No votes yet

Opioid Safety: Is Your Patient at Risk for Respiratory Depression?

Lisa Hartkopf Smith
CJON 2007, 11(2), 293-296 DOI: 10.1188/07.CJON.293-296

Case Study: S.J. is a 42-year-old woman with stage III ovarian cancer who underwent a total abdominal hysterectomy and bilateral oophorectomy today. Other than ovarian cancer, she has no other significant medical history except sleep apnea. She is five feet, two inches tall and weighs 200 pounds. Her serum creatinine and liver function tests are within normal limits. She was taking no medication prior to admission. Her medications now include hydromorphone (1 mg IV push every three hours as needed for pain) and promethazine (25 mg IV push every four hours as needed for nausea). At 1 am, she puts on her call light. "I really have a lot of pain. It is a 9/10, and I feel sick to my stomach. Could you get me something?" she says. Her last hydromorphone was four hours earlier, and she is due for promethazine. She is alert, and her respirations are 12. The nurse gives her hydromorphone and promethazine. One hour later, the nurse returns to the room and finds S.J. difficult to arouse. S.J.'s pupils appear constricted, and her respirations are 7 and shallow. The nurse notifies the resident on call and obtains an order for naloxone. The nurse administers the naloxone and oxygen and monitors the patient's vital signs. S.J.'s respirations quickly return to normal, and she is alert and oriented.


American Pain Society. (1992). <i>Principles of analgesic use in the treatment of acute and cancer pain</i> (3rd ed.). Glenview, IL: Author.

American Pain Society. (1996). Consensus statement: The use of opioids for the treatment of chronic pain. Retrieved March 9, 2007, from <a target="_blank" href='http://www.ampainsoc.org/advocacy/opioids.htm'>http://www.ampainsoc.org/...

Bennett, R., Batenhorst, R., Graves, D.A., Foster, T.S., Griffen, W.O., & Wright, B.D. (1982). Variation in postoperative analgesic requirements in the morbidly obese following gastric bypass surgery. <i>Pharmacotherapy</i>, 2, 50-53.

Borgbjerg, F.M., Nielsen, K., & Franks, J. (1996). Experimental pain stimulates respiration and attenuates morphineinduced respiratory depression: A controlled study in human volunteers. <i>Pain</i>, 64, 123-128.

Cashman, J.N., & Dolin, S.J. (2004). Respiratory and haemodynamic effects of acute postoperative pain management: Evidence from published data. <i>British Journal of Anaesthesia</i>, 93, 212-223.

Cepeda, M.S., Farrar, J.T., Baumgarten, M., Boston, R., Carr, D.B., & Strom, B.L. (2003). Side effects of opioids during short-term administration: Effect of age, gender, and race. <i>Clinical Pharmacology and Therapeutics</i>, 74, 102-112.

Chulay, M. (2004). Sedation assessment: Easier said than done! <i>Critical Care Nursing Clinics of America</i>, 16, 359-364.

Etches, R.C. (1994). Respiratory depression associated with patient-controlled analgesia: A review of eight cases. <i>Canadian Journal of Anesthesia</i>, 41, 125-132.

Flisberg, P., Rudin, A., Linner, R., & Lundberg, C.J. (2003). Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2,696 patients. <i>Acta Anaesthesiologica Scandinavica</i>, 47, 457-465.

Fu, E.S., Downs, J.B., Schweiger, J.W., Miguel, R.V., & Smith, R.A. (2004). Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. <i>Chest</i>, 126, 1552-1558.

Hauer, M., Cram, E., Titler, M., Alpen, M., & Harp, J. (1995). Intravenous patient-controlled analgesia in critically ill postoperative/trauma patients: Research-based practice recommendations. <i>Dimensions of Critical Care Nursing</i>, 14, 144-153.

Institute of Safe Medication Practices. (2002). ISMP medication safety alert! Pain scales don't weigh every risk. Retrieved October 24, 2006, from <a target="_blank" href='http://www.ismp.org/newsletters/acutecare/articles/20020724.asp?ptr=y'>h...

Lavand'Homme, P., & De Kock, M. (1998). Practical guidelines on the postoperative use of patient-controlled analgesia in the elderly. <i>Drugs and Aging</i>, 13, 9-16.

McCaffery, M., & Pasero, C. (1999). <i>Pain: Clinical manual</i> (2nd ed.). St. Louis, MO: Mosby.

Ostermeier, A.M., Roizen, M.F., Hautkappe, M., Klock, P.A., & Klafta, J.M. (1997). Three sudden postoperative respiratory arrests associated with epidural opioids in patients with sleep apnea. <i>Anesthesia and Analgesia</i>, 85, 452-460.

Overdyk, F., Carter, R., & Maddox, R. (2006). New JCAHO pain standards bigger threat to patient safety than envisioned. <i>Anesthesia and Analgesia</i>, 102, 1596-1597.

Overdyk, F., Maddox, R., & Carter, R. (2006). Incidence of respiratory depression with PCA using continuous oximetry and capnography monitoring. Presented at the American Society of Anesthesiologists, Chicago, IL. Retrieved January 4, 2007, from http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid...

Parikh, S.N., Stuchin, S.A., Maca, C., Fallar, E., & Steiger, D. (2002). Sleep apnea syndrome in patients undergoing total joint arthroplasty. <i>Journal of Arthroplasty</i>, 17, 635-642.

Pasero, C., & McCaffery, M. (2002). Monitoring sedation. <i>American Journal of Nursing</i>, 102(2), 67-69.

Rawal, N., & Allvin, R. (1996). Epidural and intrathecal opioids for postoperative pain management in Europe—A 17-nation questionnaire study of selected hospitals. Euro Pain Study Group on Acute Pain. <i>Acta Anaesthesiologica Scandinavica</i>, 40(9), 1119-1126.

Sargent, C. (2002). Naloxone: How well do you know this drug? <i>Clinical Journal of Oncology Nursing</i>, 6(1), 17-18.

Schug, S.A., & Torrie, J.J. (1993). Safety assessment of postoperative pain management by an acute pain service. <i>Pain</i>, 55, 387-391.

Shapiro, A., Zohar, E., Zaslansky, R., Hoppenstein, D., Shabat, S., & Fredman, B. (2005). The frequency and timing of respiratory depression in 1,524 postoperative patients treated with systemic or neuraxial morphine. <i>Journal of Clinical Anesthesia</i>, 17, 537-542.

Sidebotham, D., Dijkhuizen, M.R., & Schug, S.A. (1997). The safety and utilization of patient-controlled analgesia. <i>Journal of Pain and Symptom Management</i>, 14, 202-209.

Taylor, S., Kirton, O.C., Staff, I., & Kozol, R.A. (2005). Postoperative day one: A high risk period for respiratory events. <i>American Journal of Surgery</i>, 190, 752-756.

Tsui, S.L., Irwin, M.G., Wong, C.M., Fung, S.K., Hui, T.W., Ng, K.F., et al. (1997). An audit of the safety of an acute pain service. <i>Anaesthesia</i>, 52, 1042-1047.

Walsh, T.D., Rivera, N.I., & Kaiko, R. (2003). Oral morphine and respiratory function amongst hospice inpatients with advanced cancer. <i>Supportive Care in Cancer</i>, 11, 780-784.

Whipple, J.K., Quebbeman, E.J., Lewis, K.S., Gaughan, L.M., Gallup, E.L., & Ausman, R.K. (1994). Identification of patient-controlled analgesia overdoses in hospitalized patients: A computerized method of monitoring adverse events. <i>Annals of Pharmacotherapy</i>, 28, 655-658.