Perioperative pain: opioids: Naloxone use in postoperative pain management

Abstract

Concerns have been raised by groups such as the Institute for Safe Medication Practices that overaggressive pain management has led to an alarming increase in fatal respiratory depression events. In 2001, of the 199 medication related sentinel events reported to the Joint Commission, 21% involve opioids. The administration of naloxone may be an important monitor of the quality and safety of postoperative pain management. However, studies supporting the use of naloxone as a quality measure are absent. The purposes of this study are to determine incidence and factors associated with naloxone administration in the postoperative setting and to critically examine naloxone as a potential quality measure. Subjects included all postoperative adult inpatients at an academic hospital who received naloxone and an equal number of matched control patients who did not receive naloxone during the calendar year 2003. Real time medical record audits were performed to examine patient demographics, relevant medical history, postoperatively administered analgesics and central nervous system depressants, documented sedation and respiratory assessments, reason provided for naloxone administration, and patient outcome. Preliminary results (as of 9/30/03) indicate that 0.68% (44/6436) of all adult inpatient postop patients received naloxone. Patients who received naloxone were significantly older (61 yrs vs. 48), had lower respiratory rates (12.66/min vs. 14.54), higher sedation scores (3.59/6 vs. 2.59), and lower pulse oximetry (86.38 vs. 95.26) than matched controls. In addition, naloxone recipients received more CNS depressants, had higher incidence of hypothyroidism, renal dysfunction, and sleep apnea, and were treated less often with epidural anlagesia than control patients. There was no significant difference in the amount of opioids taken by the two groups. Reversal of excessive opioid sedation was the primary reason provided for naloxone administration, however 25% (11/44) of the patients were later determined to have new diagnosis which contributed to the need for naloxone.