Respiratory Depression In Patients Research Articles

Postoperative Oxygen Therapy in Patients With OSA: A Randomized Controlled Trial

Surgical patients with OSA are at increased risk for perioperative complications. Postoperative supplemental oxygen is commonly used, but it may contribute to respiratory depression in patients with OSA receiving opioids. The objective of the study is to investigate the effect of postoperative supplemental oxygen on arterial oxygen saturation (Sao2), sleep respiratory events, and CO2 level in patients with untreated OSA. Consented patients with an apnea hypopnea index (AHI) > 5 events per hour on a preoperative polysomnography were randomized (1:1) to oxygen (O2 group) or no oxygen (control group). The O2 group received oxygen at 3 L/min via nasal prongs for three postoperative nights. The primary outcomes were polysomnographic parameters measuring Sao2, sleep respiratory events, and Pco2 measured by transcutaneous CO2 monitor (PtcCO2) on nights 1 through 3. The intention-to-treat and per protocol analysis were completed. There were 123 patients randomized (O2 group: n= 62; control group: n= 61). On night 3, the O2 vscontrol group had a higher average Sao2 (95.2%± 3%vs91.4%± 4%, respectively; P< .001) and lower oxygen desaturation index (median, 2.3; 25th-75th percentile, 0.2-13.8 vsmedian, 18.5; 25th-75th percentile, 8.2-45.9 events per hour, respectively; P< .0001). The O2 group had a decreased AHI (median, 8.0; 25th-75th percentile, 2.1-19.9 vsmedian, 15.6; 25th-75th percentile, 9.5-45.8, respectively; P= .016), hypopnea index (P< .001), and central apnea index (P= .026) and a shortened longest apnea hypopnea duration (P= .002). Although time percentage with PtcCO2≥ 55mmHg≥ 10%on postoperative night 1, 2, or 3 was found in 11.4%patients, there was no difference in PtcCO2 between the groups. Postoperative supplemental oxygen was found to improve oxygenation and decrease the AHI without increasing the duration of apnea-hypopnea event or PtcCO2 level. A small number of patients had significant CO2 retention while receiving supplemental oxygen. ClinicalTrials.gov; No.: NCT01552304; URL: www.clinicaltrials.gov.

Sa1012 Integrated Pulmonary IndexTM Is a Simple and Valuable Assessment System for the Detection of Respiratory Depression in Patients Undergoing Sedation for Pancreatobiliary Endoscopy

Sa1012 Integrated Pulmonary IndexTM Is a Simple and Valuable Assessment System for the Detection of Respiratory Depression in Patients Undergoing Sedation for Pancreatobiliary Endoscopy

Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society.

The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm. A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convulsive status epilepticus treated with placebo indicating that respiratory problems are an important consequence of untreated convulsive status epilepticus (Level A). When both are available, fosphenytoin is preferred over phenytoin based on tolerability but phenytoin is an acceptable alternative (Level A). In adults, compared to the first therapy, the second therapy is less effective while the third therapy is substantially less effective (Level A). In children, the second therapy appears less effective and there are no data about third therapy efficacy (Level C). The evidence was synthesized into a treatment algorithm. Despite the paucity of well-designed randomized controlled trials, practical conclusions and an integrated treatment algorithm for the treatment of convulsive status epilepticus across the age spectrum (infants through adults) can be constructed. Multicenter, multinational efforts are needed to design, conduct and analyze additional randomized controlled trials that can answer the many outstanding clinically relevant questions identified in this guideline.

(418) Subanesthetic doses of ketamine produce respiratory depression in patients receiving methadone, but not in controls or patients receiving other long-term opioids

(418) Subanesthetic doses of ketamine produce respiratory depression in patients receiving methadone, but not in controls or patients receiving other long-term opioids

Inside preview of procuring narcotic license.

