Respiratory Depression in Adult Patients With Intravenous Patient-Controlled Analgesia

Hagle, Mary; Lehr, Victoria Tutag; Brubakken, Karen; Shippee, Angela

doi:10.1097/00006416-200401000-00007

Cited by 70 publications

(47 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…This high degree of sensitivity will likely drive the technology to become pervasive in the post-anesthesia care unit, intensive care units and floors, where patients may be on patient controlled analgesia devices (PCAs). The latter potentially has the greatest safety impact, as a significant number of respiratory depression events occur in patients on PCAs [13]. According to Overdyk, respiratory failure after surgery is the "third most common cause patient safety-related adverse events affecting the Medicare population in U.S. hospitals, accounting for 113 events per 1,000 at-risk patient admissions, and (results) in death or anoxic brain injury in the majority of cases" [14].…”

Section: Resultsmentioning

confidence: 99%

Preventing Extubation Failure by Monitoring Minute Ventilation with the ExSpiron 1Xi

Mehta¹,

Rohleder²,

Amaro-Driedger³

2015

J Anesth Clin Res

View full text Add to dashboard Cite

In the continuing care of postoperative patients who have been extubated, being able to monitor tidal volume and minute ventilation can provide objective criteria to identify respiratory depression and allow for earlier intervention. We present a morbidly obese female patient that was not extubated at the end of the case due to a low tidal volume detected by the anesthesia machine and a real-time non-invasive ventilation monitor that was being trialed for the procedure. This non-invasive ventilation monitor was subsequently useful in continuing to provide continuous information on the patient's respiratory status to provide objective criteria for extubation and after a trial of extubation. Because of its ability to provide values for minute ventilation and tidal volume, rather than subjective criteria such as chest wall rise, this device may prove useful in the context of extubation trials and beyond.Keywords: Anesthesia; Reversal; Neostigmine; Minute ventilation; Tidal volume; Exspiron; Real-time monitor ObjectivesIn current practice, oxygen saturation has been used as the standard for assessing adequate ventilation in postoperative patients [1]. However, in the setting of decreased ventilation, oxygen diffusion still takes place within the functional residual capacity of the lung, thereby consuming the oxygen present [2]. As there is no replacement of the oxygen due to the decreased minute ventilation, a patient's oxygen saturation will decrease rapidly and with little warning. There is latency in pulse oximetry that coincides with the plateau in the sigmoid oxygen dissociation curve [3]. During this time frame, diminished minute ventilation can be detected before the pulse oximetry begins to plummet. In patients with opioid or propofol induced respiratory depression, inadequate reversal of muscle relaxation, or emergence from anesthesia, monitoring of minute ventilation in real time, can be accomplished with the ExSpiron 1Xi. This monitoring device may prove to be a critical patient safety device, by allowing more timely notification of the underlying physiology, thereby allowing for earlier intervention than current pulse oximetry [4]. In postoperative patients, deciding when to extubate can be greatly facilitated by going beyond the information provided by oxygen saturation. While patients are often times extubated in the operating room, others receive a trial extubation or require extended ventilation in the post-anesthesia care unit (PACU). It has been demonstrated that in patients with traumatic brain injury, outcomes are negatively impacted by extubation failures, highlighting the importance of having a means of monitoring ventilation parameters during a trial extubation [5]. Weissman, et al. found that "hypoxemic episodes are common in the PACU…(and) timely resolution of desaturation events outside of the operating room is challenging and protracted, potentially placing patients at increased risk" [6] (Figure 1). MethodsWe present a morbidly obese 49 year old female patient with obstructive sl...

show abstract

Section: Resultsmentioning

confidence: 99%

Preventing Extubation Failure by Monitoring Minute Ventilation with the ExSpiron 1Xi

Mehta¹,

Rohleder²,

Amaro-Driedger³

2015

J Anesth Clin Res

View full text Add to dashboard Cite

show abstract

“…ASA = American Society of Anesthesiologists physical status classification; BMI = body mass index; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; CVD = cerebrovascular disease Dexmedetomidine and total knee arthroplasty 573 postoperative pain after total knee arthroplasty, which may place patients at increased risk of postoperative respiratory depression. 20 In a recent closed claims analysis of postoperative opioid-induced respiratory depression, Lee et al make note that 88% of closed claims involving postoperative opioid-induced respiratory depression events occurred within 24 hr of the surgical procedure. 21 As well, Chung et al found that, during the first postoperative night, increases in the central apnea index and obstructive apnea index in non-obstructive sleep apnea patients are correlated with the first 24-hr opioid requirement.…”

