analog Scale scales (r=0.92, r=0.85). The research findings will help to assert Richmond Agitation Sedation Scale as a daily assessment tool in the intensive care unit, and it will pave the way for construction a sedation protocol according to the Richmond Agitation Sedation Scale level.     

American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression

As the complexity of analgesic therapies increases, priorities of care must be established to balance aggressive pain management with measures to prevent or minimize adverse events and to ensure high quality and safe care. Opioid analgesia remains the primary pharmacologic intervention for managing pain in hospitalized patients. Unintended advancing sedation and respiratory depression are two of the most serious opioid-related adverse events. Multiple factors, including opioid dosage, route of administration, duration of therapy, patient-specific factors, and desired goals of therapy, can influence the occurrence of these adverse events. Furthermore, there is an urgent need to educate all members of the health care team about the dangers and potential attributes of administration of sedating medications concomitant with opioid analgesia and the importance of initiating rational multimodal analgesic plans to help avoid adverse events. Nurses play an important role in: 1) identifying patients at risk for unintended advancing sedation and respiratory depression from opioid therapy; 2) implementing plans of care to assess and monitor patients; and 3) intervening to prevent the worsening of adverse events. Despite the frequency of opioid-induced sedation, there are no universally accepted guidelines to direct effective and safe assessment and monitoring practices for patients receiving opioid analgesia. Moreover, there is a paucity of information and no consensus about the benefits of technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy. To date, there have not been any randomized clinical trials to establish the value of technologic monitoring in preventing adverse respiratory events. Additionally, the use of technology-supported monitoring is costly, with far-reaching implications for hospital and nursing practices. As a result, there are considerable variations in screening for risk and monitoring practices. All of these factors prompted the American Society for Pain Management Nursing to approve the formation of an expert consensus panel to examine the scientific basis and state of practice for assessment and monitoring practices for adult hospitalized patients receiving opioid analgesics for pain control and to propose recommendations for patient care, education, and systems-level changes that promote quality care and patient safety.     

Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC

Purpose

We hypothesized that reduced arousability (Richmond Agitation Sedation Scale, RASS, scores ?2 to ?3) for any reason during delirium assessment increases the apparent prevalence of delirium in intensive care patients. To test this hypothesis, we assessed delirium using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) in intensive care patients during sedation stops, and related the findings to the level of sedation, as assessed with RASS score.

Methods

We assessed delirium in 80 patients with ICU stay longer than 48 h using CAM-ICU and ICDSC during daily sedation stops. Sedation was assessed using RASS. The effect of including patients with a RASS of ?2 and ?3 during sedation stop (“light to moderate sedation”, eye contact less than 10 s or not at all, respectively) on prevalence of delirium was analyzed.

Results

A total of 467 patient days were assessed. The proportion of CAM-ICU-positive evaluations decreased from 53 to 31 % (p < 0.001) if assessments from patients at RASS ?2/?3 (22 % of all assessments) were excluded. Similarly, the number of positive ICDSC results decreased from 51 to 29 % (p < 0.001).

Conclusions

Sedation per se can result in positive items of both CAM-ICU and ICDSC, and therefore in a diagnosis of delirium. Consequently, apparent prevalence of delirium is dependent on how a depressed level of consciousness after sedation stop is interpreted (delirium vs persisting sedation). We suggest that any reports on delirium using these assessment tools should be stratified for a sedation score during the assessment.     

Development of the American association of critical-care nurses' sedation assessment scale for critically ill patients.

Clinicians commonly sedate critically ill patients. Sedatives should be administered to achieve predetermined end points. Most currently available scales used to assess sedation are inadequate because they focus on a single domain, such as consciousness. The development of the American Association of Critical-Care Nurses' Sedation Assessment Scale is described. This new scale consists of 5 domains: consciousness, agitation, anxiety, sleep, and patient-ventilator synchrony. A major advantage of the scale is that its domains parallel common goals of sedation therapy for critically ill patients. The proposed measurements for each domain are based on a comprehensive evaluation of the science and expert recommendations. Before the scale is widely used, clinical testing is required to determine its validity and reliability in a variety of critically ill patients and care situations.     

Sedation assessment in critically ill adults.

OBJECTIVE: To review methods for assessing sedation in critically ill adults, discuss their impact on patient outcomes, and provide recommendations for implementing these methods into clinical practice in the intensive care unit (ICU). DATA SOURCES: A computerized search of MEDLINE from 1980 through June 2000 and a manual search of abstracts presented at recent critical care meetings were performed. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools that have been used to titrate therapy in adult, critically ill patients were identified. Special emphasis was placed on sedation assessment instruments that have been prospectively validated. Objective methods that have been used to assess sedation therapy were also identified. DATA SYNTHESIS: Twenty-three adult sedation assessment instruments were identified. Few scales have been prospectively evaluated for validity (n = 6) or reliability (n = 7). Other methods of sedation assessment were identified (e.g., bispectral index monitor); however, most of these methods have only been studied in small subsets of critically ill patients. CONCLUSIONS: Incorporation of sedation assessment into ICU clinical practice may improve patient care. These sedation assessment instruments must be further evaluated to determine their impact on quality of care and ICU length of stay.     

Cerebral effects of long-term oral opioids in cancer patients measured by continuous reaction time

Cerebral function was studied in a group of 34 cancer patients being treated with stable doses of 30-920 mg morphine/24 h using measurement of continuous reaction time. Sedation visual analog scale, pain visual analog scale and time from last medication were registered. This group was compared to a group of 32 healthy controls taking no opioids. Small but statistically significant prolongations of continuous reaction time were seen in the opioid group. Analgesic dose and sedation visual analog scales were weakly positively correlated to continuous reaction time, but factors other than opioid treatment must influence cancer patients' performance of continuous reaction time.     

