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

1. Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration Troy Tada, DO October 21, 2009

2. 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

3. 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

4. Overview • Surveys given to two groups: • Task Force-appointed expert consultants • ASA member

5. 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).

6. Guidelines: Prevention • Identify pts at increased risk • Focused H/P • Literature suggests certain pt or clinical characteristics • Obesity, OSA, neuromuscular disease • Prior opioid administration

7. 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

8. 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

9. 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

10. 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

11. Guidelines: Drug selection • Prevention • Based on duration of action, morphine and hydromorphone should not be given to outpatient surgical patients

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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