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Current Drug Safety

Author(s): Julien Raft*, Kévin Podrez, Cédric Baumann, Philippe Richebé and Hervé Bouaziz

DOI: 10.2174/1574886314666190306110434

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Postoperative Clinical Monitoring After Morphine Administration: A Retrospective Multicenter Practice Survey

Page: [140 - 146] Pages: 7

  • * (Excluding Mailing and Handling)

Abstract

Background: The objective of this survey was to describe the clinical monitoring practically used after intravenous, subcutaneous or neuraxial (epidural or intrathecal) administration of morphine.

Methods: It was a descriptive, retrospective, multicenter (10 hospitals) survey based on the medical charts’ analysis, which evaluated the postoperative clinical monitoring after morphine administration.

Results: Morphine was delivered intravenously (69%), intrathecally (19%), epidurally (10%) and/or subcutaneously (12%). Clinical monitoring protocols and protocols for the management of side effects were both present in 60% (n=6/10), only one of the two types of protocols in 10% (n=1/10) and both absent in 30% (n=3/10). Protocols for the management of respiratory depression and consciousness evaluation were present in 70% of cases (n=7/10). These events were reported on medical records without any prescription or protocol in 35% (n=14/40) and 37,5% (n=15/40) respectively. Prescriptions for respiratory rate evaluation and clinical monitoring of consciousness were in agreement with only 20% of the medical data and medical records. Different levels of respiratory rate were observed: 43% (n=3/7) below 8/min, 43% (n=3/7) below 10/min and 14% (n=1/7) below 12/min. Clinical monitoring was not performed in 31% (n=31/100) for consciousness and in 35% (n=35/100) for respiratory rate. Pulse oximeter was used in 48% (n=48/100) of patients. Capnography was never used. Respiratory depression occurred in 1% (n=1/100) of cases.

Conclusion: This survey emphasizes an important disparity in the prescription of medical monitoring and a lack of use of protocols when morphine is administered. It demonstrates the need for a standardization of protocols according to the existing guidelines.

Keywords: Clinical monitoring, protocols, morphine, respiratory depression, consciousness, PCA.

Graphical Abstract

[1]
Cashman JN, Dolin SJ. Respiratory and haemodynamic effects of acute postoperative pain management: Evidence from published data. Br J Anaesth 2004; 93: 212-23.
[2]
Lee LA, Caplan RA, Stephens LS, et al. Postoperative opioid-induced respiratory depression: A closed claims analysis. Anesthesiology 2015; 122: 659-65.
[3]
Aubrun F, Benhamou D, Bonnet F, et al. Practical attitude for the management of postoperative pain Available from: http://sfar.org/attitude-pratique-pour-la-prise-en-charge-de-la-douleur-postoperatoire/ (accessed 02 juin 2012)
[4]
American Society of Anesthesiologists Task Force on Neuraxial Opioids, Horlocker TT, Burton AW, et al. . Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009; 110: 218-30.
[5]
Ramachandran SK, Haider N, Saran KA, et al. Life-threatening critical respiratory events: A retrospective study of postoperative patients found unresponsive during analgesic therapy. J Clin Anesth 2011; 23: 207-13.
[6]
Brown KA, Laferrière A, Lakheeram I, Moss IR. Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology 2006; 105: 665-9.
[7]
Baxter AD. Respiratory depression with patient-controlled analgesia. Can J Anaesth J Can Anesth 1994; 41: 87-90.
[8]
Gustafsson LL, Schildt B, Jacobsen K. Adverse effects of extradural and intrathecal opiates: Report of a nationwide survey in Sweden 1982. Br J Anaesth 1998; 81: 86-93.
[9]
Wolff J, Bigler D, Christensen CB, Rasmussen SN, Andersen HB, Tønnesen KH. Influence of renal function on the elimination of morphine and morphine glucuronides. Eur J Clin Pharmacol 1988; 34: 353-7.
[10]
Fleming BM, Coombs DW. A survey of complications documented in a quality-control analysis of patient-controlled analgesia in the postoperative patient. J Pain Symptom Manage 1992; 7: 463-9.
[11]
Overdyk FJ, Carter R, Maddox RR, Callura J, Herrin AE, Henriquez C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg 2007; 105: 412-8.
[12]
Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs Off J Am Soc Pain Manag Nurses 2011; 12: 118-45.
[13]
SFAR Committees on Pain and Local Regional Anaesthesia and on Standards. Expert panel guidelines (2008). Postoperative pain management in adults and children. SFAR Committees on pain and local regional anaesthesia and on standards. Ann Fr Anesth Reanim 2009; 28: 403-9.
[14]
Mercadante S. Intravenous patient-controlled analgesia and management of pain in post-surgical elderly with cancer. Surg Oncol 2010; 19: 173-7.
[15]
Notcutt WG, Morgan RJ. Introducing patient-controlled analgesia for postoperative pain control into a district general hospital. Anaesthesia 1990; 45: 401-6.
[16]
Looi-Lyons LC, Chung FF, Chan VW, McQuestion M. Respiratory depression: An adverse outcome during patient controlled analgesia therapy. J Clin Anesth 1996; 8: 151-6.
[17]
Ko S, Goldstein DH, VanDenKerkhof EG. Definitions of “respiratory depression” with intrathecal morphine postoperative analgesia: A review of the literature. Can J Anaesth 2003; 50: 679-88.
[18]
Choinière M, Rittenhouse BE, Perreault S, et al. Efficacy and costs of patient-controlled analgesia versus regularly administered intramuscular opioid therapy. Anesthesiology 1998; 89: 1377-88.
[19]
Aubrun F, Monsel S, Langeron O, Coriat P, Riou B. Postoperative titration of intravenous morphine. Eur J Anaesthesiol 2001; 18: 159-65.
[20]
Aubrun F, Monsel S, Langeron O, Coriat P, Riou B. Postoperative titration of intravenous morphine in the elderly patient. Anesthesiology 2002; 96: 17-23.
[21]
Flisberg P, Rudin A, Linnér R, Lundberg CJF. Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients. Acta Anaesthesiol Scand 2003; 47: 457-65.
[22]
Butler-Williams C, Cantrill N, Maton S. Increasing staff awareness of respiratory rate significance. Nurs Times 2005; 101: 35-7.
[23]
McQuillan P, Pilkington S, Allan A, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998; 316: 1853-8.
[24]
Hogan J. Why don’t nurses monitor the respiratory rates of patients? Br J Nurs Mark Allen Publ 2006; 15: 489-92.
[25]
McCormack JG, Kelly KP, Wedgwood J, Lyon R. The effects of different analgesic regimens on transcutaneous CO2 after major surgery. Anaesthesia 2008; 63: 814-21.
[26]
Shapiro A, Zohar E, Zaslansky R, Hoppenstein D, Shabat S, Fredman B. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. J Clin Anesth 2005; 17: 537-42.
[27]
Hutchison R, Rodriguez L. Capnography and respiratory depression. Am J Nurs 2008; 108: 35-9.
[28]
Zeitz K, McCutcheon H. Observations and vital signs: Ritual or vital for the monitoring of postoperative patients? Appl Nurs Res ANR 2006; 19: 204-11.
[29]
Flisberg P, Jakobsson J, Lundberg J. Apnea and bradypnea in patients receiving epidural bupivacaine-morphine for postoperative pain relief as assessed by a new monitoring method. J Clin Anesth 2002; 14: 129-34.
[30]
Beydon L, Hassapopoulos J, Quera MA, et al. Risk factors for oxygen desaturation during sleep, after abdominal surgery. Br J Anaesth 1992; 69: 137-42.