Evaluation of respiratory volume monitoring (RVM) to detect respiratory compromise in advance of pulse oximetry and help minimize false desaturation alarms (original) (raw)
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Journal of Trauma and Acute Care Surgery, 2014
BACKGROUND: Opioid-induced respiratory depression (OIRD) and postoperative apnea (POA) can lead to complications after surgery or traumatic injury. Previously, real-time monitoring of respiratory insufficiency and identification of apneic events have been difficult. A noninvasive respiratory volume monitor (RVM) that reports minute ventilation (MV), tidal volume, and respiratory rate is now available. The RVM was used to report the effect of opioids on respiratory status as well as demonstrate apneic breathing patterns in a hospital postanesthesia care unit. METHODS: RVM traces were collected from 132 patients. Predicted MV (MV PRED) for each patient was used to calculate and the ''percent predicted'' MV (MV MEASURED / MV PRED Â 100%) before opioid administration. Patients were stratified patients into two categories: ''at risk,'' MV of less than 80% MV PRED , and ''not at risk,'' MV of 80% MV PRED or greater. After opioid dosing, patients with MV of less than 40% MV PRED were categorized as ''unsafe.'' POA was defined as more than five apneic or hypopneic events per hour. RESULTS: Of the 132 patients, 50 received opioids. Baseline MV was 7.2 T 0.5 L/min. The MV-based protocol classified 18 of 50 patients as at risk before opioid administration. After the first opioid dose administration, at-risk patients experienced an average MV decrease (36.7% T 8.5% MV PRED) and 13 of 18 decreased into unsafe; the 32 not at-risk patients experienced a lesser average MV decrease (76.9% T 6.3% MV PRED). Only 1 of 32 not at-risk patients had a decrease in MV to unsafe. The proposed protocol had a sensitivity of 93% and a specificity of 86%. Of the 132 patients, 26 displayed POA. Of the 26 patients, 12 experienced POA without receiving opioids. Of the 26 patients with POA, 14 also received opioids, and of those, 6 were classified as unsafe. CONCLUSION: This investigation indicates that at risk and unsafe respiratory patterns occur frequently after procedure. RVM provides continuous noninvasive objective measurements of OIRD and POA. The RVM may prove a useful tool in opioid dosing and in recognition and management of POA and strong potential value in the rapid detection of OIRD and apnea in the contemporary combat casualty environment.
BJA: British Journal of Anaesthesia, 2019
Respiratory depression is common in patients recovering from surgery and anaesthesia. Failure to recognise and lack of timely institution of intervention can lead to catastrophic cardiorespiratory arrest, anoxic brain injury, and mortality. Opioid-induced respiratory depression (OIRD) is a common and often under-diagnosed cause of postoperative respiratory depression. Other causes include residual anaesthesia, residual muscle paralysis, concurrent use of other sedatives, splinting from inadequate pain control, and obstructive sleep apnoea. Currently used methods to identify and monitor respiratory safety events in the post-surgical setting have serious limitations leading to lack of universal adoption. New tools and technologies currently under development are expected to improve the prediction of respiratory depression especially in patients requiring opioids to alleviate acute postoperative pain. In this narrative review, we discuss the various causes of postoperative respiratory depression, and highlight the advances in monitoring and early recognition of patients who develop this condition with an emphasis on OIRD.
