The problem with PRN opioids

National Inpatient Medication Chart
Australia

How often do you see an order for morphine written up as follows?

2.5 – 5 mg (per dose)

up to a total of 30 mg (per 24 hour period)

for pain (indication)

That’s a fairly common drug order in our Emergency Department. Our morphine stock consists of ampoules of either 5 or 10 mg, so this type of order often requires drawing up 5 mg and discarding 2.5 mg – which of course has to be witnessed by a second RN and legally documented in the schedule 8 drug book. I won’t ask how often ED nurses wander around with a half-filled syringe of morphine, waiting for 5 minutes to see if the first dose of 2.5 mg had any effect…. because we don’t do that, right?

So what’s the problem?

Clearly drugs such as paracetamol and ibuprofen should be written up as above, ensuring that patients receive no more than the recommended safe limits of these drugs. In contrast, however, the correct ‘maximum dose’ of morphine for one patient could be inadequate or excessive for the next. Additionally, the amount appropriate for a patient at 8pm today may be completely inappropriate for that same patient six hours later. Predicting how much opioid a patient may need throughout a 24 hour period is a guessing game at best.

“Both oversedation and undersedation of critically ill patients can have significant adverse effects.”

Safe management of opioid administration requires regular assessment not only of a patient’s pain and vital signs, but also of their level of sedation. This is clearly a nursing responsibility. Increasing sedation should be assumed to be related to opioid administration until proven otherwise. Unfortunately, a busy nurse may continue to administer 5 mg doses of morphine to a patient complaining of pain, without once evaluating their patient’s sedation level.

In my two years as an ED nurse, I have once seen the PRN morphine dose written up as follows:

2.5 – 5 mg

if sedation score <2

for pain

This led me to go searching for a sedation scale – not something I’d had to use with medication administration before. Sedation scales are commonly used to monitor patients during procedural sedation, but our acute bedside charts don’t generally leave space for regular sedation monitoring. In our department, the closest measurement is the AVPU scale on the ADDS chart – where A = alert, V = responds to voice, P = responds to pain, and U = unresponsive. This scale clearly isn’t sensitive enough to detect subtle changes in a patient’s level of sedation.

Of course, the next problem would be ensuring that all staff in a department used the same sedation scale, and understood it to mean the same thing! A quick google search for “sedation scale” shows that this might not be as simple as it sounds (eg. RASS, RS, AVRIPAS, BLOOMSBURY, ATICE, SAS, MAAS, VICS). But that’s another problem for another day.

What I learned from the rather unusual drug order quoted above, is that my job as a nurse includes careful, regular assessment of my patients’ level of sedation whenever I administer opioids. Irregardless of the sedation scale of choice, it only takes a few extra moments to document whether your patient is awake and alert, easy to rouse, unable to remain awake, or is difficult to rouse. Incorporating this as part of my vital signs assessments really isn’t all that difficult (where “pain” is the 5th vital sign, and “level of sedation” the 6th).

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Oscillopsi-wha?

