Original contributionLife-threatening critical respiratory events: a retrospective study of postoperative patients found unresponsive during analgesic therapy☆
Introduction
Opioids are the mainstay of acute pain management, despite significant side effects that include respiratory depression, which causes alveolar hypoventilation and hypoxemia. Postoperative hypoxemia, defined as oxygen saturation (SpO2) < 90%, is typically multi-factorial and affects 12% to 15% of all patients [1]. While hypoxemia affects large numbers of patients postoperatively, the clinical significance of episodic postoperative hypoxemia is still unknown. In addition, only a small minority of patients with respiratory depression go on to develop a clinically severe respiratory event necessitating rescue intervention [2]. Identifying risk factors for these more serious events constitutes a significant step in advancing perioperative patient safety.
In recent years there has been increasing concern over unmonitored mortality and morbidity in patients during opioid therapy for acute pain [3], [4]. A variety of respiratory monitoring devices have been studied in postoperative patients, including pulse oximetry, capnography, acoustic sensors, and various combinations of each. However, there is a paucity of literature about severe respiratory depression and sudden death during opioid therapy. In this context, we reviewed the risk management incident reporting database at our university hospital for critical respiratory events associated with opioid therapy to treat acute postoperative pain. The purpose of this analysis was to identify risk factors that contribute to adverse outcome during parenteral opioid therapy for acute postoperative pain.
Section snippets
Materials and methods
After obtaining University of Michigan Medical Center Institutional Review Board (IRB) approval, we reviewed the medical records of all patients who were reported to the risk management group of our institution for “respiratory depression”, “respiratory event”, or “respiratory arrest” from August 1, 2000 to July 31, 2007. In addition, postoperative cardiac arrests are automatically referred to the risk management team for root cause analysis, and those deemed on expert review to be related to
Results
A total of 32 LT-CREs were collected over the 6-year evaluation period. An additional 8 cases were excluded for lack of documentation of the critical event, wrong diagnosis, pediatric age group, or those that were associated with death or acute respiratory failure unrelated to opioids. During the same period, 87,650 adult patients were given an anesthetic at our institution. This finding yields a reporting incidence of 3.6 per 10,000 (or 0.038%) adult patients with a LT-CRE during opioid
Discussion
This study describes a low reported incidence of LT-CRE in patients undergoing analgesic therapy after general anesthesia. In patients who develop a postoperative LT-CRE, such an event is more likely to occur in the first 24 hours following surgery and anesthesia. We identified 7 significant co-morbid risk factors, namely, postoperative acute renal failure, OSA, hypertension, CAD, diabetes mellitus, history of CHF, and cardiac dysrhythmia. OSA, hydromorphone therapy, postoperative acute renal
References (21)
- et al.
Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data
Br J Anaesth
(2004) - et al.
Postoperative day one: a high risk period for respiratory events
Am J Surg
(2005) - et al.
Supplemental oxygen impairs detection of hypoventilation by pulse oximetry
Chest
(2004) - et al.
Independent association between obstructive sleep apnea and subclinical coronary artery disease
Chest
(2008) - et al.
Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea: during patient-controlled analgesia
Anesth Analg
(2007) - et al.
The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings?
Anesth Analg
(2005) - et al.
Improving pain management: are we jumping from the frying pan into the fire?
Anesth Analg
(2007) - et al.
Incidence and predictors of difficult and impossible mask ventilation
Anesthesiology
(2006) - et al.
Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function
Anesthesiology
(2007) Statistical methods for Rates and Proportions
(1981)
Cited by (129)
Use and misuse of opioid after gynecologic surgery
2022, Best Practice and Research: Clinical Obstetrics and GynaecologyPostpartum Respiratory Depression
2021, Anesthesiology ClinicsPostoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial
2021, Journal of Clinical AnesthesiaPostoperative opioid-induced respiratory depression or oversedation requiring naloxone treatment in a community hospital: a case series
2024, Baylor University Medical Center Proceedings
- ☆
There are no financial disclosures to be made about this study. This is an internal review of respiratory events in a University hospital.