Risk Factors for Opioid-Induced Respiratory Depression

Risk Factors for Opioid-Induced Respiratory Depression
Patient may have any one or more of the following to be considered high risk: Opioid naïvety (patients who have not been taking regular daily doses of opioids for several days). Older age (e.g., > 65 years There is no consensus on what age constitutes “older”; some cite it as over 65 years and others cite it as over 75 years. It is important to consider the patient’s general health and condition in addition to age. ). Obesity (e.g., BMI > 35 kg/m²). Obstructive sleep apnea (OSA). Most people with OSA do not know they have the condition; therefore, all patients and particularly their family members should be asked on admission if the patient snores or has apneic episodes during sleep or is excessively sleepy during the day. Other risk factors for OSA should be assessed as well (ASA, 2014). History of snoring or witnessed apneas. Excessive daytime sleepiness. Preexisting pulmonary disease or dysfunction (e.g., chronic obstructive pulmonary disease [COPD]). Major organ failure. Smoker. American Society of Anesthesiologists (ASA) Patient Status Classification 3, 4, or 5 in surgical patients (level determined by anesthesia provider preoperatively). Classification 3: A patient who has a severe systemic disease. Classification 4: A patient with severe systemic disease that is a constant threat to life. Classification 5: A moribund patient who is not expected to survive without the operation. Increased opioid dose requirement. Opioid-naïve patients who require more than 10 mg morphine equivalent in a short period of time (e.g., in the PACU). Patients who require 20 mg or more of morphine are at very high risk for opioid-induced sedation and clinically significant respiratory depression (Abou Hammoud et al., 2009). , It is recommended that patients be watched closely for at least 3 hours past the peak concentration of the last opioid dose (APS, 2008). Opioid-tolerant patients who are given a significant amount of opioid in addition to their usual amount, such as the patient who takes an opioid analgesic preoperatively for persistent pain and receives several IV opioid bolus doses in the PACU followed by high-dose IV PCA for ongoing acute postoperative pain. Pain is controlled after a period of poor control. Prolonged surgery. Thoracic and other large incisions that may interfere with adequate ventilation. Concomitant administration of sedating agents, such as benzodiazepines, anxiolytics, or antihistamines. Large single bolus techniques (e.g., single-injection neuraxial morphine). Continuous opioid infusion in opioid-naïve patients (e.g., IV PCA with basal rate [background infusion]). Naloxone administration: Patients who are given naloxone for clinically significant respiratory depression are at risk for repeated respiratory depression; another dose of naloxone may be needed as early as 30 minutes after the first dose because the duration of naloxone is shorter than the duration of most opioids. Copyright 2010, Chris Pasero. Used with permission. From Opioid analgesics. In C. Pasero & M. McCaffery, Pain assessment and pharmacologic management. St. Louis, MO: Mosby.

Patient may have any one or more of the following to be considered high risk:

Opioid naïvety (patients who have not been taking regular daily doses of opioids for several days).
Older age (e.g., > 65 years
There is no consensus on what age constitutes “older”; some cite it as over 65 years and others cite it as over 75 years. It is important to consider the patient’s general health and condition in addition to age.
).
Obesity (e.g., BMI > 35 kg/m²).
Obstructive sleep apnea (OSA).
Most people with OSA do not know they have the condition; therefore, all patients and particularly their family members should be asked on admission if the patient snores or has apneic episodes during sleep or is excessively sleepy during the day. Other risk factors for OSA should be assessed as well (ASA, 2014).
History of snoring or witnessed apneas.
Excessive daytime sleepiness.
Preexisting pulmonary disease or dysfunction (e.g., chronic obstructive pulmonary disease [COPD]).
Major organ failure.
Smoker.
American Society of Anesthesiologists (ASA) Patient Status Classification 3, 4, or 5 in surgical patients (level determined by anesthesia provider preoperatively).
- Classification 3: A patient who has a severe systemic disease.
- Classification 4: A patient with severe systemic disease that is a constant threat to life.
- Classification 5: A moribund patient who is not expected to survive without the operation.
Increased opioid dose requirement.
- Opioid-naïve patients who require more than 10 mg morphine equivalent in a short period of time (e.g., in the PACU).
  Patients who require 20 mg or more of morphine are at very high risk for opioid-induced sedation and clinically significant respiratory depression (Abou Hammoud et al., 2009).
  ,
  It is recommended that patients be watched closely for at least 3 hours past the peak concentration of the last opioid dose (APS, 2008).
- Opioid-tolerant patients who are given a significant amount of opioid in addition to their usual amount, such as the patient who takes an opioid analgesic preoperatively for persistent pain and receives several IV opioid bolus doses in the PACU followed by high-dose IV PCA for ongoing acute postoperative pain.
- Pain is controlled after a period of poor control.
Prolonged surgery.
Thoracic and other large incisions that may interfere with adequate ventilation.
Concomitant administration of sedating agents, such as benzodiazepines, anxiolytics, or antihistamines.
Large single bolus techniques (e.g., single-injection neuraxial morphine).
Continuous opioid infusion in opioid-naïve patients (e.g., IV PCA with basal rate [background infusion]).
Naloxone administration: Patients who are given naloxone for clinically significant respiratory depression are at risk for repeated respiratory depression; another dose of naloxone may be needed as early as 30 minutes after the first dose because the duration of naloxone is shorter than the duration of most opioids.

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