An elderly man presents with a one-week history of dizziness following a syncopal episode. He was treated with prochlorperazine (Stemetil) by his GP but is now almost unable to mobilise. Lives with spouse. Independent with ADLs. Enjoys beach walks and lawn bowls. A quick gait assessment from ambulance stretcher to the trolley reveals a left-sided list and ‘zombie gait’ – arms held straight ahead, feet picked up in exaggerated movements.  Zombie is obviously not the correct medical word, but it describes his gait perfectly. You’re picturing it now, aren’t you?
This patient presented during the very early days of my ED career. I’d never heard anyone do an assessment of patients with dizziness before, and it certainly wasn’t part of my nursing training. So I am thankful to report that this patient got a rare two-nurse workup on his arrival. I launched into the physical and neurological assessment while my colleague fired off a detailed questionnaire. I listened quietly, with growing amazement and respect, while I jotted down his vital signs (hypertensive, afebrile) and neurological obs (GCS 15, PEARL size 2mm, good bilateral limb strength).  Her line of questioning was instructive, to say the least.
Approximately 8 minutes after he rolled into our care, my fellow RN announced “sounds like oscillopsia, treatment is stemetil followed by a short course of high dose steroids if the stemetil was unsuccessful”. I try not to let my mouth hang open before I slink away to see if oscillopsia rates a mention in the department’s textbook (it didn’t). Nowadays I’d first check whether EMBasic has a podcast about dizziness (it does), because I want to ask the right questions and understand why I’m asking them. I want to know the correct terminology to describe what the patient tells me. In short, I WANT WHAT SHE’s GOT!
Three further comments:
First, this post isn’t really about oscillopsia. In fact, after listening to the EMBasic dizziness podcast (which never mentions the term) I’d have to call oscillopsia a symptom, rather than a diagnosis. The important thing is that I learned something new that translated into improved care for my future patients with and without dizziness. While writing this reflection, the excellent EMBasic podcast led me to a thought-provoking EMCrit podcast about posterior strokes. Thanks to Steve Carroll and Scott Weingart for consistently producing such high quality, free medical education!
Second, I am not in the doctor-business and am happy to keep it that way. Having said that, one of the many things I love about emergency nursing is anticipating what patients will need in their workup, and making that happen. What bloods shall I draw? Will they need IV fluids? What paperwork can I get ready for the doctor (medication chart, medical imaging form, fluid chart). Can I nurse-initiate any analgesia or do they need something stronger? etc etc. The more knowledge I have about pathophysiology and potential diagnoses, the more useful my nursing care becomes.
Third, this small episode shows the value of working side-by-side with our fellow nurses if/when it can be achieved. What I gained from listening to my colleague that day was a sense of the variety of questions that should be asked of patients with dizziness. Sadly most graduates in this district are only given 2 or 3 days of buddy time before they’re thrown in on their own.  Such a loss. Our department has recently introduced team nursing, which has somewhat increased the chances of working side-by-side during a patient work-up. The jury is still out on the success of this initiative.
FYI, after a head CT, the patient was diagnosed with a cerebellar infarct.
Never under-estimate the badness that can underlie the familiar patient complaint of dizziness.
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Disclaimer

In the interest of patient safety and confidentiality, I reserve the right to liberally change identifying information about any case studies presented on this site. This includes gender, age, time, location, and other details which I consider to be ‘identifying’. Any resemblance to persons who may at some time have been under my care as RN is therefore unintentional and accidental. Case studies are presented for reflection and in the interest of ongoing education. Vive la FOAM! (Free Online Medical Education).

This site is not intended to provide medical advice. Any actions that you take as a result of reading information on the site is taken at your own risk. Care is taken to provide information that is as accurate and up-to-date as possible, however, the medical profession is dynamic and ever-changing. You are responsible to ensure that your own practice is safe, within your scope of practice, and evidence-based. Now get out there and keep caring….

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SCUH

A preview of the Sunshine Coast University Hospital project. My future workplace:

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Medical Clogs

Born in Holland, I couldn’t resist showing off the medical clogs that (some) Dutch nurses wear. I don’t think Queensland Health would go for it, but I’m still tempted to buy a pair.

I am not affiliated with the company, Tjoelup (pronounced tulip).

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Standing BP

As a student nurse on placement in a busy ED, I recall taking a blood pressure measurement on a patient and rushing off to the primary care nurse – “the patient is really hypotensive!”. The experienced RN glanced at the patient and merely said, “you have to do it again on the lower arm”. Bewildered, I returned to the patient and obediently shifted the cuff down the patient’s arm towards the wrist…. resulting in some odd looks from other staff. Now I know – of course – that he meant I should take the BP on the arm that was level with the patient’s heart.

Meanwhile, I have blithely performed lying and standing BP measurements on patients with suspected orthostatic hypotension – you know, the (usually elderly) patients who present with pre-syncope, light-headedness, or increased falls. I usually try to do the standing blood pressure quickly, while the patient sways on their feet and I stretch to reach the “start” button on the BP machine without letting them slip through my grasp. My goal? To get them back into bed as quickly and safely as possible.

However, I recently noticed that one of the RNs at work was doing the standing BP after letting the patient stand for a minute. No-one had ever told me to do that, so I went searching and sure enough… an accurate standing BP should be taken after the patient has been standing for 2-5 minutes. Not satisfied with this, I continued my search, because when I change my practice I like to know why.

Usually, when you stand up, about 500-1000mL of blood pools in your lower legs. The body responds by increasing venous return to the heart, resulting in a small fall in systolic blood pressure (5 to 10 mmHg). When autonomic reflexes are impaired, blood pressure falls progressively after standing because the pooling of blood in the legs cannot be compensated by sympathetic vasoconstriction. Orthostatic hypotension is diagnosed when, within two to five minutes of quiet standing (after a five minute period of supine rest), one or more of the following is present:

  • at least a 20 mmHg fall in systolic pressure
  • at least a 10 mmHg fall in diastolic pressure
  • symptoms of cerebral hypoperfusion.

