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Case
The patient is illustrative. Mrs. B., 67, is on day 1 after an open hysterectomy. She has obstructive sleep apnea and doesn't use her CPAP machine in the hospital. She has hydromorphone through a patient-controlled analgesia (PCA) pump, and her daughter has been pressing the button "so she doesn't wake up in pain." At 0300 the nurse finds her snoring loudly and difficult to wake. Her respiratory rate is 9, SpO₂ 89% on 2 L of oxygen, and she falls asleep mid-sentence.
Questions and answers
1. What is happening, and why is she at risk?
Opioids act on mu receptors in the brainstem and depress the drive to breathe, and sedation usually comes before respiratory depression. Mrs. B. has several risk factors: sleep apnea, older age, the first 24 hours after surgery, and "PCA by proxy," in which someone other than the patient presses the button and removes the safety of the patient having to be awake to dose.
2. How should sedation be assessed?
The Pasero Opioid-Induced Sedation Scale (POSS) rates sedation from S (sleep, easy to arouse) through 1 (awake and alert), 2 (slightly drowsy, easily aroused), 3 (frequently drowsy, arousable, drifts off to sleep during conversation) and 4 (somnolent, minimal or no response to stimulation). Levels S, 1 and 2 are acceptable. Level 3 is unacceptable and calls for closer monitoring and a lower opioid dose, and level 4 calls for stopping the opioid and considering naloxone (Pasero, 2009). Mrs. B. is at level 3, close to 4.
3. What should the nurse do now?
- Stay with her, try to wake her, and tell her to take deep breaths.
- Stop the PCA and remove the button from the daughter's reach.
- Raise the head of the bed, keep oxygen on, and call the rapid response team or provider using SBAR.
- Have naloxone ready and give it as ordered if she can't be roused or her breathing worsens.
- Monitor sedation, respiratory rate and SpO₂ continuously until she is stable, and consider capnography if available.
4. How could this have been prevented?
The postoperative pain guideline from the American Pain Society and partner societies made 32 recommendations, including multimodal analgesia (combining drugs and techniques with different mechanisms) and appropriate monitoring of sedation and respiratory status in patients receiving systemic opioids (Chou et al., 2016). For Mrs. B., scheduled acetaminophen and an NSAID if not contraindicated would have reduced her opioid needs. Teaching the family that only the patient presses the PCA button, and checking POSS with every set of vital signs, would have caught her sedation earlier.
5. What does the CDC guideline add?
The 2022 CDC guideline covers adult outpatients, including those discharged after surgery. It notes that nonopioid therapies are at least as effective as opioids for many common types of acute pain, and that when opioids are needed, clinicians should prescribe no more than the quantity needed for the expected duration of severe pain (Dowell et al., 2022). Discharge teaching for Mrs. B. should cover using nonopioid medications first, safe storage and disposal, and avoiding alcohol and sedatives with opioids.
Nursing takeaways
Sedation is the early warning sign. Assessing it with a scale, not just counting breaths, gives the nurse time to act before respiratory depression becomes an arrest.
References
Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., Carter, T., Cassidy, C. L., Chittenden, E. H., Degenhardt, E., Griffith, S., Manworren, R., McCarberg, B., Montgomery, R., Murphy, J., Perkal, M. F., Suresh, S., Sluka, K., Strassels, S., . . . Wu, C. L. (2016). Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain, 17(2), 131–157. https://doi.org/10.1016/j.jpain.2015.12.008
Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recommendations and Reports, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1
Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 24(3), 186–190. https://doi.org/10.1016/j.jopan.2009.03.005
