Incidence and Demographics of Post-Operative Naloxone Administration: A 13-Year Experience at a Major Tertiary Teaching Institution

Abstract

Background: Perioperative use of opioids is associated with the risk of opioid-induced respiratory depression. Naloxone is a competitive opioid antagonist typically administered to reverse opioidinduced respiratory depression. Postoperative administration of naloxone may be considered a proxy for significant postoperative opioid-induced respiratory depression and data regarding its use may be utilized as a quality measure. Few large studies have been done to characterize the population and define an incidence of naloxone recipients in the postoperative inpatient setting. Objectives: We aimed to characterize the demographics of patients receiving postoperative naloxone, as well as the incidence of administration in the first 72 post-operative hours at a large urban academic medical center in the United States. Study Design: This is a retrospective cohort study. Setting: Major urban tertiary teaching institution. Methods: The robust electronic record database of The Department of Anesthesiology at The Icahn School of Medicine at Mount Sinai, as well as the institution’s data warehouse were instrumental in allowing almost 450,000 surgical cases performed between 2001 and 2014 to be screened for naloxone administration within the first 72 postoperative hours. Organ harvests, outside of OR intubations, cancelled cases, and patients age less than or equal to 18 were excluded from the total case count. Results: Naloxone was administered 433 times in a total of 442,699 postoperative cases. This yielded an incidence of 0.1%. Additionally, the demographics of the group receiving naloxone were described. The mean age was 60, mean body mass index (BMI) was 27, 60% were women, and the mean American Society of Anesthesiologists (ASA) status was 3. Average time to naloxone administration was 21 hours (standard deviation 7) after surgery. Thirteen percent of the cases were emergent. Breakdown of anesthetic technique revealed that 81% of the cases were performed under general anesthesia, 7% with monitored anesthesia care (MAC), and 12% under neuraxial anesthesia. This study lays the groundwork for further elucidating risk factors for postoperative administration of naloxone. Limitations: This is a retrospective study. Conclusion: The overall incidence of postoperative naloxone administration over a 13 year period in approximately 450,000 patients was 0.1%. Demographics of this group were older, ASA 3 women, qualifying as overweight, but not obese, undergoing elective surgery with a general anesthetic technique. Average time to administration was 21 hours postoperatively. Key words: Post-operative, naloxone, respiratory depression, incidence

An update on postoperative respiratory depression

“…41 Several retrospective studies utilized naloxone administration as a proxy for severe opioid "toxicity" among hospitalized patients. [56][57][58][59][60][61][62] These studies reviewed the hospital records of 870,390 surgical patients and identified 954 patients who received naloxone and the reported rates of naloxone administration were from 3.6 59 to 53.3 57 per 10,000 patients (Table 1). There are several studies of naloxone administration among nonsurgical patients (Table 1).…”

“…That said, PRODIGY patients with at least one episode of ventilatory depression compared with those without RD were at 1.4 times more risk of having an adverse reaction requiring intervention, and 2.5 times more risk for an adverse event to increase hospital length of stay 41. Several retrospective studies utilized naloxone administration as a proxy for severe opioid “toxicity” among hospitalized patients 56–62. These studies reviewed the hospital records of 870,390 surgical patients and identified 954 patients who received naloxone and the reported rates of naloxone administration were from 3.659 to 53.357 per 10,000 patients (Table 1).…”

Review of Postoperative Respiratory Depression: From Recovery Room to General Care Unit

“…The literature examining the timing of critical postoperative respiratory events clearly demonstrates that most of these events occur within the first 24 postoperative hours. 2,12–14,30–32 Among such studies, three provide sufficient granularity to create a detailed temporal map of when events occur—namely, they tend to occur both early in the postoperative period and during the afternoon and evening. 12–14 Ramachandran et al .…”

“…The literature examining the timing of critical postoperative respiratory events clearly demonstrates that most of these events occur within the first 24 postoperative hours. 2,[12][13][14][30][31][32] Among such studies, three provide sufficient granularity to create a detailed temporal map of when events occur-namely, they tend to occur both early in the postoperative period and during the afternoon and evening. [12][13][14] Ramachandran et al 13 found that 37.5% of cases occurred between 12:00 and 5:59 pm and another 25% between 6:00 and 11:59 pm, with 18.75% of events both between midnight and 5:59 am and between 6:00 and 11:59 am.…”

Pharmacologically Induced Ventilatory Depression in the Postoperative Patient: A Sleep-Wake State-Dependent Perspective

“…12 There have been 6 large retrospective studies that have utilized naloxone administration as a meaningful index of PIVD. 1,[12][13][14][15][16] These studies, similar in design, reviewed the medical records of 763,583 surgical patients and identified 891 patients who received naloxone to treat overnarcotization, defined as severe sedation or ventilatory depression attributed to opioid medications. The rate of naloxone administration 1).…”