Practice Guidelines

Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration

 Summary of Recommendations

I. Identification of Patients at Increased Risk of Respiratory Depression

* The anesthesiologist should conduct a focused history and physical examination before administering neuraxial opioids.

○ Particular attention should be directed toward signs, symptoms, or a history of sleep apnea, coexisting diseases or conditions (e.g., diabetes, obesity), current medications (including preoperative opioids), and adverse effects after opioid administration.

○ A physical examination should include, but is not limited to, baseline vital signs, airway, heart, lung, and cognitive function.

II. Prevention of Respiratory Depression after Neuraxial Opioid Administration

* Noninvasive positive-pressure ventilation

○ Patients with a history of sleep apnea treated with noninvasive positive airway pressure should be encouraged to bring their own equipment to the hospital.

* Drug selection

○ Single-injection neuraxial opioids may be safely used in place of parenteral opioids without altering the risk of respiratory depression or hypoxemia.

○ Single-injection neuraxial fentanyl or sufentanil may be safe alternatives to single-injection neuraxial morphine.

○ When clinically suitable, extended-release epidural morphine may be used in place of intravenous or conventional (i.e., immediate-release) epidural morphine, although extended monitoring may be required.

○ Continuous epidural opioids are preferred to parenteral opioids for anesthesia and analgesia for reducing the risk of respiratory depression.

○ When clinically suitable, appropriate doses of continuous epidural infusion of fentanyl or sufentanil may be used in place of continuous infusion of morphine or hydromorphone without increasing the risk of respiratory depression.

○ Given the unique pharmacokinetic effect of the various neuraxially administered opioids, appropriate duration of monitoring should be matched with the drug.

○ Neuraxial morphine or hydromorphone should not be given to outpatient surgical patients.

* Dose selection

○ The lowest efficacious dose of neuraxial opioids should be administered to minimize the risk of respiratory depression.

○ Parenteral opioids or hypnotics should be cautiously administered in the presence of neuraxial opioids.

○ The concomitant administration of neuraxial opioids and parenteral opioids, sedatives, hypnotics, or magnesium requires increased monitoring (e.g., intensity, duration, or additional methods of monitoring).

III. Detection of Respiratory Depression

* All patients receiving neuraxial opioids should be monitored for adequacy of ventilation (e.g., respiratory rate, depth of respiration [assessed without disturbing a sleeping patient]), oxygenation (e.g., pulse oximetry when appropriate), and level of consciousness.##

* Single-injection neuraxial lipophilic opioids (e.g., fentanyl)

○ Monitoring should be performed for a minimum of 2 h after administration.

○ Continual (i.e., repeated regularly and frequently in steady rapid succession***) monitoring should be performed for the first 20 min after administration, followed by monitoring at least once per hour until 2 h has passed.

○ After 2 h, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

* Continuous infusion or patient-controlled epidural analgesia (PCEA) with neuraxial lipophilic opioids

○ Monitoring should be performed during the entire time the infusion is in use.

○ Monitoring should be continual for the first 20 min after initiation, followed by monitoring at least once per hour until 12 h has passed.

○ From 12 to 24 h, monitoring should be performed at least once every 2 h.

○ After 24 h, monitoring should be performed at least once every 4 h.

○ After discontinuation of continuous infusion or PCEA with neuraxial lipophilic opioids, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

* Single-injection neuraxial hydrophilic opioids (e.g., morphine, not including sustained- or extended-release epidural morphine)

○ Monitoring should be performed for a minimum of 24 h after administration.

○ Monitoring should be performed at least once per hour for the first 12 h after administration, followed by monitoring at least once every 2 h for the next 12 h (i.e., from 12 to 24 h).

○ After 24 h, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

* Continuous infusion or PCEA with neuraxial hydrophilic opioids

○ Monitoring should be performed during the entire time the infusion is in use.

○ Monitoring at least once every hour should be performed for the first 12 h after initiation, followed by monitoring at least once every 2 h for the next 12 h.

○ After 24 h, monitoring should be performed at least once every 4 h.

○ After discontinuation of continuous infusion or PCEA, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

* Sustained- or extended-release epidural morphine

○ Monitoring at least once every hour should be performed during the first 12 h after administration, and at least once every 2 h for the next 12 h (i.e., from 12 to 24 h).

○ After 24 h, monitoring should be performed at least once every 4 h for a minimum of 48 h.

* Increased monitoring (e.g., intensity, duration, or additional methods of monitoring) may be warranted in patients at increased risk of respiratory depression (e.g., unstable medical condition, obesity, obstructive sleep apnea,††† concomitant administration of opioid analgesics or hypnotics by other routes, extremes of age).

IV. Management and Treatment

* Supplemental oxygen

○ For patients receiving neuraxial opioids, supplemental oxygen should be available.

○ Supplemental oxygen should be administered to patients with altered level of consciousness, respiratory depression, or hypoxemia and continued until the patient is alert and no respiratory depression or hypoxemia is present.

○ Routine use of supplemental oxygen may increase the duration of apneic episodes and may hinder detection of atelectasis, transient apnea, and hypoventilation.

* Reversal agents

○ Intravenous access should be maintained if recurring respiratory depression occurs.

○ Reversal agents should be available for administration to all patients experiencing significant respiratory depression after neuraxial opioid administration.

○ In the presence of severe respiratory depression, appropriate resuscitation should be initiated.

* Noninvasive positive-pressure ventilation

○ Noninvasive positive-pressure ventilation may be considered for improving ventilatory status.

○ If frequent or severe airway obstruction or hypoxemia occurs during postoperative monitoring, noninvasive positive-pressure ventilation should be initiated.

source: Anesthesiology:February 2009 - Volume 110 - Issue 2 - pp 218-230

February 2009 - Volume 110 - Issue 2 - pp 218-230