Journal of Clinical Monitoring and Computing, 2014
Continuous respiratory assessment is especially important during post-operative care following extubation. Respiratory depression and subsequent adverse outcomes can arise due to opioid administration and/or residual anesthetics. A non-invasive respiratory volume monitor (RVM) has been developed that provides continuous, real-time, measurements of minute ventilation (MV), tidal volume (TV), and respiratory rate (RR) via a standardized set of thoracic electrodes. Previous work demonstrated accuracy of the RVM versus standard spirometry and its utility in demonstrating response to opioids in postoperative patients. This study evaluated the correlation between RVM measurements of MV, TV and RR to ventilator measurements during general anesthesia (GA). Continuous digital RVM and ventilator traces, as well as RVM measurements of MV, TV and RR, were analyzed from ten patients (mean 62.6 ± 7.4 years; body mass index 28.6 ± 5.2 kg/m 2) undergoing surgery with GA. RVM data were compared to ventilator data and bias, precision and accuracy were calculated. The average MV difference between the RVM and ventilator was-0.10 L/min (bias:-1.3 %, precision: 6.6 %, accuracy: 9.0 %. The average TV difference was 40 mL (bias: 0.4 %, precision: 7.3 %, accuracy: 9.1 %). The average RR difference was-0.22 breaths/ minute (bias:-1.8 %, precision: 3.7 % accuracy: 4.1 %). Correlations between the RVM traces and the ventilator were compared at various points with correlations[0.90 throughout. Pairing the close correlation to ventilator measurements in intubated patients demonstrated by this study with previously described accuracy compared to spirometry in nonintubated patients, the RVM can be considered to have the capability to provide continuity of ventilation monitoring post-extubation This supports the use of real-time continuous
Anesthesia & Analgesia, 2020
Background: Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring. Methods: PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate 5 breaths/min (bpm), oxygen saturation 85%, or end-tidal carbon dioxide 15 or 60 mm Hg for 3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping. Results: One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age 60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30; P < .001) between the high-and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with 1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring. Conclusions: A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
Monitoring of hypoxaemic episodes in the late postoperative period
Anaesthesia, 1998
Remifentanil as an analgesic in the critically ill Recently some correspondence has been generated in this journal regarding remifentanil in the critically ill, some of it urging care in its unfettered use prior to 'well-designed studies'. Surely some circumspection is called for when considering its use as a sedative over a
Pain Management Nursing, 2011
opioid 12,003 citations respiratory depression 3,378 citations risk 436,675 citations Medline Search (5/11/2010) MeSH keywords: opioid and respiratory depression and risk Limits: last 20 years; age >19; English language; human Combined using AND 448 citations Combined using AND 55 citations Limited to case reports, clinical trials, comparative study, and meta analysis 41 citations (insufficient evidence) Two subcategories identified from these 6 articles Sleep Disordered Breathing Postoperative Pulmonary Complications Keyword with limits: sleep apnea 7,647 citations Keyword with limits: risk factors 436,675 citations Title with limits: risk 180,339 citations Title with limits: postoperative complications 11,861 citations Combined using AND, with limitations to case reports, clinical trials, comparative study, and meta analysis 1639 citations 1639 citations reviewed with 91 found to be relevant Combined using AND, with limitations to case reports, clinical trials, comparative study, and meta analysis 521 citations 521 citations reviewed with 68 found to be relevant
Anesthesiology, 2009
PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. This document updates the "Practice Guidelines for the Prevention, Detection and Management of Respiratory Depression Associated with Neuraxial Opioid Administration" adopted by ASA in 2007, and includes new survey data and recommendations pertaining to monitoring for respiratory depression.
Oxygen Reserve Index: Utility as an Early Warning for Desaturation in High-Risk Surgical Patients
Anesthesia & Analgesia, 2020
BACKGROUND: Perioperative pulse oximetry hemoglobin saturation (Spo 2) measurement is associated with fewer desaturation and hypoxia episodes. However, the sigmoidal nature of oxygen–hemoglobin dissociation limits the accuracy of estimation of the partial pressure of oxygen (Pao 2) >80 mm Hg and correspondingly limits the ability to identify when Pao 2 >80 mm Hg but falling. We hypothesized that a proxy measurement for oxygen saturation (Oxygen Reserve Index [ORI]) derived from multiwavelength pulse oximetry may allow additional warning time before critical desaturation or hypoxia. To test our hypothesis, we used a Masimo multiwavelength pulse oximeter to compare ORI and Spo 2 warning times during apnea in high-risk surgical patients undergoing cardiac surgery. METHODS: This institutional review board–approved prospective study (NCT03021473) enrolled American Society of Anesthesiologists physical status III or IV patients scheduled for elective surgery with planned preinductio...