Respiratory depression associated with patient-controlled analgesia: a review of eight cases

Etches, Richard C.

doi:10.1007/bf03009805

Cited by 215 publications

(88 citation statements)

References 30 publications

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“…Unfortunately, analgesics are a leading cause of adverse drug events; 2,3 and PCA, compared to narcotic administration by other routes, has a similar incidence of severe respiratory depression (< 1%). 4,5 The incidence of PCA associated respiratory depression varies from 0.3 to 6% depending on the patient population and definition of respiratory depression. [6][7][8] Numerous reports of safety hazards and deaths associated with PCA pumps have been reported in the literature since the introduction of this technology.…”

Section: Conclusion : Ce Cas Souligne Comment De Multiples Erreurs Inmentioning

confidence: 99%

“…[6][7][8] Numerous reports of safety hazards and deaths associated with PCA pumps have been reported in the literature since the introduction of this technology. 4,5,[8][9][10][11][12][13][14][15][16][17][18][19][20][21] The following report is a case of respiratory arrest associated with PCA morphine, and illustrates the multiple levels at which errors can occur with PCA administration. Consent was obtained from the patient for use of personal health information in this case report in accordance with our institutional guidelines.…”

Section: Conclusion : Ce Cas Souligne Comment De Multiples Erreurs Inmentioning

confidence: 99%

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Morphine overdose from error propagation on an acute pain service

Syed

Paul

Hueftlein

et al. 2006

Can J Anesth/J Can Anesth

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Purpose: To highlight a case in which multiple errors occurred during programming and administration of analgesia via a patient-controlled analgesia (PCA) pump, and to formulate recommendations on how to avoid such errors in the future. Clinical features:Following lumbar surgery, a 43-yr-old woman was switched from epidural analgesia to a PCA pump. This change was associated with numerous errors at several points of delivery of her care. Errors included incorrect connection of the PCA adapter, incorrect pump programming, and communication lapses which resulted in a morphine overdose and subsequent respiratory arrest. The patient was promptly resuscitated, and she had an uneventful recovery. The event resulted in a complete review of pain management equipment and the training and education of staff using this equipment at our institution. Conclusion:This case highlights how multiple individual errors can combine to result in a serious adverse event. While equipment design was an important factor in this adverse event, human factors played a critical role at multiple levels. Objectif : Présenter un cas où de multiples erreurs sont survenues pendant la programmation et l'administration de l'analgésie autocontrôlée (AAC) et formuler des recommandations sur les moyens d'éviter ces erreurs à l'avenir.

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Section: Conclusion : Ce Cas Souligne Comment De Multiples Erreurs Inmentioning

confidence: 99%

Section: Conclusion : Ce Cas Souligne Comment De Multiples Erreurs Inmentioning

confidence: 99%

Morphine overdose from error propagation on an acute pain service

Syed

Paul

Hueftlein

et al. 2006

Can J Anesth/J Can Anesth

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“…4 Reports of safety hazards and deaths associated with PCA pumps have appeared since this technology was first introduced, and now number in the dozens. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Therefore, it is important to understand the factors that threaten patient safety with the use of PCA pumps. To contribute to this goal, we report a case where a patient died as a result of a drug overdose.…”

mentioning

confidence: 99%

Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability

Vicente

Kada-Bekhaled

Hillel

et al. 2003

Can J Anesth/J Can Anesth

147

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“…Postoperative respiratory depression and subsequent adverse outcomes can arise from pain, residual effects of drugs given during anaesthesia and administration of opioids for pain management [1]. Respiratory depression often occurs in association with postoperative opioid analgesia [2,3,4]. The risk of respiratory depression increases with age [1], morbid obesity [5] and pre-existing sleep apnea syndrome [2].…”

Section: Introductionmentioning

confidence: 99%

“…Respiratory depression often occurs in association with postoperative opioid analgesia [2,3,4]. The risk of respiratory depression increases with age [1], morbid obesity [5] and pre-existing sleep apnea syndrome [2].…”

Section: Introductionmentioning

confidence: 99%

Continuous Postoperative Respiratory Monitoring with Calibrated Respiratory Effort Belts: Pilot Study

Seppänen

Alho

Vakkala

et al. 2017

Biomedical Engineering Systems and Technologies

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Abstract. Postoperative respiratory complications are common in patients after surgery. Respiratory depression and subsequent adverse outcomes can arise from pain, residual effects of drugs given during anaesthesia and administration of opioids for pain management. There is an urgent need for a continuous, realtime and non-invasive respiratory monitoring of spontaneously breathing postoperative patients. For this purpose, we used rib cage and abdominal respiratory effort belts for the respiratory monitoring pre-and postoperatively, with a new calibration method that enables accurate estimates of the respiratory airflow waveforms even when breathing style changes. Five patients were measured with respiratory effort belts and mask spirometer. Preoperative measurements were done in the operating room, whereas postoperative measurements were done in the recovery room. We compared five calibration models with pre-and postoperative training data. The postoperative calibration approach with two respiratory effort belts produced the most accurate respiratory airflow waveforms and tidal volume, minute volume and respiratory rate estimates. Average results for the best model were: coefficient of determination R 2 was 0.91, tidal volume error 5.8 %, minute volume error 8.5 % and BPM (Breaths per Minute) error 0.21. The method performed well even in the following challenging respiratory cases: low airflows, thoracoabdominal asynchrony and hypopneic events. It was shown that a single belt measurement can be sufficient in some cases. The proposed method is able to produce estimates of postoperative respiratory airflow waveforms to enable accurate, continuous, real-time and noninvasive respiratory monitoring postoperatively. It provides also potential to optimize postoperative pain management and enables timely interventions.

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Respiratory depression associated with patient-controlled analgesia: a review of eight cases

Abstract: Patient-controlled iv delivery of opioids for

Cited by 215 publications

References 30 publications

Morphine overdose from error propagation on an acute pain service

Morphine overdose from error propagation on an acute pain service

Programming errors contribute to death from patient-controlled analgesia: case report and estimate of probability

Continuous Postoperative Respiratory Monitoring with Calibrated Respiratory Effort Belts: Pilot Study

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