Sir, In India, around 555,000 people died of cancer in 2010, representing 8% of estimated cancer deaths globally and 6% of deaths in India.[1] Physical and psychological effects of chronic pain affect the progression of the disease.[2] Opioids are considered as a key component for treatment of moderate to severe pain in cancer patients. Despite the abundant opium availability in India, opioid consumption, as estimated by World Health Organisation Collaborating Centre in 2012, is only 0.24 mg/person [Table 1].[3]Table 1: Opioid consumption 2010 (Pain and Policy Studies Group, UWCCC/WHO Collaborating Center, 2012)In India, only 0.4% of the total population have access to the opioids. Complicated rules and regulations along with problems related to attitude and knowledge regarding pain relief and opioids among the medical professionals and the public are major hindrances for poor access to opioids.[4] According to Narcotic Drugs and Psychotropic Substances (NDPS) Act (1985), to procure opioids, all the medical institutes should possess a license; they should specify the drug, the required quantity and also the formulation of the drug. The procedure to procure the license includes filing an application to the Drug Controller in the capital city; the drug inspector then institutes an inspection. Inspector inspects for adequate storage facilities, security setup, facilities to discard drugs, etc. Approval by the Drug Inspector is transmitted to the Drug Controller. Then the health authority confirms the approval to Drug Controller and License is issued. Frequently, the validity of one licence expires by the time another licence is obtained. Thus, it becomes a tedious job for doctors and hospitals to get all the licences to procure morphine.[5] Narcotic Drugs and Psychotropic Substances Amendment Bill, 2014 has been passed in 2014 with path-breaking changes for access to narcotics by medical specialty, breaking the various barriers which were included in the 1985 act. Parliament has adopted a new category of essential narcotic drugs in which central government can notify on the basis of expediency in medical practice. Drugs considered as essential will be subjected to central rules and will apply uniformly throughout the country. With the relaxation of rules, chances of misuse may be more and also due to the possibility of pilferage, chances of addiction increase. Physicians are scared to prescribe narcotic drugs due to unfounded fear of addiction and respiratory depression in patients. Patients who want pain relief are seen as drug addicts and doctors fear prosecution under NDPS Act.[6] Many laws and government policies so far were restrictive, and availability was difficult, without realising their rational medical use in pain management.[78] Next is fear of dependence; for a patient in pain, dependence rarely results and this is not the reason for not prescribing opioids to ailing patients.[9] Studies in palliative care showed that increased use of morphine did not lead to misuse.[10] Our aim is to update the readers on improved access and awareness of opioids to patients and identify regulatory barriers in the availability of opioids. Physicians and nurses should be educated about the principles of palliative care. Sustained and persistent efforts should be made by the palliative care leaders so that regulatory barriers can be overcome. Awareness can be created by conducting more and more workshops on the proper use of narcotics. Administration also plays a great role as it monitors the administration of narcotics and ensures the accountability of these drugs. It also guides and helps in maintaining the records. License should be issued to the institution or to the panel of physicians rather than on the individual basis and punishment should be harsher. New ampoules are expected to be exchanged for the discarded ones. According to the the Drug Inspector, the provisions of the NDPS Act, 2014 will allow medical institutes to have uninterrupted supply of narcotics for the patient care and process of getting the different licences is expected to be less tedious. It is better to remember that by simplifying the narcotic regulation, opioid availability cannot be improved to the cancer patients as it needs education of health care professionals in pain management and palliative care along with the integration of the palliative care programmes into the health care system.[4]

Unrecognized hypoxia and respiratory depression in emergency department patients sedated for psychomotor agitation: pilot study.

IntroductionThe incidence of respiratory depression in patients who are chemically sedated in the emergency department (ED) is not well understood. As the drugs used for chemical restraint are respiratory depressants, improving respiratory monitoring practice in the ED may be warranted. The objective of this study is to describe the incidence of respiratory depression in patients chemically sedated for violent behavior and psychomotor agitation in the ED.MethodsAdult patients who met eligibility criteria with psychomotor agitation and violent behavior who were chemically sedated were eligible. SpO2 and ETCO2 (end-tidal CO2) was recorded and saved every 5 seconds. Demographic data, history of drug or alcohol abuse, medical and psychiatric history, HR and BP every 5 minutes, any physician intervention for hypoxia or respiratory depression, or adverse events were also recorded. We defined respiratory depression as an ETCO2 of ≥50 mmHg, a change of 10% above or below baseline, or a loss of waveform for ≥15 seconds. Hypoxia was defined as a SpO2 of ≤93% for ≥15 seconds.ResultsWe enrolled 59 patients, and excluded 9 because of ≥35% data loss. Twenty-eight (28/50) patients developed respiratory depression at least once during their chemical restraint (56%, 95% CI 42–69%); the median number of events was 2 (range 1–6). Twenty-one (21/50) patients had at least one hypoxic event during their chemical restraint (42%, 95% CI 29–55%); the median number of events was 2 (range 1–5). Nineteen (19/21) (90%, 95% CI 71–97%) of the patients that developed hypoxia had a corresponding ETCO2 change. Fifteen (15/19) (79%, 95% CI 56–91%) patients who became hypoxic met criteria for respiratory depression before the onset of hypoxia. The sensitivity of ETCO2 to predict the onset of a hypoxic event was 90.48% (95% CI: 68–98%) and specificity 69% (95% CI: 49–84%). Five patients received respiratory interventions from the healthcare team to improve respiration [Airway repositioning: (2), Verbal stimulation: (3)]. Thirty-seven patients had a history of concurrent drug or alcohol abuse and 24 had a concurrent psychiatric history. None of these patients had a major adverse event.ConclusionAbout half of the patients in this study exhibited respiratory depression. Many of these patients went on to have a hypoxic event, and most of the incidences of hypoxia were preceded by respiratory depression. Few of these events were recognized by their treating physicians.

