Zero Tolerance May Be Unrealistic

Babak Roboubi, MD

To the Editor:

I read with interest the many articles in the winter 2006-2007 issue of APFS Newsletter regarding respiratory complications from opioid administration. Recommendations should be practical and applicable in a typical hospital setting. But it is unrealistic to have a policy of “zero tolerance” as some have suggested. Any intervention carries risks; even if a perfect respiratory monitor is discovered some patients will still experience adverse events due to both known and unknown factors.

Furthermore, any monitor employed should be convenient for the patient, as otherwise it will be associated with low to no compliance, and have a low false-positive alert system so as to not condition the providers to ignore the warning signs. Dr. Caplan’s closed claims analysis of cases involving postoperative PCA and neuraxial narcotics identified the care to be inappropriate in half of the cases, thereby suggesting that adherence to the existing guidelines might immediately cut the complication rates by half. More important than any monitor is knowing your patients, educating them, and having their support. Having guidelines in place and adhering to them through education and monitoring should be the cornerstone of the effort to reduce complications from opioid use. The bar should not be set so high as to make it impractical or impossible to administer any narcotics, as uncontrolled pain is associated with its own set of adverse events.

Babak Roboubi, MD
Washington, DC