Neuraxial analgesia and non sedating antihistamines
ABSTRACT Background: Postoperative opioid-induced respiratory depression (RD) is a significant cause of death and brain damage in the perioperative period.
κ of 0.40 is considered acceptable, and 0.75 or higher is generally accepted as excellent agreement beyond chance. Risk factors assessed were male gender, patient age ≥50 yr, body mass index 35 kg/m2, and hypertension.
Methods: From the Anesthesia Closed Claims Project database of 9,799 claims, three authors reviewed 357 acute pain claims that occurred between 19 for the likelihood of RD using literature-based criteria.
The authors examined anesthesia closed malpractice claims associated with RD to determine whether patterns of injuries could guide preventative strategies.
The patients were mostly middle aged, obese, § Bureau of Labor Statistics, U. One quarter of the patients were either diagnosed with OSA preoperatively (16%) or were at high risk for OSA (9%, table 1). Somnolence was noted in 62% of patients before the event. Careful review of rare sentinel events is one method to identify causal factors that if modified or attended to could prevent undesirable outcomes. ‡ Stoelting RK and Overdyk FJ for the Anesthesia Patient Safety Foundation: Conclusions and Recommendations from June 8, 2011, Conference on Electronic Monitoring Strategies (Essential Electronic Monitoring Strategies to Detect Clinically Significant Drug-induced Respiratory Depression in the Postoperative Period). For this study, we examined the Anesthesia Closed Claims Project database comprising 9,799 claims. Criteria for definitive RD were as follows: (1) patient received naloxone and showed evidence of reversal of RD, or (2) other clear and objective signs of RD or opioid toxicity, for example, patient with a constellation of clinical signs such as oversedation, respiratory arrest, and need for resuscitation. The time between the last nursing check and the discovery of a patient with RD was within 2 h in 42% and within 15 min in 16% of claims. D.); and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (T. Copyright © 2014, the American Society of Anesthesiologists, Inc. However, the recommended intervention(s) to reduce RD and prevent poor outcomes are based largely on consensus opinion because data regarding their efficacy are lacking due to the rarity of serious complications. The Closed Claims Project Investigator Committee reviewed the claims, and any disagreements in assessments were resolved by an additional Committee member. We used predefined, literature-based1,2 criteria to identify RD.Forty-one percentage of patients underwent a lower extremity orthopedic procedure, primarily knee or hip replacement (table 1).Most (62%) of these lower extremity procedures occurred in the 1990s. (Anesthesiology 2015; 19-65) P OSTOPERATIVE opioid-induced respiratory depression (RD)1 has gained increasing attention as a potentially preventable cause of death and brain damage after surgery. We hypothesized that trends identified in medical malpractice claims could guide or reinforce strategies to reduce the potential for opioid-related adverse outcomes. A two-stage screening process was used to identify RD-related claims. The criterion for possible RD was a patient found in cardiopulmonary arrest without another identified cause (e.g., pulmonary embolism or neuraxial cardiac arrest) and with a presumed risk for RD (e.g., obese patient receiving significant amounts of opioids, history of snoring, loud breathing, or somnolence). Conclusions: This claims review supports a growing consensus that opioid-related adverse events are multifactorial and potentially preventable with improvements in assessment of sedation level, monitoring of oxygenation and ventilation, and early response and intervention, particularly within the first 24 h postoperatively. With these goals in mind, we analyzed the Anesthesia Closed Claims Project Database to identify clinical characteristics and management factors in malpractice claims associated with RD. Inclusion criteria were claims associated with acute pain management in which the damaging event occurred between 19 (n = 357). Criteria for probable RD were as follows: (1) respiratory rate less than 8/min, (2) somnolence, (3) Spo2 less than 90% in the absence of abnormal baseline Spo2, (4) pinpoint pupils, (5) administration of high doses of opioids in opioid-naive patient, or (6) qualitative observation of RD (e.g., snoring, airway obstruction, or cyanosis) that required intervention (e.g., jaw lift, positive pressure mask ventilation, or intubation). and decrease motor drive to the upper airway dilator and ..... High risk for OSA was defined as the presence of three or more criteria from the STOP-Bang screening tool.7 Risk factors assessed were male gender, patient age greater than or equal to 50 yr, body mass index greater than 35 kg/m2, and hypertension. combine to affect respiratory mechanics and increase overall ... The three anesthesiologists independently identified the presence of the following potential contributory factors for RD: preoperative diagnosis of obstructive sleep apnea (OSA), high risk for OSA, more than one opioid modality, more than one physician prescribing opioids or nonopioid sedating medications for the patient during the episode of care, history of chronic use of opioids, and the timing (in minutes) between the last nursing check and the RD event. Figure 3-Virus Isolation, Respiratory Illness, and Acute Phase Antibody During ..... C., on October 13, 2012, and in the ASA Newsletter of May 2013; –6. Data collected included patient demographics, type of surgery, details regarding the anesthesia care, patient outcomes, * The Joint Commission Sentinel Event Alert Issue 49: Safe Use of Opioids in Hospitals. Pain Medicine intramuscular injection, non-PCA intravenous therapy, or oral routes). The lowest estimates were reported when naloxone administration was used as the criterion for RD, followed sequentially by higher estimates based on respiratory rate, hypercarbia, and oxygen desaturation.2 In The Joint Commission’s review of opioid-related events from What We Already Know about This Topic • Postoperative opioid-related respiratory depression is an important cause of iatrogenic injury in the perioperative period • Risk factors for this injury are numerous and not applicable to all patients who develop respiratory depression What This Article Tells Us That Is New • In a review of 357 acute pain claims from the Anesthesia Closed Claims Project database, 92 cases involved likely opioid-related respiratory depression • The vast majority of these injuries occurred within 24 h of surgery and 97% were judged as preventable with better monitoring and response their Sentinel Event Database from 2004 to 2011, wrong dose medication errors were present in half of the events, improper monitoring occurred in almost one third, and other factors related to medication dosing and interactions This article is featured in “This Month in Anesthesiology,” page 1A. These findings were presented, in part, at the American Society of Anesthesiologists 2012 Annual Meeting in Washington, D. From the Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee (L. L.); Department of Anesthesiology, Virginia Mason Hospital and Seattle Medical Center, Seattle, Washington (R. C.); Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington (L. Information was collected from medical records, consultant evaluations, expert witness reports, claims manager summaries, and legal summaries. jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_ The reliability of these evaluations was judged to be acceptable.6 Modalities by which opioids were administered for pain control were classified as neuraxial (epidural or spinal), patient-controlled analgesia (PCA), or other (including Anesthesiology 2015; 19-65 660 Lee et al.