Opioid-Induced Ventilatory Impairment: An Ongoing APSF Initiative

Steven Greenberg, MD, FCCP, FCCM

A substantial number of preventable deaths and other adverse events are associated with opioid-induced ventilatory impairment (OIVI).1 In fact, opioids are the most common category of drugs prescribed in U.S. hospitals today and the second most common category (hormone and synthetic substitutes being the first) associated with serious patient adverse outcomes.2,3 While the exact incidence of OIVI in hospitals is difficult to quantify, one study suggested that it may occur in as many as 1 in 200 postoperative patients.4 Unfortunately, risk stratification and heightened awareness of risk factors does not identify all patients who develop postoperative OIVI.5

The APSF’s mission is the ongoing improvement of patient safety through advancement of research, education, and quality improvement programs that stimulate ideas for positive safety change. As one step toward fulfilling that mission, the APSF has sponsored two multidisciplinary conferences: the first one in October 2006 in San Francisco and the most recent one in June 2011 in Phoenix. The Phoenix conference was titled, “Essential Monitoring Strategies to Detect Clinically Significant Drug Induced Respiratory Depression in the Postoperative Period.” The premise of the conferences was summarized by the statement that, “No patient shall be harmed by opioid-induced respiratory depression in the postoperative period.”5 The consensus of the 136 conference participants was that continuous electronic monitoring should be utilized for postoperative patients receiving opioids. At that time, pulse oximetry was determined to be the most reliable and readily available monitor in those patients not receiving supplemental oxygen.5 In addition, if supplemental oxygen is being used, the consensus was to use monitors of gas exchange (i.e., capnography) to detect hypoventilation.5 Although participants recognized that the lack of local resources may thwart universal continuous monitoring, they hoped to see a period when all patients receiving opioids would be monitored for OIVI.5 As part of its ongoing efforts in this area, the APSF developed an innovative educational video with real-life patient and family experiences involving OIVI (https://www.apsf.org/resources/oivi/). Experts in this field, with the support of APSF, have continued to promote the use of continuous electronic monitoring for those patients receiving postoperative opioids. In addition, several research projects involving OIVI have been funded by the APSF to advance this patient safety topic.

Throughout the year, the APSF Newsletter will continue to focus on topics related to the ongoing problem of OIVI. These topics include an examination of the closed claims data involving OIVI, an update on methods for monitoring OIVI, the perspective of the Joint Commission on OIVI, and a review of the impact of perioperative prescribing practices on OIVI. We hope all readers will reflect on their own clinical practices related to opioid administration. In addition, we hope that the information will motivate practitioners and their organizations to address the challenge of reducing harm from perioperative opioid administration.

Dr. Greenberg is presently Editor of the APSF Newsletter and Vice Chairperson of Education in the Department of Anesthesiology, Critical Care and Pain Medicine at NorthShore University HealthSystem in Evanston, IL. He is Clinical Associate Professor in the Department of Anesthesia/Critical Care at the University of Chicago.


He has no disclosures pertaining to this introduction.


References

  1. The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert #49 2012;Aug 8;1–4.
  2. Lucado J, Paez K, Elixhauser A. Medication-Related adverse outcomes in U.S. hospitals and emergency departments, 2008. HCUP Statistical Brief #109. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ncbi.nlm.nih.gov/books/NBK54566/.
  3. Davies EC, Green CF, Taylor S, et al. Adverse drug reactions in hospital inpatients: a prospective analysis of 3695 patient-episodes. PLoS ONE 2009;4:e4439.
  4. Dahan A, Aarts L, Smith TW. Incidence, reversal, and prevention of opioid-induced respiratory depression. Anesthesiology 2010;112:226–238.
  5. Weinger MB, Lee LA. No patient shall be harmed by opioid-induced respiratory depression. APSF Newsletter 2011;26:21–40.