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

Weingarten, Toby N.; Šprung, Juraj

doi:10.1097/aln.0000000000004391

Cited by 6 publications

(4 citation statements)

References 46 publications

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“…More importantly, none of the respiratory events were detected by hourly nursing observations [11]. Respiratory events may develop without warning, as assessment notes before critical respiratory events rarely document bradypnea [12]. Respiratory indications for the activation of a rapid response team (RRT) are probably a clinically much more relevant outcome.…”

Section: A Critical Discussion Of Respiratory Depression After Intrat...mentioning

confidence: 99%

Analgesia after cesarean section – what is new?

Lewald

Girard

2023

Current Opinion in Anaesthesiology

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Purpose of reviewCesarean section is the most frequent surgical intervention, and pain following cesarean delivery unfortunately remains a common issue. The purpose of this article is to highlight the most effective and efficient options for postcesarean analgesia and to summarize current guidelines.Recent findingsThe most effective form of postoperative analgesia is through neuraxial morphine. With adequate dosing, clinically relevant respiratory depression is extremely rare. It is important to identify women with increased risk of respiratory depression, as they might require more intensive postoperative monitoring. If neuraxial morphine cannot be used, abdominal wall block or surgical wound infiltration are very valuable alternatives. A multimodal regimen with intraoperative intravenous dexamethasone, fixed doses of paracetamol/acetaminophen, and nonsteroidal anti-inflammatory drugs reduce postcesarean opioid use. As the use of postoperative lumbar epidural analgesia impairs mobilization, double epidural catheters with lower thoracic epidural analgesia are a possible alternative.SummaryAdequate analgesia following cesarean delivery is still underused. Simple measures, such as multimodal analgesia regimens should be standardized according to institutional circumstances and defined as part of a treatment plan. Neuraxial morphine should be used whenever possible. If it cannot be used, abdominal wall blocks or surgical wound infiltration are good alternatives.

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Section: A Critical Discussion Of Respiratory Depression After Intrat...mentioning

confidence: 99%

Analgesia after cesarean section – what is new?

Lewald

Girard

2023

Current Opinion in Anaesthesiology

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“…Nonetheless, oversedation in the PACU is a harbinger of respiratory complications (eg, naloxone administration) on general care wards. 26,27 Recognition is important that the use of sevoflurane or desflurane can decrease the risk of oversedation and respiratory depression, more so during longer exposures. This observation may be important for anesthetic management among patients who may be at increased risk for oversedation and respiratory depression, such as older adults, frail patients undergoing longer procedures, and those with severe obstructive sleep apnea.…”

Section: Discussionmentioning

confidence: 99%

Postanesthesia Care Unit Recovery Time According to Volatile Anesthetic Used in Clinical Practice