Opioid-Induced Sedation and Respiratory Depression: Evidence-Based Monitoring Guidelines

RESPIRATORY DEPRESSION IS the most feared of the opioid adverse effects. Nurses in hospitals and all settings nationwide are challenged every day to prevent this life-threatening adverse effect. In 2011, the American Society for Pain Management Nursing (ASPMN) released evidence-based guidelines on monitoring for opioid-induced sedation and respiratory depression in patients receiving opioids for painmanagement in the acute care setting. The guidelines provide answers to frequently asked questions and may be useful in the development of hospital policies and procedures related to this important aspect of patient care. This article describes the development of the guidelines and provides its key recommendationswith implications for nursing practice and the care of patients with pain.

Neonatal Respiratory Depression and Intrathecal Fentanyl

ObjectiveTo establish the prevalence of neonatal respiratory depression in patients exposed to intrathecal fentanyl during Cesarean section. MethodsCross-sectional Analytical Observational Retrospective Study conducted at the Mother and Child Clinic of the Saludcoop Corporation in patients undergoing C-section who received intrathecal fentanyl for regional anesthesia in 2007 and 2008. Primary endpoints: low APGAR score (APGAR<7) and severe APGAR (APGAR<4). Results2165 records of C-sections and intrathecal fentanyl with a mean dose of 19.21mcg (SD=0.206mcg). Prevalence of low APGAR at 1.5 and 10 minutes was 1.77% (SD=0.63%), 0.11% (SD 0.163%), and 0%, respectively. The latter two values were different from the 1-minute value (ANOVA Scheffé Test, p=0.031) and there was no difference between them (minutes 5 and 10) (ANOVA p=0.861). Severely diminished APGAR results were, 0.059% (SD 0.058) 1 minute after birth and 0% at 5 and 10 minutes. There were no statistically significant differences between the three severely diminished values (ANOVA p=0.861). ConclusionsThe prevalence of respiratory depression measured with the APGAR test at birth is low; severely compromised APGAR shows a trend towards 0 in the different minutes of assessment. However, the reliability of the diagnostic tool (APGAR) is questionable, considering discrepancies when the analysis is done with a far more sensitive diagnostic tool (Silverman test).The importance of this study relates only to the assessment of prevalence and its use as a source of a research hypothesis, and not as an association or prediction study.

Depresión respiratoria neonatal y fentanilo intratecal

ObjectiveTo establish the prevalence of neonatal respiratory depression in patients exposed to intrathecal fentanyl during Cesarean section. MethodsCross-sectional Analytical Observational Retrospective Study conducted at the Mother and Child Clinic of the Saludcoop Corporation in patients undergoing C-section who received intrathecal fentanyl for regional anesthesia in 2007 and 2008. Primary endpoints: low APGAR score (APGAR<7) and severe APGAR (APGAR<4). Results2165 records of C-sections and intrathecal fentanyl with a mean dose of 19.21mcg (SD=0.206mcg). Prevalence of low APGAR at 1, 5 and 10 minutes was 1.77% (SD=0.63%), 0.11% (SD 0.163%), and 0%, respectively. The latter two values were different from the 1-minute value (ANOVA Scheffé Test, p=0.031) and there was no difference between them (minutes 5 and 10) (ANOVA p=0.861). Severely diminished APGAR results were, 0.059% (SD 0.058) 1 minute after birth and 0% at 5 and 10 minutes. There were no statistically significant differences between the three severely diminished values (ANOVA p=0.861). ConclusionsThe prevalence of respiratory depression measured with the APGAR test at birth is low; severely compromised APGAR shows a trend towards 0 in the different minutes of assessment. However, the reliability of the diagnostic tool (APGAR) is questionable, considering discrepancies when the analysis is done with a far more sensitive diagnostic tool (Silverman test).The importance of this study relates only to the assessment of prevalence and its use as a source of a research hypothesis, and not as an association or prediction study.

