Last updated March 14, 2022

Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration

Summary of 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.
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Prevention of Respiratory Depression after Neuraxial Opioid Administration

Noninvasive Positive Pressure Ventilation

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

Administer the lowest efficacious dose of neuraxial opioids to minimize the risk of respiratory depression.
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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).
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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).
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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.
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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.
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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.
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Continuous Infusion or patient-controlled epidural opioids (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 the next 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.
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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.
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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.
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Recommendation Grading

Overview

Title

Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration

Authoring Organization

Publication Month/Year

March 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Improve patient safety and enhance the quality of anesthetic care by redung the incidence and the severity of neuraxial opioid-related respiratory depression or hypoxemia.

Target Patient Population

Patients receiving epidural or spinal opioids

Target Provider Population

Anesthesiologists

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient

Intended Users

Epidemiology infection prevention

Scope

Diagnosis, Prevention, Management

Diseases/Conditions (MeSH)

D009293 - Opioid-Related Disorders

Keywords

Anesthesiology, Respiratory Depression, Neuraxial Opioid Administration

Source Citation

Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration: An Updated Report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine*. Anesthesiology 2016;124(3):535-552. 

Methodology

Number of Source Documents
84
Literature Search Start Date
January 1, 2008
Literature Search End Date
July 31, 2015