Sprung,

Deljou,

Warner

et al. 2023

Anesthesia &Amp; Analgesia

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BACKGROUND: Whether volatile anesthetic solubility affects postanesthesia recovery time in clinical practice is unclear. We investigated the association among 3 volatile agents and 2 clinically relevant outcomes—postanesthesia care unit (PACU) recovery time (time from PACU admission to fulfillment of discharge criteria) and oversedation (Richmond Agitation-Sedation Scale score ≤−3)—as a potential contributor to delaying PACU discharge. The volatile agents studied were isoflurane, desflurane, and sevoflurane. We hypothesized that increased solubility of the volatile agent (isoflurane versus desflurane or sevoflurane) would be associated with longer PACU recovery time and higher rates of oversedation. METHODS: This retrospective observational study included adults (≥18 years) who underwent surgical procedures under general anesthesia with a volatile agent and were admitted to the PACU from May 5, 2018, to December 31, 2020. The primary outcome was PACU recovery time, and the secondary outcome was oversedation. PACU recovery time was log-transformed and analyzed with linear regression. Oversedation was analyzed by using logistic regression. To account for potential confounding, inverse probability of treatment weighting (IPTW) was used. Pairwise comparisons of the 3 agents were performed, with P < .017 (Bonferroni-adjusted) considered significant. RESULTS: Of 47,847 patients included, 11,817 (24.7%) received isoflurane, 11,286 (23.6%) received desflurane, and 24,744 (51.7%) received sevoflurane. Sevoflurane had an estimated 4% shorter PACU recovery time (IPTW-adjusted median [interquartile range {IQR}], 61 [42–89] minutes) than isoflurane (64 [44–92] minutes) (ratio of geometric means [98.3% confidence interval {CI}], 0.96 [0.95–0.98]; P < .001). Differences in PACU recovery time between desflurane and the other agents were not significant. The IPTW-adjusted frequency of oversedation was 8.8% for desflurane, 12.2% for sevoflurane, and 16.7% for isoflurane; all pairwise comparisons were observed to be significant (odds ratio [98.3% CI], 0.70 [0.62–0.79] for desflurane versus sevoflurane, 0.48 [0.42–0.55] for desflurane vs isoflurane, and 0.69 [0.63–0.76] for sevoflurane versus isoflurane; all P < .001). Although oversedated patients had longer PACU recovery time, differences in the oversedation rate across agents did not result in meaningful differences in time to PACU recovery. CONCLUSIONS: In clinical practice, only small, clinically unimportant differences in PACU recovery time were observed between the volatile anesthetics. Although oversedation was associated with increased PACU recovery time, differences in the rate of oversedation among agents were insufficient to produce meaningful differences in overall PACU recovery time across the 3 volatile agents. Practical attempts to decrease PACU recovery time should address factors other than volatile agent selection.

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“…Notably, the action of anesthetics on the respiratory response to CO 2 is different in disease states. After injection of midazolam and thiopental, the CO 2 response curve slope decreased more profoundly in subjects suffering from chronic obstructive pulmonary disease than in healthy volunteers [ 89 ]. On the basis of these studies, such patient populations should be more closely observed because they are more vulnerable to respiratory depression.…”

Section: Behavioral Characteristics Of Respiration Are Modulated By G...mentioning

confidence: 99%

The Modulation by Anesthetics and Analgesics of Respiratory Rhythm in the Nervous System

Hao

Yang

Liu

et al. 2024

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Rhythmic eupneic breathing in mammals depends on the coordinated activities of the neural system that sends cranial and spinal motor outputs to respiratory muscles. These outputs modulate lung ventilation and adjust respiratory airflow, which depends on the upper airway patency and venti- latory musculature. Anesthetics are widely used in clinical practice worldwide. In addition to clinically necessary pharmacological effects, respiratory depression is a critical side effect induced by most gen- eral anesthetics. Therefore, understanding how general anesthetics modulate the respiratory system is important for the development of safer general anesthetics. Currently used volatile anesthetics and most intravenous anesthetics induce inhibitory effects on respiratory outputs. Various general anes- thetics produce differential effects on respiratory characteristics, including the respiratory rate, tidalvolume, airway resistance, and ventilatory response. At the cellular and molecular levels, the mechanisms underlying anesthetic-induced breathing depression mainly include modulation of synaptictransmission of ligand-gated ionotropic receptors (e.g., γ-aminobutyric acid, N-methyl-D-aspartate,and nicotinic acetylcholine receptors) and ion channels (e.g., voltage-gated sodium, calcium, and po-tassium channels, two-pore domain potassium channels, and sodium leak channels), which affect neu-ronal firing in brainstem respiratory and peripheral chemoreceptor areas. The present review compre-hensively summarizes the modulation of the respiratory system by clinically used general anesthetics,including the effects at the molecular, cellular, anatomic, and behavioral levels. Specifically, analgesics, such as opioids, which cause respiratory depression and the “opioid crisis”, are discussed. Finally, underlying strategies of respiratory stimulation that target general anesthetics and/or analgesics aresummarized.

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

Abstract: Contemporary evidence suggests that episodes of respiratory depression during anesthesia recovery are associated with subsequent respiratory complications in general care units.

Cited by 6 publications

References 46 publications

Analgesia after cesarean section – what is new?

Analgesia after cesarean section – what is new?

Postanesthesia Care Unit Recovery Time According to Volatile Anesthetic Used in Clinical Practice

The Modulation by Anesthetics and Analgesics of Respiratory Rhythm in the Nervous System

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