Section: Discussionmentioning

confidence: 99%

Dexmedetomidine during total knee arthroplasty performed under spinal anesthesia decreases opioid use: a randomized-controlled trial

Chan

Maslany

Gorman

et al. 2016

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

Background It remains unclear whether the opioidsparing effects of dexmedetomidine seen in patients undergoing general anesthesia are reproducible in patients undergoing spinal anesthesia. We hypothesized that the administration of intravenous dexmedetomidine for sedation during total knee arthroplasty under spinal anesthesia would decrease postoperative morphine consumption in the first 24 hr following surgery. Methods We conducted this prospective double-blind randomized-controlled trial in 40 patients (American Society of Anesthesiologists physical status I-III) undergoing total knee arthroplasty with a standardized spinal anesthetic. Patients were randomized to receive either a dexmedetomidine loading dose of 0.5 lgÁkg -1 over ten minutes, followed by an infusion of 0.5 lgÁkgÁhr -1 for the duration of the surgery, or a normal saline loading dose and an infusion of an equivalent volume. The primary outcome was the consumption of morphine delivered via patientcontrolled analgesia in the first 24 hr following surgery. Results The mean (SD) cumulative morphine at 24 hr in the dexmedetomidine group was 29.2 (11.2) mg compared with 61.2 (17.2) mg in the placebo group (mean difference, 32.0 mg; 95% confidence interval, 22.7 to 41.2; P \ 0.001). In the dexmedetomidine group, there was a delay in the time to first analgesic request (P = 0.003) and a reduction in the mean morphine use at six and 12 hr following surgery (both P \ 0.001).Conclusions Dexmedetomidine was associated with a significant decrease in morphine use in the first 24 hr following total knee arthroplasty. Our study shows that an intraoperative infusion of dexmedetomidine for sedation in patients receiving spinal anesthesia can produce postoperative analgesic effects. This offers another potential adjunct in the multimodal pain management of these patients. This trial was registered at ClinicalTrials.gov (identifier NCT02026141).

show abstract

“…However, the basal administration increases the risk of respiratory depression without providing necessarily an additional analgesia patern [19].…”

Section: Pca: Principles and Pharmacological Aspectsmentioning

confidence: 99%

Patient-Controlled Analgesia (PCA) in Acute Pain: Pharmacological and Clinical Aspects

Fernandes¹,

Hernandes²,

Almeida³

et al. 2017

Pain Relief - From Analgesics to Alternative Therapies

View full text Add to dashboard Cite

Moderate or severe pain are important sources of complications as well as morbidity and mortality in the postoperative period after surgical procedures. Patient-controlled analgesia (PCA) is an efective strategy for postoperative analgesia, since it may provide suitable analgesic dose just after system activation, with reduced periods of pain and an increase in patients' satisfaction. Although intravenous and epidural routes are the typical approaches used for PCA, regional patient-controlled analgesia has been shown to be an efective alternative providing a higher standard of analgesia with lower incidence of adverse efects. New devices and routes of PCA administration (transdermal, sublingual, inhalation, and oral routes) have shown to be promising alternatives in clinical studies. Nowadays, there is still no consensus regarding which is the best route or drug used since clinical eicacy/safety depends on the complex comprehension of the drugs pharmacokinetic proile through different routes of administration. Additionally, pharmacoeconomic studies are needed to evaluate the cost-efectiveness of these approaches.

show abstract

Respiratory Depression in Adult Patients With Intravenous Patient-Controlled Analgesia

Cited by 70 publications

References 26 publications

Preventing Extubation Failure by Monitoring Minute Ventilation with the ExSpiron 1Xi

Preventing Extubation Failure by Monitoring Minute Ventilation with the ExSpiron 1Xi

Dexmedetomidine during total knee arthroplasty performed under spinal anesthesia decreases opioid use: a randomized-controlled trial

Patient-Controlled Analgesia (PCA) in Acute Pain: Pharmacological and Clinical Aspects

Contact Info

Product

Resources

About