Sedation assessment: easier said than done!

Sedation assessment commonly is performed in critically ill patients to evaluate their need for, and response to, sedation therapy. Although many sedation assessment scales have been published, few have been tested properly to assure their appropriateness for use in critically ill patients. This article highlights the published sedation assessment scales that have the strongest scientific basis, identifies limitations of the current scales, and suggests characteristics for future sedation assessment scales that would overcome many of the current problems.     

Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review

ContextNear the end of life when patients experience refractory symptoms, palliative sedation may be considered as a last treatment. Clinical guidelines have been developed, but they are mainly based on expert opinion or retrospective chart reviews. Therefore, evidence for the clinical aspects of palliative sedation is needed.ObjectivesTo explore clinical aspects of palliative sedation in recent prospective studies.MethodsSystematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered at PROSPERO. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014–December 2019), combining sedation, palliative care, and prospective. Article quality was assessed.ResultsTen prospective articles were included, involving predominantly patients with cancer. Most frequently reported refractory symptoms were delirium (41%–83%), pain (25%–65%), and dyspnea (16%–59%). In some articles, psychological and existential distress were mentioned (16%–59%). Only a few articles specified the tools used to assess symptoms. Level of sedation assessment tools were the Richmond Agitation Sedation Scale, Ramsay Sedation Scale, Glasgow Coma Scale, and Bispectral Index monitoring. The palliative sedation practice shows an underlying need for proportionality in relation to symptom intensity. Midazolam was the main sedative used. Other reported medications were phenobarbital, promethazine, and anesthetic medication—propofol. The only study that reported level of patient's discomfort as a palliative sedation outcome showed a decrease in patient discomfort.ConclusionAssessment of refractory symptoms should include physical evaluation with standardized tools applied and interviews for psychological and existential evaluation by expert clinicians working in teams. Future research needs to evaluate the effectiveness of palliative sedation for refractory symptom relief.     

Análisis de 4 escalas de valoración de la sedación en el paciente crítico

BackgroundThis study aimed to verify the relationship between different Sedation Rating Scales (SRSs) for critical patients on mechanical ventilation and to know the relationship between the SRSs, clinical information and the dose of sedative and analgesia drugs (SAD).Material and methodsA longitudinal, prospective analytic pilot study conducted in a Medical-Surgical Intensive Care Unit of a tertiary hospital from October-December 2006. The sample included patients who required administration of SAP and mechanical ventilation. The following biological parameters and scales were evaluated: patient's demographics, RAMSAY, Sedation Agitation Scale (SAS), Richmond Agitation Sedation Scale (RASS), Motor Activity Assessment Scale (MASS), SAD dose, mean blood pressure, cardiac rate, pupil diameter and respiratory frequency. Spearman coefficient of interrelation was used to compare the relationship between the different scales.ResultsA total of 2.412 measurements were made for each variable: SRS, clinical information and SAD dose in 30 patients with different diseases, 63 % males, age 52 ± 19 years, APACHEII 24 ± 8, SAPSII 44 ± 16, with an ICU mortality UCI 34 %. Median and IQ range of stay in ICU 15.5 and 20 days, of mechanical ventilation 9 and 14 days, of SAD 6 and 5.5 days and of paralyzing drugs (PD) 2 and 5 days, respectively. Interrelation was detected between all the SRSs, with p < 0.0001. The relationship between SAS, RASS and MASS was direct, whereas these were related inversely to RAMSAY. No evidence of interrelation was found between the SRSs, the clinical information and the SAD doses.ConclusionThe RAMSAY scale that has not been validated in ICU patients has a strong interrelation with the other already validated SRSs. SRSs are subjective and do not correlate with the clinical information and the SAD doses, probably due to the sample's small size and heterogeneity.     

Halving the volume of AnaConDa: initial clinical experience with a new small-volume anaesthetic reflector in critically ill patients—a quality improvement project

AnaConDa-100 ml (ACD-100, Sedana Medical, Uppsala, Sweden) is well established for inhalation sedation in the intensive care unit. But because of its large dead space, the system can retain carbon dioxide (CO₂) and increase ventilatory demands. We therefore evaluated whether AnaConDa-50 ml (ACD-50), a device with half the internal volume, reduces CO₂ retention and ventilatory demands during sedation of invasively ventilated, critically ill patients. Ten patients participated in this cross-over protocol. After sedation with isoflurane via ACD-100 for 24 h, the 5-h observation period started. During the first hour, ACD-100 was used; for the next 2 h, ACD-50; and for the last 2 h, ACD-100 was used again. Sedation was titrated to Richmond Agitation and Sedation Scale (RASS) score ??3 to ??4 and a processed electroencephalogram (Narcotrend Index, Narcotrend-Gruppe, Hannover, Germany) was recorded. Minute ventilation, CO₂ elimination, and isoflurane consumption were compared. All patients were deeply sedated (Narcotrend Index, mean?±?SD: 38?±?10; RASS scores ??3 to ??5) and breathed spontaneously with pressure support throughout the observation period. Infusion rates of isoflurane and opioid, either remifentanil or sufentanil, as well as ventilator settings were unchanged. Minute ventilation and end-tidal CO₂ were significantly reduced with the ACD-50, respiratory rate remained unchanged, and tidal volume decreased by 66?±?43 ml. End-tidal isoflurane concentrations were also slightly reduced while haemodynamic measures remained constant. The ACD-50 reduces the tidal volume needed to eliminate carbon dioxide without augmenting isoflurane consumption.