Download Practice Guidelines for the Prevention, Dectection, and Management

Practice Guidelines for the Prevention,
Detection, and Management of
Respiratory Depression Associated with
Neuraxial Opioid Administration
Troy Tada, DO
October 21, 2009
Overview
• This article was chosen to review the updated
from previous ASA practice guidelines in 2007 for
prevention, detection and management of
respiratory depression associated with neuraxial
opioid administration.
• The updated includes new survey data and
recommendation pertaining to monitoring for
respiratory depression
• The purpose of these guidelines are to improve
patient safety and enhance quality of anesthetic
care
Overview
• These guidelines focus on the treatment of all
patients receiving epidural or spinal opioids in
inpatient or ambulatory settings
• They do not apply to chronic or cancer pain,
patients with preexisting implantable drug
delivery systems
Overview
• Surveys given to two groups:
– Task Force-appointed expert consultants
– ASA member
Overview
• The 2009 guidelines includes more specific
recommendations in 4 areas:
– Identification of patients at increased risk of respiratory
depression (specific recommendations for focused history and
physical examination);
– Preventive strategies for respiratory depression after neuraxial
opioid depression (recommendations for noninvasive positive
pressure ventilation, drug selection, and dose selection);
– Detection of respiratory depression and management
(recommendations for monitoring for adequacy of ventilation,
oxygenation, and level of consciousness);
– Management and treatment of respiratory depression when it
occurs (recommendations for supplemental oxygen, reversal
agents, and noninvasive positive pressure ventilation).
Guidelines: Prevention
• Identify pts at increased risk
– Focused H/P
– Literature suggests certain pt or clinical
characteristics
• Obesity, OSA, neuromuscular disease
– Prior opioid administration
Guidelines
• Prevention
– Noninvasive PPV: no agreement of its effectiveness
• However, pts who already utilizes these devises are
encouraged to bring their own equipment to the hospital
– Single-injection VS Parenteral opioids
• Both groups disagree that single injections increase the
occurrence of RD when compared to parenteral
• Single injection neuraxial opioids may be safely used in place
of parenteral opioids without altering the risk of RD or
hypoxemia
Guidelines: Drug selection
• Prevention
– Fentanyl-sufentanil VS morphine-hydromorphone
• Single injection
– Both groups agree that RD increase with
morphine/hydromorphone
– May be safely used in place of parenteral opioids without altering
risk of RD or hypoxia
• Continuous
– Literature reports no difference in epidural adm.
– However, ASA members agree that RD increase with
morphine/hydromorphone
– consultants are equivocal regarding this issue
– Appropiate doses of continuous epidural fentanyl/sufentanil may
be used in place of morphine/hydromorphone without increasing
risk of RD
Guidelines: Drug selection
• Prevention
– Extended release morphine
• Both groups equivocal regarding it increasing RD
compared with either parenteral opioid or conventional
epidural morphine
• May be used in place of intravenous or conventional
epidural morphine
• Extended monitoring may be required
Guidelines: Drug selection
• Prevention
– Continuous epidural VS parenteral opioids
• Meta-analysis of literature indicates less RD with
continuous epidural
• Both groups disagree that continuous epidural increase
the occurrence of RD
• Continuous epidurals preferred to parenteral for
reducing the risk of RD
Guidelines: Drug selection
• Prevention
– Based on duration of action, morphine and
hydromorphone should not be given to outpatient
surgical patients
Guidelines: Dose selection
• Prevention
– Low VS high dose
• Literature indicates RD reduced with low doses of single injections
• However, no difference in RD or sedation when used in continuous
epidural
• Both groups strongly agrees RD increased with higher doses for
intrathecal or epidural, in addition to continuous epidural
• Recom: lowest efficacious dose should be administered to
minimize RD
– Neuraxial combined with parenteral
• Literature is insufficient
• Both groups strongly agree that it increases occurrence of RD
• Recom: Parenteral opioids should be cautiously administered,
requires increased monitoring (intensity, duration, methods)
Literature on Detection of RD
• Literature:
– Insufficient to examine the efficacy of pulse oximetry
or ETCO2 monitoring to diagnose RD for pt receiving
neuraxial opioids
– Comparative studies show
• Pulse oximetryeffective in detecting hypoxemia in pt
receiving a variety of anesthetic techniques
– ETCO2 monitoring is effecting in detecting
hypercapnia for parenteral opioids
– Insufficient regarding using pulse oximetry, EKG, or
ventilation is associated with improved detection of
RD or hypoxemia for patients with neuraxial opioid
Pulse Oximetry/ETCO2/Level of
Consciousness
• Both groups disagree that pulse oximetry
monitoring is more likely to detect RD than are
clinical signs.
• Both groups agree that continuous pulse
oximetry monitoring is more likely to detect RD
than periodic pulse ox monitoring
• Both agree that ETCO2 monitoring is more likely
to detect hypercapnia and RD than clinical signs
• Both agree that checking level of alertness will
identify pts at increased risk of RD
Guidelines: Detection
• Monitoring
– All patients receiving neuraxial opioids should be
monitored for adequacy of ventilation
•
•
•
•
RR
Depth or respiration
Oxygenation
Level of consciousness
– In cases with concerning signs, it is acceptable to awaken a
sleeping patient to assess level of consciousness
Guidelines: Detection
• Detection: Single-Injection neuraxial
– lipophilic opioid
• Continual monitoring should be performed for the first
20 minutes after adm., followed by monitoring at least
once/hour until 2 hours has passed
– hydrophilic opioid
• Monitoring should be performed for a minimum of 24
hours
• First 12 hours: once per hour
• Next 12 hours: once per 2 hours
Guidelines: Detection
• Detection: Continuous infusion or PCEA
– lipophilic /hydrophilic opioid
• Monitoring should be performed during the entire time the
infusion is in use
• First 12 hours: Once per hour
• Next 12 hours: once per 2 hours
• After 24 hours: should be performed at least once every 4
hours
• After discontinuation, monitoring should be dictated by the
patient’s overall clinical condition and concurrent
medications
– Lipophilic opioid only
– necessitates continual monitoring for the first 20 minutes
Guidelines: Detection
• Detection: Sustained- or extended-release
epidural morphine
– First 12 hours: once per hour
– Next 12 hours: once per 2 hours
– After 24 hours: at least every 4 hours for a
minimum of 48 hours
Guidelines: Management & Treatment
• Supplemental O2: literature
– Literature is insufficient to assess whether it will
reduce the frequency or severity of hypoxia or
hypoxemia
– Literature does support use when non-neuraxial
anes. Utilized
Guidelines: Management & Treatment
• Supplemental O2: guidelines
– Both groups agree on all three of following:
– Should be available for any use of neuraxial
opioids
– Administer when, respiratory depression
develops, hypoxemia, altered mental status
– Routine use may increase duration of apneic
episodes and hinder detection of atelectasis,
transient apnea, and hypoventilation
Guidelines: Management & Treatment
• Reversal agents
– Literature: insufficient comparative studies to
assess the efficacy with the use of naloxone or
naltrexone
– IV access should be established and/or maintained
– Agents should be available
– Administer when clinical signs of RD develop and
initiate resuscitation
Guidelines: Management & Treatment
• Non-invasive positive pressure ventilation
– Should be considered for improving ventilation
status
– Should consider to utilize if frequent or severe
airway obstruction or hypoxemia occurs during
postoperative monitoring