386: The Incidence of Hypoxia and Respiratory Depression During Emergency Department Chemical Restraint of Patients With Psychomotor Agitation

This is a prospective observational study to describe the incidence of hypoxia and respiratory depression in patients chemically restrained for psychomotor agitation in the emergency department (ED). Any patient over the age of 18 with psychomotor agitation who was to be chemically restrained with a benzodiazepine and/or a phenothiazine was eligible for enrollment. Routine management of these patients in our ED requires that they receive electronic monitoring of SpO2 and ETCO2. The ETCO2 monitor used recorded SpO2 and ETCO2 every 5 seconds, this data was saved and downloaded into Excel. A trained research associate recorded demographic data, history of drug or ETOH abuse, medical and psychiatric history. They also recorded HR and BP every 5 minutes, any physician intervention for hypoxia and/or respiratory depression, or adverse events. Hypoxia was defined as a SpO2 of <92% for >15 seconds, respiratory depression was defined as an ETCO2 of >50 mmHg, a change of 10% above or below baseline, or a loss of waveform for >15 seconds. 59 patients enrolled, 9 patients were excluded due to >35% data loss, leaving 50 patients for analysis. 21/50 patients developed hypoxia during their chemical restraint (42%). 28/50 developed respiratory depression during their chemical restraint (56%). 19/21 patients that developed hypoxia had an ETCO2 change. Of the 19 patients that developed hypoxia with a corresponding ETCO2 change. 15/19 had these changes before the onset of hypoxia. The mean length of time between the onset of an ETCO2 change to the onset of hypoxia was 5 minutes (SD +3.34 min). The average Ramsay sedation score was 4.36 (SD 0.57). The sensitivity of ETCO2 to predict the onset of a hypoxic event in this population is 90.48%, the sensitivity is 75.86%. 9 patients received an intervention for respiratory depression and hypoxia (5 verbal, 4 physical, 6 got supplemental O2). 37 pts had a history of concurrent drug or ETOH abuse; 24 patients had a concurrent psychiatric history. None of these patients had an adverse event. Almost half of the patients in this study exhibited hypoxia and/or respiratory depression. Most of the incidences of hypoxia were preceded by respiratory depression. Few of these events were recognized by their treating physicians. No adverse events were noted.

Randomized Clinical Trial of Propofol Versus Ketamine for Procedural Sedation in the Emergency Department

The objective was to compare the occurrence of respiratory depression, adverse events, and recovery duration of propofol versus ketamine for use in procedural sedation in the emergency department (ED). This was a randomized nonblinded prospective clinical trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients were randomized to receive either propofol 1 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed or ketamine 1.0 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed. Doses, vital signs, nasal end-tidal CO(2) (ETCO(2)), and pulse oximetry were recorded. Subclinical respiratory depression was defined as a change in ETCO(2) of >10 mm Hg, an oxygen saturation of <92% at any time, or an absent ETCO(2) waveform at any time. Clinical interventions related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure and had recall of the procedure. Physicians were asked to describe any adverse events or the occurrence of recovery agitation. One-hundred patients were enrolled; 97 underwent sedation and were included in the analysis. Fifty patients received propofol and 47 received ketamine. Subclinical respiratory depression was seen in 20 of 50 patients in the propofol group and 30 of 47 patients in the ketamine group (p = 0.019, effect size 22.8%; 95% CI = 4.0% to 43.6%). Clinical interventions related to respiratory depression were used in 26 of 50 propofol patients and 19 of 47 ketamine patients (p = 0.253, effect size = -13.7%; 95% CI = -33.8% to 6.4%). The median times of the procedures were 11 minutes (range = 4 to 33 minutes) for the ketamine group versus 10 minutes (range = 5 to 33 minutes) for the propofol group (p = 0.256). The median time to return to baseline mental status after the procedure was completed was 14 minutes (range = 2 to 47 minutes) for the ketamine group and 5 minutes (range = 1 to 32 minutes) for the propofol group (p < 0.001). Pain during the procedure was reported by 3 of 50 patients in the propofol group and 1 of 47 patients in the ketamine group (effect size = -3.9%, 95% confidence interval [CI] = -11.9 to 4.1). Recall of some part of the procedure was reported by 4 of 50 patients in the propofol group and 6 of 47 patients in the ketamine group (effect size = 4.8%, 95% CI = -7.6% to 17.1%). Forty-eight of 50 procedures were successful in the propofol group and 43 of 47 in the ketamine group (p = 0.357, effect size = 0.3%; 95% CI = -7.8% to 8.4%). Recovery agitation was reported in 4 of 50 in the propofol group and 17 of 47 in the ketamine group (effect size = 28.2%, 95% CI = 12.4% to 43.9%). This study detected a higher rate of subclinical respiratory depression in patients in the ketamine group than the propofol group. There was no difference in the rate of clinical interventions related to respiratory depression, pain, or recall of the procedure between the groups. Recovery agitation was seen more frequently in patients receiving ketamine than in those receiving propofol. The time to regain baseline mental status was longer in the ketamine group than the propofol group. This study suggests that the use of either ketamine or propofol is safe and effective for procedural sedation in the ED.

