An update on postoperative respiratory depression

Weingarten, Toby N.; Šprung, Juraj

doi:10.1097/aia.0000000000000362

Cited by 8 publications

(7 citation statements)

References 108 publications

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“…71 Other studies have shown that most respiratory complications were reported during the first 24 postoperative hours. 9,15,69,70,72 Specific aspects of postoperative analgesic regimens have also been associated with increased risk for postoperative OIRD. Use of patient-controlled analgesic devices, which can increase opioid doses, boosts the risk for respiratory complications.…”

Section: Patient and Procedural Factorsmentioning

confidence: 99%

Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients

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McGrath,

Ochs Kinney

et al. 2024

Anesthesia &Amp; Analgesia

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In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual’s risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a “surveillance model” can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.

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Section: Patient and Procedural Factorsmentioning

confidence: 99%

Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients

Blike,

McGrath,

Ochs Kinney

et al. 2024

Anesthesia &Amp; Analgesia

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“…Compared to low-risk scored patients, intermediate-risk patients have a two-fold increase and high-risk patients a six-fold increased risk for experiencing respiratory depressive episodes on the general care ward. Data from [8 ▪▪ ,62].…”

Section: Obstructive Sleep Apnea and Self-limited Postoperative Respi...mentioning

confidence: 99%

Perioperative considerations for adult patients with obstructive sleep apnea

Weingarten

Šprung

2022

Current Opinion in Anaesthesiology

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Purpose of reviewObstructive sleep apnea (OSA) is a common, but often undiagnosed, sleep breathing disorder affecting approximately a third of adult surgical patients. OSA patients have increased sensitivity to anesthetic agents, sedatives, and opioid analgesics.Recent findingsNewer technologies (e.g., bedside capnography) have demonstrated that OSA patients have repetitive apneic spells, beginning in the immediate postoperative period and peaking in frequency during the first postoperative night. Compared to patients without OSA, OSA patients have double the risk for postoperative pulmonary as well as other complications, and OSA has been linked to critical postoperative respiratory events leading to anoxic brain injury or death. Patients with OSA who have respiratory depression during anesthesia recovery have been found to be high-risk for subsequent pulmonary complications. Gabapentinoids have been linked to respiratory depression in these patients.SummarySurgical patients should be screened for OSA and patients with OSA should continue using positive airway pressure devices postoperatively. Use of shorter acting and less sedating agents and opioid sparing anesthetic techniques should be encouraged. In particular, OSA patients exhibiting signs of respiratory depression in postanesthesia recovery unit should receive enhancer respiratory monitoring following discharge to wards.

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“…12 examined naloxone administration within 48 postoperative hours in general care units and showed that 58% and 51% of cases occurred within the first 12 postoperative hours, and 82% and 80% of cases occurred within the first 24 h. Another study showed 70% of cases to occur between noon and midnight, whereas only 18% occurred in the early morning hours (midnight to 6:00 am ). 3…”

Section: Temporal Patterns Of Postoperative Respiratory Depression In...mentioning

confidence: 99%

“…Weingarten et al 14 and Deljou et al 12 examined naloxone administration within 48 postoperative hours in general care units and showed that 58% and 51% of cases occurred within the first 12 postoperative hours, and 82% and 80% of cases occurred within the first 24 h. Another study showed 70% of cases to occur between noon and midnight, whereas only 18% occurred in the early morning hours (midnight to 6:00 am). 3 The most plausible explanation for this peak occurrence of respiratory depression early in the postoperative period are the residual effects of anesthesia‚ and pain treatments with opioids being more intense in the first hours after surgery. Good evidence supports the idea that respiratory depression occurring in the afternoon results from residual postanesthesia sedation.…”

Section: Risk Factorsmentioning

confidence: 99%

“…1,2 In many cases, the respiratory failure seems to develop acutely and without warning, often shortly after seemingly reassuring nursing assessments. 2 Severe respiratory depression on general care units, however, is rare (3.7 to 53.3 opioid naloxone reversals per 10,000 general anesthetics), 3 and this infrequency of events has presented a barrier for healthcare organizations to invest in the equipment and personnel required for universal continuous monitoring.…”

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confidence: 99%

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