Practice Guidelines for the Prevention, Detection, and Management of

Respiratory Depression Associated with Neuraxial Opioid Administration

Troy Tada, DOOctober 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 oximetryeffective 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