APA national audit of pediatric opioid infusions

A prospective audit of neonates, infants, and children receiving opioid infusion techniques managed by pediatric acute pain teams from across the United Kingdom and Eire was undertaken over a period of 17 months. The aim was to determine the incidence, nature, and severity of serious clinical incidents (SCIs) associated with the techniques of continuous opioid infusion, patient-controlled analgesia, and nurse-controlled analgesia in patients aged 0-18. The audit was funded by the Association of Paediatric Anaesthetists (APA) and performed by the acute pain services of 18 centers throughout the United Kingdom. Data were submitted weekly via a web-based return form designed by the Document Capture Company that documented data on all patients receiving opioid infusions and any SCIs. Eight categories of SCI were identified in advance, and the reported SCIs were graded in terms of severity (Grade 1 (death/permanent harm); Grade 2 (harm but full recovery and resulting in termination of the technique or needing significant intervention); Grade 3 (potential but no actual harm). Data were collected over a period of 17 months (25/06/07-25/11/08) and stored on a secure server for analysis. Forty-six SCIs were reported in 10 726 opioid infusion techniques. One Grade 1 incident (1 : 10,726) of cardiac arrest occurred and was associated with aspiration pneumonitis and the underlying neurological condition, neurocutaneous melanosis. Twenty-eight Grade 2 incidents (1 : 383) were reported of which half were respiratory depression. The seventeen Grade 3 incidents (1 : 631) were all drug errors because of programming or prescribing errors and were all reported by one center. The overall incidence of 1 : 10,000 of serious harm with opioid infusion techniques in children is comparable to the risks with pediatric epidural infusions and central blocks identified by two recent UK national audits (1,2). Avoidable factors were identified including prescription and pump programming errors, use of concurrent sedatives or opioids by different routes and overgenerous dosing in infants. Early respiratory depression in patients with specific risk factors, such as young age, neurodevelopmental, respiratory, or cardiac comorbidities, who are receiving nurse-controlled analgesia or continuous opioid infusion suggests that closer monitoring for at least 2 h is needed for these cases. As a result of this audit, we can provide parents with better information on relative risks to help the process of informed consent.

Temazepam 10 mg does not affect breathing and gas exchange in patients with severe normocapnic COPD

Benzodiazepines can improve sleep quality, but are also thought to cause respiratory depression in patients with chronic obstructive pulmonary disease (COPD). The aims of this study were to assess the effects of temazepam on indices of circadian respiratory function, dyspnea, sleep quality, and sleepiness in patients with severe COPD and insomnia. In a double-blind, randomized, placebo-controlled, cross-over study in 14 stable patients with COPD (mean FEV(1) 0.99+/-0.3L) with insomnia, polysomnography with continuous transcutaneous capnography and oximetry, arterial gas sampling, hypercapnic ventilatory response, multiple sleep latency test, Epworth Sleepiness Scale, dyspnea and sleep visual analogue scales (VAS) were performed at baseline, after one week of temazepam 10mg at bedtime and after one week of placebo. Temazepam did not cause statistically significant changes in mean transcutaneous carbon dioxide tension during sleep compared to placebo (5.9+/-1.0 kPa vs. 6.3+/-1.4 kPa, p-value 0.27), nor in mean oxygen saturation (92+/-3% vs. 92+/-2%, p-value 0.31), nor in any of the other investigated variables, except for the total sleep time and sleep latency VAS, which improved with temazepam. One week usage of temazepam 10mg does not influence circadian respiratory function, dyspnea, and sleepiness in patients with stable, severe, normocapnic COPD and insomnia and it improves total sleep time and subjective sleep latency. However, this is a preliminary explorative study for assessing the feasibility to perform a larger study on this topic. The clinical implications of this study are very limited.