So there you have it. A personal practice-changer. Lots more fascinating information can be found in the article “Mechanisms, causes, and evaluation of orthostatic and postprandial hypotension” by Kaufmann, H, Mann, NM, and Freeman, R. (Last updated August 1, 2012).

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ABG app review

A while back I asked the twitterverse whether anyone could recommend a good app for arterial blood gas (ABG) interpretation. The deafening silence showed me that (a) I have very few followers and (b) if I want an ABG app review, I have to write it myself. Hence this blog post. A few preliminary remarks are in order. If you don’t already know how to interpret tricky blood gases, go listen to the four-part podcast series by Scott Weingart  part one can be found here

I used the same blood gas results to test every app – based on the gases provided in the post “A Really Tricky ABG?” (at LITFL). My reasoning is that this not only keeps the reviews fair, but it highlights the difference between mechanical apps and informed clinical judgement (a scan through the comments on that post is very instructive).

Finally, a disclaimer. I do not have any affiliation with any of these apps or their creators. I was not asked to do this review, and if an app cost money, I paid for it myself. Whenever there was a free “lite” version and a paid “pro” version, I chose to review the paid app. I downloaded 14 apps in total, that being all I could find in the iTunes store. Having said all that, on with the review!

SPECIAL MENTION:

ABG Acid-Base eval (free) = values for pH, pCO2, Na, HCO3 and Cl are input using scroll bars (good ranges available). The app steps the user through an analysis, requiring some (very) simple evaluation of results – a nice teaching feature not seen in other apps. After working through the steps and calculations (cheat option is provided for calculations if desired), the app compares your findings with the expected findings. Nice to see a reminder that “patients and their physiology are more than just numbers”. Provides email address for app creator. Includes list of references.

Graphical arterial BG ($0.99) = initially not intuitive to use. Separates gases from acid-base. Allows user to save patients’ values in a Patient List. Input values via sliders on sides of graph, with limited ranges. Includes a description of 6 diagnoses. Plots values on nomograms. Allows for trends to be plotted on nomogram for a particular patient. Creates PDF files of data in a graph (automatically) – which can then be printed or emailed. Can search for previous results by date. Can swap between mmHg and KPa.

PRETTY GOOD APPS:

Blood Gas ($0.99) = Asks for pH, PCO2, HCO3, Na, bicarb, chloride, albumin and anion gap. Input values by typing (no range limits). Able to leave blanks. Result “primary metabolic acidosis with normal anion gap, with superimposed respiratory acidosis”. Gives expected values for Pco2 (23-27), pH (7.12), CO2 (37) and HCO3 (11). Reset button. No further options, no further information provided.

Acid Plus ($4.49) = asks for input (via scroll bars) for pH, PCO2, Na, Cl, and HC. Result: primary non-gap metabolic acidosis, which is uncompensated (AG = 6; BE -17). Secondary concomitant respiratory acidosis. Right arrow provides more info about the analysis. Lists a variety of possible causes and the anion gap mnemonic (MUDPILES). Information is referenced.  Preferences screen allows user to set upper limit for normal anion gap, enables base excess to be turned on or off, and allows selection between mmHg and kPa. Able to email feedback and visit the website. No ability to share or save information.

ABG Pro ($1.99. Free version – ABG Simple) = type in values for chosen calculation. Possible calculations: A-a gradient, osmolar gap, simple ABG, complex ABG, ABG & osmolar gap. Complex ABG asks for pH, pCO2, bicarb, Na, Cl, Alb (can leave blank), with result “Primary non-AG metabolic acidosis with secondary respiratory acidosis” – differential diagnoses provided for both. Lists expected pCO2 and bicarb. Able to set SI units (default is on), bicarb and pCO2 ranges, and whether problem is chronic or acute (default is acute).  No options to share or save data. Reference provided.

Acidosis ($4.49. Lite version available) = asks for patient weight, gender. Options for total body water (child, adult, elder). Asks for input (via scroll bars, with good ranges) for pH, Co2, Na, K, Cl. Calculates bicarb (10.5), BE (- 17.1) and AG (6.5mmol). No chance to leave values blank. Result: severe acute metabolic acidosis. Click on arrow to obtain further information on the analysis and possible causes. No options provided to save or share information. Can change unit of measurement from mmHg/kPa and anion gap negative/positive. Provides option to email creator of app, has link to a website, and references provided.

