Conflict of Interest Disclosure

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interest: Medtronic Nurse Advisory board (no relationship to this lecture) Educational Objectives At the end of this presentation

1 Carla R. Jungquist, ANP-BC, PhD, FAAN Association Professor University at Buffalo Conflict of Interest Disclosure Author s conflicts of interest: Medtronic Nurse Advisory board (no relationship to this lecture) Educational Objectives At the end of this presentation the audience will understand evidence based practice for the use of supplemental oxygen understand how to choose the most sensitive electronic monitoring device for the patient on supplemental oxygen be able to increase patient safety in the post-operative period. 1

Review of Respiratory Physiology Chemoreceptors regulate breathing by detecting rising CO2 levels Central receptors in medulla Peripheral receptors in carotid and aortic bodies CO2 crosses the BBB,

2 Review of Respiratory Physiology Chemoreceptors regulate breathing by detecting rising CO2 levels Central receptors in medulla Peripheral receptors in carotid and aortic bodies CO2 crosses the BBB, changes the ph via H+ ions that causes increase in respiratory rate to normalize the ph. Measuring Respiratory Status Current practice includes assessing respiratory rate and pulse oximetry level. Threshold for being concerned is RR < 8 and O2 sat < 90% Adverse event ending with Anoxic Brain Injury 100 Pulse Oximetry Over 36 Hours Pulse Ox Intermittent Oxygen Saturation Checks 2

3 Monitoring in PACU Study n=49 What happens when we add supplemental O2? 3

Evidence Supplemental oxygen in the first 24 hours after surgery is considered standard care by most nurses, although often applied without evidence-based justification (1-6).

4 Evidence Supplemental oxygen in the first 24 hours after surgery is considered standard care by most nurses, although often applied without evidence-based justification (1-6). Supplemental oxygen is recommended for patients experiencing intermittent or sustained hypoxia (< 90%) in the post-operative setting (5, 7). Higher (50%) concentrations of supplemental O2 may be associated with more pronounced respiratory depression (8, 9). Evidence Supplemental oxygen therapy may mask the detection of respiratory compromise when using pulse oximetry as a method of assessment (4, 10-14). Only 1 study proposing that supplemental oxygen use does notmask the detection of deteriorating respiratory status when monitoring with pulse oximetry (15). Scant evidence that oxygen therapy will prevent negative health effects (48). My recommendations Consider evidenced based application of supplemental oxygen. patients experiencing intermittent or sustained hypoxia (< 90%) in the post-operative setting (5, 7). If using supplemental oxygen: consider removing the oxygen before your assessment. OR use capnography or minute ventilation instead of pulse oximetry. 4

5 Future considerations Encourage PACU nurses to assess for OIRD, identify the patient and communicate at hand-off to general care floor with recommendations for continuous monitoring. References 1. Komara JJ, Jr., StollerJK. The impact of a postoperative oxygen therapy protocol on use of pulse oximetry and oxygen therapy. RespirCare. 1995;40(11): Epub1995/11/01. PubMed PMID: Al-Mobeireek AF, Abba AA. An audit of oxygen therapy on the medical ward in 2 different hospitals in Central Saudi Arabia. Saudi medical journal. 2002;23(6): PubMed PMID: Voepel-Lewis T, Parker ML, Burke CN, Hemberg J, PerlinL, Kai S, Ramachandran SK. Pulse oximetry desaturation alarms on a general postoperative adult unit: a prospective observational study of nurse response time. International journal of nursing studies. 2013;50(10): doi: /j.ijnurstu PubMed PMID: Shapiro A, Zohar E, ZaslanskyR, Hoppenstein D, Shabat S, FredmanB. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. Journal of clinical anesthesia. 2005;17(7): doi: /j.jclinane PubMed PMID: American Society of Anesthesiologists Task Force on Neuraxial O, HorlockerTT, Burton AW, Connis RT, Hughes SC, NickinovichDG, Palmer CM, Pollock JE, Rathmell JP, RosenquistRW, Swisher JL, Wu CL. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology. 2009;110(2): Epub 2009/02/06. doi: /ALN.0b013e31818ec946. PubMed PMID: AlbinRJ, Criner GJ, Thomas S, Abou-JaoudeS. Pattern of non-icu inpatient supplemental oxygen utilization in a university hospital. Chest. 1992;102(6): PubMed PMID: de Raaff CAL, Gorter-Stam MAW, de VriesN, Sinha AC, JaapBonjerH, Chung F, Coblijn UK, Dahan A, van den HelderRS, HilgevoordAAJ, Hillman DR, Margarson MP, MattarSG, Mulier JP, RaveslootMJL, ReiberBMM, van Rijswijk AS, Singh PM, SteenhuisR, Tenhagen M, Vanderveken OM, Verbraecken J, White DP, van der WielenN, van Wagensveld BA. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg ObesRelatDis. 2017;13(7): Epub 2017/07/02. doi: /j.soard PubMed PMID: Dahan A, DoumaM, OlofsenE, NiestersM. High inspired oxygen concentration increases the speed of onset of remifentanil-induced respiratory depression. Br J Anaesth. 2016;116(6): Epub2016/05/21. doi: /bja/aew130. PubMed PMID: NiestersM, Mahajan RP, Aarts L, Dahan A. High-inspired oxygen concentration further impairs opioid-induced respiratory depression. British journal of anaesthesia. 2013;110(5): doi: /bja/aes494. PubMed PMID: Whitney JD, Parkman S. The effect of early postoperative physical activity on tissue oxygen and wound healing. BiolRes Nurs. 2004;6(2): Epub2004/09/25. doi: / PubMed PMID: Fu ES, Downs JB, Schweiger JW, Miguel RV, Smith RA. Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest. 2004;126(5): doi: /chest PubMed PMID: Maddox RR, Williams CK, Oglesby H, Butler B, ColclasureB. Clinical experience with patient-controlled analgesia using continuous respiratory monitoring and a smart infusion system. Am J Health SystPharm. 2006;63(2): Epub 2006/01/05. doi: /ajhp PubMed PMID: Kopka A, Wallace E, Reilly G, Binning A. Observational study of perioperative PtcCO2 and SpO2 in non-ventilated patients receiving epidural infusion or patient-controlled analgesia using a single earlobe monitor (TOSCA). Br J Anaesth. 2007;99(4): Epub 2007/07/28. doi: /bja/aem206. PubMed PMID: RozarioL, SloperD, Sheridan MJ. Supplemental oxygen during moderate sedation and the occurrence of clinically significant desaturation during endoscopic procedures. GastroenterolNurs. 2008;31(4): doi: /01.SGA bf. PubMed PMID: TaenzerAH, Perreard IM, MacKenzie T, McGrath SP. Characteristics of Desaturation and Respiratory Rate in Postoperative Patients Breathing Room Air Versus Supplemental Oxygen: Are They Different? AnesthAnalg Epub 2018/01/03. doi: /ANE PubMed PMID: WadhwaA, Kabon B, Fleischmann E, Kurz A, SesslerDI. Supplemental postoperative oxygen does not reduce surgical site infection and major healing-related complications from bariatric surgery in morbidly obese patients: a randomized, blinded trial. Anesthesia and analgesia. 2014;119(2): doi: /ANE PubMed PMID:

Conflict of Interest Disclosure Authors Conflicts of Interest:

MONITORING FOR OPIOID- INDUCED RESPIRATORY DEPRESSION: REVIEW OF NEW EVIDENCE Carla R. Jungquist, ANP-BC, PhD Assistant Professor School of Nursing 1 Conflict of Interest Disclosure Authors Conflicts of