Foreword

The increasing use of opioids in the perioperative period has increased opioid-associated morbidity and mortality. There is a well-established connection between opioids, sleep-disordered breathing (SDB), and respiratory depression. The treatment of postoperative pain with opioids in patients with SDB may result in respiratory depression. In an unmonitored setting, it may lead to life-threatening respiratory events. More studies are required to evaluate the effective management and prevention of respiratory depression in patients with SDB. This review summarizes the current state of knowledge relating to the pathophysiology of respiratory depression by opioids and opioid-related respiratory depression and appraises the association between opioids and SDB.

Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration.

Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration.

Intranasal Naloxone Is Effective for Opioid Overdose

Intravenous naloxone is the most rapid and predictable option for reversing respiratory depression in patients with opioid overdose, but gaining timely IV access in such patients is often difficult. Researchers retrospectively reviewed records for 154 patients with suspected opioid overdose who were treated with naloxone in a single prehospital setting over 17 months. Patients were …

Transdermal patient-controlled analgesia

Viscusi and Schechter1 provide a useful summary of various techniques of pain management using patient-controlled analgesia (PCA) delivered by different routes including epidural, i.v., and transdermal. Their analysis of the potential benefits of patient-activated transdermal analgesia system (PATS) delivery of fentanyl for PCA over other routes of administration suggests that this method may enhance effectiveness and minimize adverse respiratory events, particularly those associated with PCA pump-programming errors. We provide additional insight into these issues on the basis of our use of new technology that assesses continuous respiratory monitoring for patients receiving i.v. PCA with multiple opioid drugs. Since June 2004, we have used two respiratory monitoring devices to continuously measure arterial oxygen saturation and exhaled end-tidal carbon dioxide as part of an integrated, modular system of i.v. PCA delivery.a These devices have identified multiple patients who have experienced respiratory depression that might not have otherwise been detected before serious negative outcomes occurred.2,3 In addition, our analysis of continuous quality improvement (CQI) data from these devices indicates that respiratory depression in patients using PCA may be more common than is currently believed.4,–6

A Comparison of Capnography and Pulse Oximetry for the Detection of Respiratory Depression in Patients Undergoing Gastrointestinal Endoscopy

A Comparison of Capnography and Pulse Oximetry for the Detection of Respiratory Depression in Patients Undergoing Gastrointestinal Endoscopy

