Download ROYAL HOSPITAL FOR WOMEN Approved by

Therapeutic & Drug Utilisation Committee 16/8/11
ROYAL HOSPITAL FOR WOMEN
LOCAL OPERATING PROCEDURES
1.
Approved by
Quality & Patient Safety Committee
CLINICAL POLICIES, PROCEDURES & GUIDELINES MANUAL
18/8/11
SEDATION – RESPIRATORY DEPRESSION
Sedation or decreased level of consciousness (LOC) is a state where the central nervous
system and cognition is not at full alert and orientation.
•
•
•
•
It may be physiologically induced by such things as hypercapnia, or hypoglycaemia etc.
It may be induced therapeutically to reduce the physiological adverse effects of stress, to
promote sleep, or to decrease anxiety.
It is also a side effect of opiate medication.
Sedation is the first indication of overdosage of opiate medication, and precedes respiratory
depression, hence timely observation and management can prevent a negative patient
outcome.
In any patient who is found to have a decreased level of consciousness the cause should be
identified and treated or the patient observed until level of consciouness improves.
If the LOC is within the therapeutic goals such as somnolence from Temazepam the patient need not
be disturbed.
If the patient is receiving both sedating medication and opiates the level of consciousness
should be monitored.
The level of decrease in consciousness should be assessed. Any patient who is difficult to rouse
should be observed 1/24 or more frequently and receive no opiate, anxiolytic or sedation medication
until this is resolved. (See sedation score = 2).
In those patients with hypovolemia or renal/hepatic dysfunction opiates and sedatives may have more
potent or prolonged effect. This should be factored into the evaluation and ordering of such
medications.
SEDATION SCORING
0=
Wide awake
1=
SEDATED BUT ROUSABLE - Patients who appear tired or very relaxed or who
wake from sleep upon hearing gentle voice or touch may be considered Sedated
but rousable. These patients may receive their analgesia as ordered if in pain,
providing their respiratory rate is 8 or more.
2=
Sedated but difficult to rouse - Patients who are sleeping and do not wake
easily to voice or gentle touch, patients who drift off to sleep mid sentence
or who close their eyes during discussion can be considered difficult to
rouse.
…./2
Approved Quality Council 15/12/03
Therapeutic & Drug Utilisation Committee 16/8/11
ROYAL HOSPITAL FOR WOMEN
LOCAL OPERATING PROCEDURES
2.
Approved by
Quality & Patient Safety Committee
CLINICAL POLICIES, PROCEDURES & GUIDELINES MANUAL
18/8/11
SEDATION – RESPIRATORY DEPRESSION cont’d
If sedation 2, count respiratory rate:
• if < 8 and patients respiratory rate (option A)
• will not improve with noise and touch stimulation• give naloxone per protocol and follow the steps below:
 Give oxygen.
 Call PACE 2 (Call 777).
 Any patient co-sleeping with an infant should have the infant
removed if their sedation score is 2.
 Oxygen saturation should be continuously monitored (call
recovery for a monitor).
 Patient should be assessed for coma position requirement.
 Bed rails should be up to protect the patient.
 Those patients on PCA should have the button removed.
 Those receiving opiates/sedatives should have them
suspended until Sedation is less than 2.
• if > 8 patients respiratory rate (option B)
 Give oxygen.
 Call APRS.
 No naloxone.
3=
Unrousable (Patients who do not respond to voice or touch )
 If score = 3 (Call Code Blue).
 Apply oxygen and monitor respiratory rate, oxygen saturation, and BP.
 Follow naloxone as in sedation score 2.
 Place in coma position.
 Any patient co-sleeping with an infant should have the infant removed if
their sedation score is 2 or more.
 Do not leave the patient unattended.
 Those patients on PCA should have the button removed.
 Those receiving Opiates/sedatives should have them suspended until
Sedation is less than 2.
S=
Sleeping normally
Patients who have received opiate and are sleeping during the night may have their
pain scores omitted and be allowed to continue sleeping providing the respiratory
rate is >/= 10. Respiratory rate can be monitored 2/24. If the respiratory rate is 8,
it is reasonable to see how easily they can rouse, then allow to sleep without
requesting pain scores. Follow guidelines for sedation score 1 or 2.
Any patient who has had their opiate medication ceased or suspended due to sedation
but continues to have pain should have an alternative analgesic plan, determined in
consultation with the Acute Pain Relief Service.
OTHER CAUSES
Patients who have not received opiate or sedation medication and are sleeping for long
periods during the day should be assessed for a cause.
…../3
Approved Quality Council 15/12/03
Therapeutic & Drug Utilisation Committee 16/8/11
ROYAL HOSPITAL FOR WOMEN
LOCAL OPERATING PROCEDURES
3.
Approved by
Quality & Patient Safety Committee
CLINICAL POLICIES, PROCEDURES & GUIDELINES MANUAL
18/8/11
SEDATION – RESPIRATORY DEPRESSION cont’d
Some other causes of decreased level of consciousness or sedation
• Hypoglycaemia
• Hyponatremia
• Hypercapnia
• Intracerebral infarction/haemorrage
• Hypotension
• Cerebral hypoxia
If a patient is found to have a decreased level of consciousness without a causative
agent, Oxygen should be administered, and further investigations conducted to
ascertain the cause. The patient should be in the coma position to protect the airway
particularly from aspiration.
AN INCREASE IN SEDATION OR REDUCED LEVEL OF CONSCIOUSNESS IN ANY
PATIENT IS AN INDICATION FOR INCREASED OBSERVATION OF RESPIRATORY
FUNCTION.
Respiratory Depression:
Respiratory rate should be assessed while the patient is asleep, as this will reflect their true basal rate.
Once a patient is roused their respiratory rate may increase, however this may only be transient and
not a reflection of the function at rest.
The risk of respiratory depression increases with:
• increasing patient age.
• high doses of intrathecal opioid.
• the concurrent use of sedatives, antihistamines and systemic opioids.
In the event of respiratory depression such as a rate of < 8 breaths per minute, it is RHW policy
for the patient to receive Naloxone - see standing orders.
If respiratory rate is less than 8 but becomes greater than 8 on rousing:
 Stop Opiate.
 It may be appropriate not to give naloxone.
 Do not leave the patient unattended - continue to stimulate level of consciousness.
 Give Oxygen.
 Increase Observations.
 Monitor oxygen saturations until the patient is stable.
 Notify the APRS to review patient and discuss a management plan.
Approved Quality Council 15/12/03