Episodes of postoperative opioid-induced respiratory depression are multifactorial and potentially preventable with improved assessment of sedation levels, monitoring of oxygenation and ventilation, and early response and intervention, concludes a study published in the March 2015 issue of Anesthesiology. The researchers identified 92 claims from the Anesthesia Closed Claims Project database that occurred between 1990 and 2009 for which respiratory depression was judged as possible, probable, or definite. Of these cases, 77% resulted in severe brain damage or death, 88% occurred within 24 hours of surgery, and 97% were judged as preventable with better monitoring and response. The data revealed several possible contributing factors, including the presence of multiple prescribers (33% of claims), concurrent administration of nonopioid sedating medications (34% of claims), unaddressed somnolence (62%), and inadequate nursing assessments or response (31% of claims). Although the ideal monitor for detecting respiratory depression remains controversial, the study's data demonstrates that life-threatening respiratory depression can evolve very rapidly, with respiratory depression discovered within 15 minutes of a nursing check in 16% of the cases; thus, the researchers suggest that preventive strategies may require continuous monitoring, rather than intermittent checks, and a focus on effective response capacity, as well as event detection. Furthermore, because basic pulse oximetry monitoring was in use at the time of the respiratory depression event in at least one-third of the claims studied, the researchers caution that respiratory monitoring without centralized or telemetric alarms may be insufficient to prevent a respiratory depression event. Additional strategies to prevent episodes of respiratory depression discussed in the study include implementing institutional policies that discourage, limit, or prevent more than one opioid-prescribing physician per patient and the use of nonopioid sedating medications in patients who are receiving opioids and considering removing or decreasing the continuous opioid infusion from local anesthetic infusions or, when coupled with patient-controlled analgesia, in patients who are at high risk for respiratory depression or who become excessively sedated.

HRC Recommends: Postoperative opioid-induced respiratory depression is a significant patient safety concern. Risk managers may wish to forward the preventive strategies and article to appropriate individuals and departments and consider whether the organization should adopt a standardized approach to assessing postoperative opioid-induced respiratory depression. Risk managers should coordinate with clinical leadership to ensure that patient assessment and monitoring adheres to clinical standards and accreditation requirements and is consistently documented.