Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea

Ostermeier, Andreas M.; Roizen, Michael F.; Hautkappe, Martin; Klock, P. Allan; Klafta, Jerome M.

doi:10.1213/00000539-199708000-00037

Cited by 30 publications

(29 citation statements)

References 38 publications

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“…In a number of case reports, the use of opioid medications in patients with OSA appeared to be a common factor in most of the cases where complications, including death, have been reported following intermittent IM, patient-controlled IV and epidural analgesia (Reeder et al, 1991;VanDercar et al, 1991;Etches, 1994;Ostermeier et al, 1997;Cullen, 2001;Lofsky, 2002;Parikh et al, 2002). However, caution is required when interpreting these reports.…”

Section: Chapter 11mentioning

confidence: 99%

Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non‐inferiority trial

Cohen

Smit

Andrianopoulos³

et al. 2017

Medical Journal of Australia

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Objectives: This study aimed to assess analgesia provided by acupuncture, alone or in combination with pharmacotherapy, to patients presenting to emergency departments with acute low back pain, migraine or ankle sprain. Design: A pragmatic, multicentre, randomised, assessor‐blinded, equivalence and non‐inferiority trial of analgesia, comparing acupuncture alone, acupuncture plus pharmacotherapy, and pharmacotherapy alone for alleviating pain in the emergency department. Setting, participants: Patients presenting to emergency departments in one of four tertiary hospitals in Melbourne with acute low back pain, migraine, or ankle sprain, and with a pain score on a 10‐point verbal numerical rating scale (VNRS) of at least 4. Main outcome measures: The primary outcome measure was pain at one hour (T1). Clinically relevant pain relief was defined as achieving a VNRS score below 4, and statistically relevant pain relief as a reduction in VNRS score of greater than 2 units. Results: 1964 patients were assessed between January 2010 and December 2011; 528 patients with acute low back pain (270 patients), migraine (92) or ankle sprain (166) were randomised to acupuncture alone (177 patients), acupuncture plus pharmacotherapy (178) or pharmacotherapy alone (173). Equivalence and non‐inferiority of treatment groups was found overall and for the low back pain and ankle sprain groups in both intention‐to‐treat and per protocol (PP) analyses, except in the PP equivalence testing of the ankle sprain group. 15.6% of patients had clinically relevant pain relief and 36.9% had statistically relevant pain relief at T1; there were no between‐group differences. Conclusion: The effectiveness of acupuncture in providing acute analgesia for patients with back pain and ankle sprain was comparable with that of pharmacotherapy. Acupuncture is a safe and acceptable form of analgesia, but none of the examined therapies provided optimal acute analgesia. More effective options are needed. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12609000989246.

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Section: Chapter 11mentioning

confidence: 99%

Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non‐inferiority trial

Cohen

Smit

Andrianopoulos³

et al. 2017

Medical Journal of Australia

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“…opioid ve sedatifler de solunum durmasına neden olabilirler (9)(10)(11). Ayrıca OUA hastalarında hiperkapni, oksijen satürasyonunun düş-mesi, kalp ritminde bozukluklar, miyokard hasarı gelişebilir ve tüm bu nedenlerden dolayı postoperatif dönemde yoğun bakıma nakilleri zorunlu hale gelebilir (12).…”

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Validation of the STOP-Bang Questionnaire: an Obstructive Sleep Apnoea Screening Tool in Turkish Population

Acar¹,

Kaya²,

Yücel³

et al. 2013

Turk J Anesth Reanim

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Giriş Son yıllarda yayınlanan makaleler incelendiğinde, anestezistlerin preoperatif muayene sırasında her hastayı obstrüktif uyku apnesi (OUA) olasılığı açısından değerlendirmesinin gerekli olduğu anlaşılmaktadır. Bu gereklilik başlıca iki nedene dayanır; ilki, OUA hastalarının %80-90'ının tanı konmamış durumda olmalarıdır (1). İkinci neden ise, Amerikan Anestezistler Birliği'nin (ASA) 2006'da yayımladığı bir kılavuzla, cerrahi hastalara preoperatif dönemde OUA açısından tarama yapılmasını önermiş olmasıdır (2). Preoperatif dönemde kullanılacak uygun bir tarama ile OUA olasılığı yüksek olan hastalar belirlenip, anestezistlerin peroperatif dönemde karşı karşıya kalabilecekleri riskler en aza indirilebilir.Temel özellikleri uykuda solunumun bozulması, horlama ve gün içinde aşırı uyku hali olan OUA, erişkin popülasyonda kadınlarda %2, erkeklerde %4 oranında görülmektedir (3). OUA'nın cerrahi hastalardaki görülme sıklığına dair rakamlar değişkenlik gösterse de, bariatrik cerrahi gibi bazı özel hasta gruplarında çok yüksek oranlarda (%78) izlendiği bildirilmektedir (4-8). Peroperatif komplikasyonlar ile OUA şiddeti arasında doğrudan bir ilişki olduğu bilindiği için, hangi nedenle cerrahi geçirecek olursa olsun OUA hastalarına önceden tanı konularak gereken önlemlerin alınması büyük önem taşımaktadır (2). Bu hastalarda anestezi indüksiyonu sırasında havayolu sağlanmasında zorlukla karşılaşılabilir (9). Ekstübasyondan hemen sonra solunum yolu obstrüksiyonu görülebileceği gibi, postoperatif dönemde verilen Methods:In 110 adult patients who were admitted to the Sleep Clinic for polysomnography with an initial diagnosis of obstructive sleep apnoea, the STOP-Bang questionnaire was used to calculate the sensitivity, specificity, negative predictive value, positive predictive value and likelihood ratios. Results:In the study, no significant difference was obtained between two sexes for the presence of high risk of obstructive sleep apnoea (p>0.05). When apnoea-hypopnoea index (AHI) ≤5 patients and AHI >5 patients were compared, no significant differences were found in the values of age, sex and body mass index (p>0.05). Mean AHI value was 1.4 in AHI ≤5 patients, while it was 33.8 in AHI >5 patients (p<0.05). Although both STOP and STOP-Bang screening tests have a high sensitivity (>90%) in various severities of OSA (AHI >5, AHI >15 and AHI >30), their specificities were found to be low. As the severity of OSA increases, the positive predictive values of both tests were decreased, while the negative predictive values were increased. Conclusion

