Management of respiratory depression associated with neuraxial opioid administration: Practice Guidelines

In march 2016, American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine came out with updated Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration.

Following are its major recommendations:-

Identification of Patients at Increased Risk of Respiratory Depression

• Conduct a focused history and physical examination before administering neuraxial opioids.
  
  
  
  • Direct particular attention toward signs, symptoms, or a history of sleep apnea, co-existing 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.
  
  
  
  

Prevention of Respiratory Depression after Neuraxial Opioid Administration

• Encourage patients with a history of sleep apnea treated with noninvasive positive airway pressure to bring their own equipment to the hospital.

Route of Administration

• 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.

Type of Drug

• 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, match the appropriate duration of monitoring with the drug.


• Based on the duration of action of hydrophilic opioids, do not administer neuraxial morphine or hydromorphone to outpatient surgical patients.

Dose Selection

• Administer the lowest efficacious dose of neuraxial opioids to minimize the risk of respiratory depression.

Drug Combinations

• Administer parenteral opioids or hypnotics cautiously 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).

Monitoring for Respiratory Depression

• Monitor all patients receiving neuraxial opioids 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.*


• Increased monitoring (e.g., intensity, duration, or additional methods of monitoring) may be warranted for 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).

*In cases with other concerning signs, it is acceptable to awaken a sleeping patient to assess level of consciousness.

†"Hospitalized patients who are at an increased risk of respiratory compromise from obstructive sleep apnea (OSA) should have continuous pulse oximetry monitoring after discharge from the recovery room. Continuous monitoring may be provided in a critical care or step-down unit, by telemetry on a hospital ward or by a dedicated, appropriately trained professional observer in the patient's room. Continuous monitoring should be maintained as long as patients remain at an increased risk. Intermittent pulse oximetry or continuous bedside oximetry without continuous observation does not provide the same level of safety." From: Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, Coté CJ, Nickinovich DG, Prachand V, Ward DS, Weaver EM, Ydens L, Yu S; American Society of Anesthesiologists Task Force on Perioperative Management of Obstructive Sleep Apnea. Practice guidelines for the perioperative management of obstructive sleep apnea: A report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006; 104:1081–93.

Single-injection Neuraxial Lipophilic Opioids (e.g., Fentanyl)

• Monitor for a minimum of 2 h after administration. Monitor continually (i.e., repeated regularly and frequently in steady rapid succession‡) for the first 20 min after administration, followed by monitoring at least once per hour until 2 h have 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 with Neuraxial Lipophilic Opioids

• Monitor during the entire time the infusion is in use.


• Monitor continually for the first 20 min after initiation, followed by monitoring at least once per hour until 12 h have passed.


• From 12 to 24 h, monitor at least once every 2 h, and after 24 h, monitor at least once every 4 h.


• After discontinuation of continuous infusion or patient-controlled epidural opioid (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)

• Monitor for a minimum of 24 h after administration.


• Monitor 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

• Monitor during the entire time the infusion is in use.


• Monitor at least once every hour for the first 12 h after initiation, followed by monitoring at least once every 2 h for thenext 12 h.


• After 24 h, monitor 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

• Monitor at least once every hour during the first 12 h after administration and at least once every 2 h for the next 12 h (i.e., 12 to 24 h).


• After 24 h, monitor at least once every 4 h for a minimum of 48 h.

Management and Treatment of Respiratory Depression

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


• Administer supplemental oxygen to patients with altered level of consciousness, respiratory depression, or hypoxemia and continue until the patient is alert and no respiratory depression or hypoxemia is present.


• Maintain intravenous access 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, initiate appropriate resuscitation.
  
  
  
  


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


• If frequent or severe airway obstruction or hypoxemia occurs during postoperative monitoring, initiate noninvasive positive pressure ventilation.

The Task Force cautions that routine use of supplemental oxygen may increase the duration of apneic episodes and may hinder detection of atelectasis, transient apnea, and hypoventilation.

You can read the full guidelines by clicking on the following link :

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2477976