Withdrawal Syndrome After Delayed Tramadol Intake

Back to table of contents Previous article Next article Letter to the EditorFull AccessWithdrawal Syndrome After Delayed Tramadol IntakeCARLA RIPAMONTI, M.D., ELENA FAGNONI, M.D., and FRANCO De CONNO, M.D., CARLA RIPAMONTISearch for more papers by this author, M.D., ELENA FAGNONISearch for more papers by this author, M.D., and FRANCO De CONNOSearch for more papers by this author, M.D., Milan, ItalyPublished Online:1 Dec 2004https://doi.org/10.1176/appi.ajp.161.12.2326AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Tramadol is a centrally active synthetic analgesic drug with opioid and nonopioid properties (norepinephrine and serotonin reuptake inhibition). Its widespread use in benign and malignant painful conditions is due to the following: 1) tramadol is a nonscheduled medication, 2) most people are unaware of its opioid nature, 3) its name does not produce “opiophobia” like morphine does, and 4) it is not considered a drug that produces severe adverse effects, dependence, or abuse. However, some studies have reported tramadol abuse, respiratory depression in patients with renal failure, cerebral depression, and even a fatal outcome in association with a benzodiazepine (1, 2).In patients with or without a history of drug abuse who were treated with tramadol for chronic benign pain, also in therapeutic doses (up until 400 mg/day), dependence and withdrawal syndrome after abrupt discontinuation have been reported (3, 4). Tramadol is the third active principle most frequently involved in withdrawal syndromes (5). We could not locate in the literature any case of withdrawal in cancer patients taking tramadol.Ms. A was a 51-year-old nonsmoking woman with breast cancer, lung metastases, and brachial plexopathy, with no history of chemical or alcohol dependence. She was referred to the outpatient clinic because of severe pain. She had been taking tramadol for 2 years: 50 mg t.i.d. increasing to 100 mg t.i.d., plus 50 mg intramuscularly as needed. Switching to a strong opioid was proposed, but Ms. A refused for 2 months, notwithstanding her uncontrolled pain, because she said she became very agitated when delaying or skipping the tramadol administration, and she had learned to recognize the onset and then fear this nervousness, which reversed only by taking tramadol.One day she did not take tramadol twice in a row. After a few hours of having missed the first administration, she became very nervous. Upon missing the second dose, she began to have anxiety, anguish, a feeling of pins and needles all over her body, sweating, and palpitations. She knelt down and rolled on the floor, pressing her hands against her head so as “not to feel and not to understand what was happening” and begged her husband to take her back home immediately so she could have her tramadol dose. When we asked about her pain on that occasion, she replied, “I do not know because I felt too bad.” She described what happened very clearly and with great preoccupation because she felt like a “drug addict,” and when we suggested changing the opioid, she agreed so as not to undergo another similar experience. We stopped tramadol and prescribed oral methadone, 5 mg t.i.d., reducing it to 3 mg t.i.d. after a week, which resulted in analgesic benefit and no adverse effects.“Physical dependence” is the term used to describe the phenomenon of withdrawal when an opioid is abruptly discontinued. The severity of withdrawal is a function of the patient’s prior opioid exposure. Here we have a case of withdrawal due to physical dependence on tramadol even if no tolerance had developed over 2 years. The patient became nervous and agitated if the tramadol intake was merely delayed. When the patient missed the dose twice in a row, her withdrawal symptoms became severe, with an overwhelming need to take the drug that could appear as psychological dependence.We believe that 1) patients must be advised to take tramadol regularly and to stop gradually especially after long treatment periods, 2) physicians should consider the potential physical dependence when they prescribe tramadol for pain, and 3) any form of “dependence” of cancer patients taking tramadol, however, needs to be further explored. In fact, we are observing some patients who continue to take tramadol in order “to achieve a feeling of well-being,” even though their pain is controlled after disease regression or switching to strong opioids. This may be related to the inhibition of serotonin reuptake of tramadol.

Comparing efficacy and safety of four intravenous sedation regimens in dental outpatients

Management of patients' fear and anxiety during dental treatment is a primary concern of dental practitioners. Pharmacological strategies used in outpatient dental settings must be both safe and effective. Regimens of intravenously administered sedative drugs were evaluated in a collaborative, multicenter study of outpatients undergoing removal of impacted third molars. A total of 997 patients randomly received one of five treatments: placebo; midazolam administered to a clinical endpoint of conscious sedation (mean dose, 8.6 milligrams); midazolam plus additional midazolam as needed during the procedure (mean total dose, 12.2 mg); fentanyl (1.4 micrograms/kilogram) plus midazolam to achieve the same endpoint of conscious sedation (mean dose, 5.7 mg); or fentanyl (1.4 (micrograms/kg), midazolam (mean dose, 5.8 mg) and methohexital as needed during the procedure (mean dose, 61.0 mg). Each drug regimen reduced anxiety during surgery in comparison with placebo, with the combination of midazolam, fentanyl and methohexital resulting in significantly less anxiety in comparison with the other treatment groups. Pain reports by patients during surgery also were reduced significantly by the combination of fentanyl, midazolam and methohexital. Patients' global evaluations of the efficacy of sedation ranked midazolam with supplemental midazolam and the combination of fentanyl, midazolam and methohexital as significantly more efficacious than the other two drug regiments. The authors noted transient respiratory depression in patients in the two opioid-treated groups, but no other physiological changes were detected. These data provide evidence that the drugs and doses evaluated resulted in therapeutic benefit to dental outpatients, with minimal incidence of potentially serious adverse effects. The results of this large-scale study provide assurance to both the public and the dental profession of the safety of parenteral sedation with these drugs and combinations of these drugs when titrated slowly in the recommended doses by appropriately trained dentists.