APPS THAT DO THE JOB:

ABG (free) = input values for pH, pCO2, HCO3 and pO2 to get result “metabolic and respiratory acidosis”. Include Na, Cl and Alb to get gap calculations “anion gap 6, NI gap alb corrected 12, corrected bicarb 5″. Values are typed in with no limits to range. Includes screen to calculate FiO2, and another for haemodynamic calculations. Also includes a drip rate calculator. No further options available.

ABG Guide (free) = requests name, email and occupation before able to use. Option to get news and updates (default is off). Input values using sliders (with good ranges of values, some have to be rounded up or down). Gives results PER PARAMETER, not for the readings as a whole. Lists clinically significant features and possible underlying causes. Information button leads to screen where can choose to use SI units (off by default), parameter order, contact information, website, and an ‘account’ page.

ABG Stat ($1.99) = Input pH, pCO2 and HCO3 using scroll bars (good ranges). Result “uncompensated metabolic acidosis”. Button provides “more info” including causes. Can calculate ABG, anion gap, A-a gradient and CaO2. A “notes” tab provides graphs, nomograms and further information about the various calculations (includes references). No ability to choose different settings or to save/share information.

TOTALLY CRAP APPS:

iAcid (free) = starts with screen requesting cations Na, K, Ca and Mg, then asks for anions BE, HCO, CL, Alb and Lac. Input values via scroll screens, with limited ranges, and no option not to include a value/leave a value blank. Results screen gives anion gap (18.2), corrected gap (24.45), SID (25.7), Na/CL effect (-12), Albumin effect (0) and unmeasured effect (6.75). No further options or settings. To be fair, this is the only app that calculates strong ion difference.

Easy ABG ($0.99) = Can select between kPa and mmHg. Type values in (no limits to range). Asks for pH, PaO2, PaCO2 and HCO3. Result “metabolic acidosis”. No further information given. No other settings available. Don’t waste your money.

 

AciAlko ($1.99) = uses sliders to input values for pH, pCO2, HCO3. Limited ranges available. Gives a simple analysis. Website provided. No further options to customise settings. Wouldn’t recommend this even if it was free.

 

Smart Nurse ($1.99) = values typed in for pH, pCO2, HCO3. Gives a simple result “metabolic acidosis”. Can click tab at bottom to get a more detailed description of the result (definition, risk factors, symptoms, diagnostic tests, treatment). No further options. No mention of secondary or mixed disorders. This app also has sections for drip calculations, EKG interpretation, ACLS practice and nursing diagnosis > none of which this reviewer has used. This review only refers to the ABG interpretation tab.

Acid Base Disorders ($1.99) = Not very user-friendly for novice ABG interpretation. Excess anion gap and delta delta calculations only available when anion gap result is over 12. Describes 6 possible disorders and expected values. Has a screen for calculation of osmolar gap (requires Na, glucose, BUN). Values are input by typing. Includes a list of possible aetiologies divided into anion gap acidosis, non anion gap acidosis, acute respiratory acidosis, metabolic acidosis, respiratory alkalosis and chronic respiratory acidosis. No detail provided for these conditions. Has a link to website. No further options provided.

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Warfarin reversal with Prothrombinex

When a warfarinised patient presents with an intracranial haemorrhage, do you automatically think “prothrombinex”? In our ED there is no stock of fresh frozen plasma (FFP), so the administration of prothrombinex has become more common of late. This post touches on some of the critical nursing care considerations surrounding the administration of prothrombinex.

With increasing numbers of patients on warfarin for atrial fibrillation (AF), it’s wise to know how to handle INR reversal in the ED. Warfarin is a vitamin K antagonist, which reduces blood clotting by inhibiting conversion of inactive vitamin K epoxide to its reduced active form. If that last sentence makes no sense to you either, don’t worry – the point is, warfarin is an anticoagulant.

INR: blood clotting time (coagulation) is measured using the international normalised ratio (INR). For patients on warfarin a reasonable target range for INR is 2 to 3 seconds. Bleeding risk increases exponentially from INR 5 to 9. However, significant bleeding episodes still occur at INR 4, therefore INR should be used as a guide only. All patients with an INR >5 require close monitoring.

