RESUMEN
BACKGROUND: The aim of this study was to identify patient and procedural characteristics associated with postoperative respiratory depression or sedation requiring naloxone intervention. METHODS: We identified patients who received naloxone to reverse opioid-induced respiratory depression or sedation within 48 hours after discharge from anesthetic care (transfer from the postanesthesia care unit or transfer from the operating room to postoperative areas) between July 1, 2008, and June 30, 2010. Patients were matched to 2 control subjects based on age, sex, and exact type of procedure performed during the same year. A chart review was performed to identify patient, anesthetic, and surgical factors that may be associated with risk for intervention requiring naloxone. In addition, we identified all patients who developed adverse respiratory events (hypoventilation, apnea, oxyhemoglobin desaturation, pain/sedation mismatch) during phase 1 anesthesia recovery. We performed conditional logistic regression taking into account the 1:2 matched set case-control study design to assess patient and procedural characteristics associated with naloxone use. RESULTS: We identified 134 naloxone administrations, 58% within 12 hours of discharge from anesthesia care, with an incidence of 1.6 per 1000 (95% confidence interval [CI], 1.3-1.9) anesthetics. The presence of obstructive sleep apnea (odds ratio [OR] = 2.45; 95% CI, 1.27-4.66; P = 0.008) and diagnosis of an adverse respiratory event in the postanesthesia recovery room (OR = 5.11; 95% CI, 2.32-11.27; P < 0.001) were associated with an increased risk for requiring naloxone to treat respiratory depression or sedation after discharge from anesthesia care. After discharge from anesthesia care, patients administered naloxone used a greater median dose of opioids (10 [interquartile range, 0-47.1] vs 5 [0-24.8] IV morphine equivalents, P = 0.020) and more medications with sedating side effects (n = 41 [31%] vs 24 [9%]; P < 0.001). CONCLUSIONS: Obstructive sleep apnea and adverse respiratory events in the recovery room are harbingers of increased risk for respiratory depression or sedation requiring naloxone after discharge from anesthesia care. Also, patients administered naloxone received more opioids and other sedating medications after discharge from anesthetic care. Our findings suggest that these patients may benefit from more careful monitoring after being discharged from anesthesia care.
Asunto(s)
Analgésicos Opioides/efectos adversos , Pulmón/efectos de los fármacos , Naloxona/administración & dosificación , Antagonistas de Narcóticos/administración & dosificación , Insuficiencia Respiratoria/tratamiento farmacológico , Anciano , Distribución de Chi-Cuadrado , Estado de Conciencia/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Registros Electrónicos de Salud , Femenino , Humanos , Modelos Logísticos , Pulmón/fisiopatología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Naloxona/efectos adversos , Antagonistas de Narcóticos/efectos adversos , Oportunidad Relativa , Insuficiencia Respiratoria/inducido químicamente , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Apnea Obstructiva del Sueño/complicaciones , Factores de Tiempo , Resultado del TratamientoRESUMEN
Serotonin syndrome is gaining attention in perioperative and chronic pain settings due to the growing prevalence of multimodal therapies that increase serotonin levels and thereby heighten patient risk. A patient's genetic make-up may further increase the risk of serotonin syndrome. A case of serotonin syndrome on emergence after general anesthesia is presented. A subsequent cytochrome P4502D6 genetic test result suggested a potential alteration in metabolism. For this patient, who was taking combination antidepressant medications and receiving common perioperative medicines, additive pharmacodynamic effects converged with a pharmacogenetic predisposition, resulting in serotonin syndrome.
Asunto(s)
Complicaciones Posoperatorias/genética , Síndrome de la Serotonina/genética , Anestesia General/efectos adversos , Citocromo P-450 CYP2D6/genética , Interacciones Farmacológicas , Clorhidrato de Duloxetina , Predisposición Genética a la Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Síndrome de la Serotonina/diagnóstico , Síndrome de la Serotonina/etiología , Inhibidores Selectivos de la Recaptación de Serotonina/efectos adversos , Tiofenos/efectos adversosRESUMEN
STUDY OBJECTIVE: To compare analgesia and opioid-related side effects of intrathecal morphine and intrathecal hydromorphone after elective Cesarean delivery. DESIGN: Retrospective, comparative study. SETTING: Labor and delivery unit of an academic hospital. PATIENTS: 114 parturients age ≥ 18 years, presenting for elective Cesarean delivery. INTERVENTIONS: Patients who received 0.04 mg intrathecal hydromorphone were compared to a random sample of patients who received 0.1 mg intrathecal morphine for postoperative analgesia. MEASUREMENTS: The primary outcome was the presence of any opioid-related complication (pruritus, nausea or vomiting, respiratory depression) requiring treatment within 24 hours of intrathecal opioid administration. Secondary outcomes included total opioid consumption (in oral morphine equivalents) within 24 hours of intrathecal opioid administration and verbal pain score (0 = none, 10 = worst) at 4, 8, 12, 18, and 24 hours after intrathecal opioid administration. MAIN RESULTS: 38 patients who received intrathecal hydromorphone 0.04 mg were compared with 76 patients given 0.1 mg of intrathecal morphine for elective Cesarean delivery. No significant differences in demographics were noted between groups. There were no statistically significant differences between the intrathecal hydromorphone and intrathecal morphine groups in overall frequency of opioid-related complications (50% vs. 34.2%; P = 0.11), 24-hour opioid consumption (33 mg oral morphine equivalent [OME] vs. 8 mg OME; P = 0.27), or pain scores at any time point up to 24 hours. CONCLUSIONS: Overall, analgesia and incidence of opioid-related side effects after 0.04 mg of intrathecal hydromorphone did not differ statistically from 0.1 mg of intrathecal morphine.