Incidence and Outcomes of Life-Threatening Events During Hospitalization: A Retrospective Study of Patients Treated with Naloxone

Abstract

Background We describe the clinical course of medical and surgical patients who received naloxone on general hospital wards for suspected opioid induced respiratory depression (OIRD). Methods From May 2018 through October 2020, patients who received naloxone on hospital wards were identified and records reviewed for incidence and clinical course. Results There were 86,030 medical and 106,807 surgical admissions. Naloxone was administered to 99 (incidence 11.5 [95%CI 9.4–14.0] per 10,000 admissions) medical and 63 (5.9 [95%CI 4.5–7.5]) surgical patients, P < 0.001. Median oral morphine equivalents administered within 24-hour before naloxone was 32 [15, 64] and 60 [32, 88] mg for medical and surgical patients, respectively, P = 0.002. Rapid response team was activated in 69 (69.7%) vs. 42 (66.7%) and critical care transfers in 51 (51.5%) vs. 30 (47.6%) medical and surgical patients respectively. In-hospital mortality was 21 (21.2%) vs. 2 (3.2%) and discharge to hospice 12 (12.1%) vs. 1 (1.6%), for medical and surgical patients respectively, P = 0.001. Naloxone did not reverse OIRD in 38 (23%) patients, and these patients had more transfers to the intensive care unit and 30-day mortality. Conclusion Medical inpatients are more likely to suffer OIRD than surgical inpatients despite lower opioid dose. Definitive OIRD was confirmed in 77% of patients because immediate naloxone response, while 23% of patients did not respond and this subset were more likely to need higher level of care and had higher 30-day mortality. Careful monitoring of mental and respiratory variables is necessary when opiates are used in hospital.

Anesthetic Management and Deep Sedation After Emergence From General Anesthesia: A Retrospective Cohort Study

“…A study examining postoperative administration of naloxone on units showed that health care staff documented sedation in 80% of cases and respiratory symptoms in only 50%. 15 A link between respiratory depression in the PACU and critical opioid-induced respiratory depression was previously observed. Two studies showed that patients with respiratory depressive episodes in the PACU had a 5-fold increased risk of requiring naloxone administration on general care units.…”

“…A study examining postoperative administration of naloxone on units showed that health care staff documented sedation in 80% of cases and respiratory symptoms in only 50%. 15…”

“…9,14 Furthermore, health care providers often do not appreciate subtle signs of respiratory depression antecedent to the critical event. 2,15 What is more commonly documented before these events is somnolence or sedation. 2,15 Given that severe postoperative respiratory depression on general care wards is associated with respiratory depression during anesthesia recovery and preceded by sedation in the wards, we asked whether deep sedation in the PACU could also be associated with this complication.…”

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

“…Two studies examining antecedent nursing notes of critical respiratory events showed that somnolence, but not respiratory depression, was documented in the majority of cases. 2,25 The possibility that healthcare professionals mistakenly identify respiratory depression as somnolence is intriguing and warrants further investigation. In the interim, healthcare staff should always be suspicious of excessive somnolence as a presentation of respiratory depression, and these patients would require more intense respiratory monitoring to avoid potentially adverse consequences.…”

“…However, patient assessment notes before critical respiratory events frequently do not document bradypnea. 2,[4][5][6][7]25 One study that implemented continuous monitoring in the postoperative period showed that isolated slow respiratory rate (bradypnea) was only a rare presentation of respiratory depression. 8 Furthermore, a closed claims analysis of postoperative respiratory depression reported that the last nursing assessment before a critical event rarely documented signs of respiratory depression ("heavy snoring" was documented in only 15% of cases), with the most predominant notes preceding the critical events being somnolence (62% of cases).…”