Onset and duration: prothrombinex is said to reach peak plasma levels in 5 minutes post-infusion, and INR reversal in 15 minutes. When given together with vitamin K (to sustain the reversal), the duration of INR effects = 12-24 hours.

Administration: reconstituted promthrombinex should be administered within 3 hours. The recommended infusion rate is 3 ml per minute, OR as tolerated by the patient. For example, a dose of 25 units/kg for a 100kg patient requires 5 vials (500 units per 20ml vial). To give the resulting 100ml dose at 3ml per minute would take about half an hour.

Contraindications: heparin allergy, active thrombosis, disseminated intravascular coagulation (DIC). Overdose increases the risk of DIC, thrombosis, myocardial ischaemia and pulmonary embolism. High or repeat doses increase the risk of thrombotic adverse effects.

Monitoring: a patient with a clinically significant bleed + warfarin should be continuously monitored until their INR drops below 5 and the bleeding stops. There is some controversy about INR as a monitoring tool post-warfarin reversal, therefore INR results should be interpreted in light of clinical signs.

What about Dabigatran (aka Pradaxa)? At present, there is no specific way to reverse the anticoagulant effect of dabigatran in the event of a major bleed. More on this in future posts.

Further information can be found via CSL Limited, Bioplasma Division

 

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myCompass

As ED nurses, we frequently encounter patients who present with at least a mild level of anxiety. No surprises there… walking into an ED waiting room is intimidating to say the least. Add to that the patient’s natural anxiety about their ‘presenting complaint’, and you expect to see some mild hyperventilation, increased pulse and raised blood pressure.

But then there are those patients who clearly have more than your ‘average’ amount of anxiety. They aren’t hard to spot in the crowd and often require more time and reassurance, starting at triage. I freely admit I know very little about anxiety and panic attacks. Something I intend to remedy in the near future.

As of today, I have a new resource for those patients. Black Dog Institute – the highly respected not-for-profit group specialising in depression – has launched a new site called myCompass.

The site is “an interactive self-help service that aims to promote resilience and wellbeing for all Australians”.

The site looks user-friendly and requires an initial sign-in to protect personal information. The tools provided are designed to be easily accessible on mobile devices. This is a nice addition to the fantastic resources already available via Black Dog, and looks like something I’d gladly recommend to patients. I’m planning to test the site’s functionality and will review again at a later date.

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Maintaining the excitement in emergency medicine

These notes are taken from a 45 minute lecture by Greg Henry, originally presented at ICEM2012, and available for viewing at Free Emergency Medicine Talks (wonderful resource!). Without any further ado, here are some of the quotes that I wanted to keep:

Patients don’t come to us for judgement. They come to us for care.

You have intrinsically interesting work!

Quality is what you sense when your patient walks out the door. ‘Did I actually make a connection that made somebody better?’

We get to the point where we can perform a mechanical act without involvement of ourselves.  We sometimes forget we do them to a human being.

The people we are least kind to in our lives are our families and each other.

We have to deal with the world not the way we would like it, but the way the world is. Beaten children, battered wives. And that affects you. We see a lot of innocent suffering. And we tend to be, again, mechanical.

Sometimes we have to separate out our job, our goal, from our knowledge base. What I do is apply a small amount of knowledge (some may think it’s desperately small) to basic human problems.

(We need) a fundamental shift from “detective” to guide, advisor, comforter.

Sometimes the way we train does not turn out the best, most caring, the most compassionate physicians. Why? Because we don’t know how to be nice to each other.  Suggestions: give 10x as many compliments as criticisms; give good news in public, criticism in private; thank people for giving great care to patients.

Burnout comes not from the work or the patients, but from unmet expectations because we don’t know what expectations to set.

Things to try:
+ call patients back (feedback, learning, continuity)
+ abandon intern mentality (“I’m just working here”)
+ thank people and be grateful (this is still the best job in the world)
+ nothing replaces caring
+ treat everyone as a volunteer
+ every moment is magic
+ shorten shifts, lighten the load
+ teach something, anything.
+ be the role model, not the critic
+ be the doctor/nurse you’d want your family to be seen by
+ limit your information sources (all change is not progress)
+ vary the experience (community work), be honest about what you really like, plan a maturing career
+ set new markers for success
+ treat pain

Recommended reading: “London” by Blake, “Bleak House” by Dickens.

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