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“…[1][2][3] Different opioid receptor agonists differentially enhance the activity of cardioinhibitory cardiac vagal neurons (CVNs) through disinhibition. More specifically, -opioid receptor agonists and nociceptin inhibit both spontaneous ␥-aminobutyric acid (GABA) and glycinergic synaptic inputs, 4 -7 whereas a -opioid agonist diminishes spontaneous glycinergic but not GABAergic neurotransmission to CVNs.…”

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confidence: 99%

5-Hydroxytryptamine 1A/7 and 4α Receptors Differentially Prevent Opioid-Induced Inhibition of Brain Stem Cardiorespiratory Function

et al. 2007

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Abstract-Opioids evoke respiratory depression, bradycardia, and reduced respiratory sinus arrhythmia, whereas serotonin (5-HT) agonists stimulate respiration and cardiorespiratory interactions. This study tested whether serotonin agonists can prevent the inhibitory effects of opioids on cardiorespiratory function. Spontaneous and rhythmic inspiratory-related activity and ␥-aminobutyric acid (GABA) neurotransmission to premotor parasympathetic cardioinhibitory neurons in the nucleus ambiguus were recorded simultaneously in an in vitro thick slice preparation. The -opioid agonist fentanyl inhibited respiratory frequency. The 5-hydroxytryptamine 1A/7 receptor agonist 8-hydroxy-2-(di-n-propylamino)tetralin increased respiratory frequency by itself and also prevented the fentanyl-induced respiratory depression. The 5-hydroxytryptamine 4␣ agonist BIMU-8 did not by itself change inspiratory activity but prevented the -opioidmediated respiratory depression. Both spontaneous and inspiratory-evoked GABAergic neurotransmission to cardiac vagal neurons were inhibited by fentanyl. 8-Hydroxy-2-(di-n-propylamino)tetralin inhibited spontaneous but not inspiratory-evoked GABAergic activity to parasympathetic cardiac neurons. However, 8-hydroxy-2-(di-npropylamino)tetralin differentially altered the opioid-mediated depression of inspiratory-evoked GABAergic activity but did not change the opioid-induced reduction in spontaneous GABAergic neurotransmission. In contrast, BIMU-8 did not alter GABAergic neurotransmission to cardiac vagal neurons by itself but prevented the fentanyl depression of both spontaneous and inspiratory-elicited GABAergic neurotransmission to cardiac vagal neurons. In the presence of tetrodotoxin, the inhibition of GABAergic inhibitory postsynaptic currents with fentanyl is prevented by coapplication of BIMU-8, indicating that BIMU-8 acts at presynaptic GABAergic terminals to prevent fentanyl-induced depression. These results suggest that activation of 5-hydroxytryptamine receptors, particularly 5-hydroxytryptamine 4␣ agonists, may be a useful therapeutic approach in preventing opioid-evoked cardiorespiratory depression. (Hypertention. 2007;50:368-376.)Key Words: heart rate Ⅲ parasympathetic Ⅲ serotonin Ⅲ opioid Ⅲ ambiguus Ⅲ GABA O piate exposure causes cardiorespiratory depression, including a centrally mediated bradycardia, respiratory inhibition, and a reduction in respiratory sinus arrhythmia. 1-3 Different opioid receptor agonists differentially enhance the activity of cardioinhibitory cardiac vagal neurons (CVNs) through disinhibition. More specifically, -opioid receptor agonists and nociceptin inhibit both spontaneous ␥-aminobutyric acid (GABA) and glycinergic synaptic inputs, 4 -7 whereas a -opioid agonist diminishes spontaneous glycinergic but not GABAergic neurotransmission to CVNs. 8 In vitro studies from both brain stem slice and brain stem-spinal cord preparations demonstrate that opioids decrease the frequency of respiratory activity. 9 -11 This opiate-induced depression of breathing is caused b...

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Three Sudden Postoperative Respiratory Arrests Associated with Epidural Opioids in Patients with Sleep Apnea

Cited by 30 publications

References 38 publications

Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non‐inferiority trial

Acupuncture for analgesia in the emergency department: a multicentre, randomised, equivalence and non‐inferiority trial

Validation of the STOP-Bang Questionnaire: an Obstructive Sleep Apnoea Screening Tool in Turkish Population

5-Hydroxytryptamine 1A/7 and 4α Receptors Differentially Prevent Opioid-Induced Inhibition of Brain Stem Cardiorespiratory Function

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