Paper
Postoperative day one: a high risk period for respiratory events

Presented at the 29th Annual Surgical Symposium of the Association of VA Surgeons, Salt Lake City, Utah, March 11–13, 2005
https://doi.org/10.1016/j.amjsurg.2005.07.015Get rights and content

Abstract

Background

In 2001, the Joint Commission on Accreditation of Healthcare Organizations released Pain Management Standards that has led to an increased focus on pain control. Since then the Institute for Safe Medication Practices has noted that overaggressive pain management has led to increases in oversedation and fatal respiratory depression. One of our previous studies found that postoperative patients may be reaching dangerously high levels of sedation as a result of pain management. Our hypothesis is that postoperative patients who have a respiratory event caused by analgesic use are more likely to have that event in the first postoperative day.

Methods

We performed a retrospective case-control analysis identifying 62 postoperative patients who had a respiratory event. A respiratory event was defined as respiratory depression caused by narcotic use in the postoperative period that was reversed by naloxone. Sixty-two postoperative patients with no such event were chosen randomly and frequency matched based on surgical procedure and diagnosis-related group. Risk factors for an event were identified.

Results

Of the cases, 77.4% had a respiratory event in the first 24 hours postoperatively. Significant risk factors for an event were as follows: 65 years of age or older, having chronic obstructive pulmonary disease, having 1 or more comorbidities, and being placed on hydromorphone.

Conclusions

The first 24 hours after surgery represents a high-risk period for a respiratory event as a result of narcotic use. The realization of this risk can lead to the implementation of standards to increase patient safety in the first postoperative day.

Section snippets

Methods

This was an institutional review board–approved retrospective case-control analysis of in-patients undergoing major surgical procedures at a large urban academic institution for fiscal years 2003 and 2004 (October 2002–September 2004). By using an administrative database (Eclipsys; Eclipsys Corporation, Boca-Raton, FL), nontrauma patients older than 18 years who underwent surgery requiring greater than 24 hours of postoperative stay were identified. We then sought the subgroup that was given

Results

From October 2002 to September 2004 there were 62 patients with a respiratory event that were identified (patients) and matched to 62 nonrespiratory event patients (controls). Table 1 includes information on age, sex, past medical history, type of surgery, and length of stay. The patients were older than the controls and there were more women in the study (77 of 124). Types of surgeries were similar between the patients and controls, with abdominal surgeries being the most prevalent. Heart,

Comments

In the postoperative period, analgesia is achieved most commonly by using narcotics. These narcotics usually are opioids, with morphine being the prototype of all opioids [7]. Because of great variability in clinical response to opioids and the steep sigmoid dose-response curve for opioid analgesics, dosing can be difficult [8]. Giving too high a dose of opioids can lead to respiratory depression. This occurs by a dose-dependent depression of ventilation when opioids bind to μ receptors in the

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