Managing Opioid-Induced Respiratory Depression

Chris Pasero, MS, RN-BC

Disclosures

November 07, 2012

Clinical Case: Postoperative Opioid-induced Sedation and Respiratory Depression

The patient is a 42-year-old man who is 10 hours post-exploratory laparotomy and hernia repair. His postoperative analgesic order is hydromorphone 2 mg intravenously (IV), every 2 hours as needed for pain. The patient has received multiple doses since his admission to the clinical unit. He appears to be sleeping when the nurse enters the room to assess him.

Upon admission to the floor, the nurse obtains the following information about the patient, who is an otherwise healthy man:

  • Weight 175 lb, height 5' 11"

  • Nonsmoker

  • No previous surgeries

  • Opioid-naive

  • Medications: daily vitamin; ibuprofen for occasional mild headache or musculoskeletal-type pain

  • Occupation: owns a small computer software development company

  • Married, with 2 high school-aged children

The patient required an extended stay (2 hours) in the postanesthesia care unit (PACU) because of difficulty getting his pain under control:

  • He received general anesthesia, including fentanyl 150 μg IV.

  • Patient reported severe pain on admission to the PACU at 11:30 AM.

  • Analgesia in the PACU: fentanyl 50 mcg IV, followed by hydromorphone 0.5 mg IV in titrated doses to 2 mg total; last 0.5-mg dose was given at 1:10 PM.

  • Status at 1:30 PM just before transfer to clinical unit:

    • Blood pressure: 115/78 mm Hg

    • Heart rate: 78 beats/min

    • Respiratory status: respiratory rate, 20 breaths/min; oxygen saturation (using pulse oximetry), 97% on room air; breath sounds equal and clear

    • Aldrete score: 9 out of a possible 12 points (not fully awake, but arouses when called by name)

    • Pain rating: 4 on the 0-10 numerical rating scale

  • Since admission to the clinical unit at 1:45 PM, the patient's vital signs have been within normal limits and stable:

    • Blood pressure 118/70 to 126/80 mm H

    • Heart rate: 70-80 beats/min

    • Respiratory rate: 16-20 breaths/min

    • Oxygen saturation by periodic "spot-check" pulse oximetry: 92%-95% on room air

Initial Pain Management

Analgesia and pain relief measures were administered as follows:

  • 3:00 PM: pain rating 7. Hydromorphone 2 mg IV given. Follow-up pain rating at 3:30 PM is 3;

  • 5:45 PM: pain rating 6. Hydromorphone 2 mg IV given. Follow-up pain rating at 6:30 is 4; and

  • 8:45 PM: pain rating 7. Hydromorphone 2 mg IV given.

The patient is observed to be sleeping and snoring after receiving hydromorphone. The patient was given 50 mg of oral diphenhydramine at 8:00 PM for reports of facial itching without evidence of rash. The family visited for a few hours after the patient was admitted to the clinical unit, but left at 8:00 PM in hopes that the patient would rest and achieve better pain relief with less noise and activity in the room.

Findings: Nursing Rounds at 9:30 PM

  • Patient is in the second bed in the room, lying on his left side, facing the window;

  • Patient is unresponsive to nurse's voice and touch;

  • Respirations are absent;

  • Skin is cool; and

  • Lips and nail beds are blue.

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