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A583
October 14, 2012
8:00:00 AM - 11:00:00 AM
Room Hall C-E-Poster area
Respiratory Depression: The Common Fatal Pathway for Non Fatal Conditions
Frank Overdyk, M.D., M.S., Marieke Niesters, M.D.,Ph.D., Albert Dahan, M.D.,Ph.D.
Hofstra University School of Medicine, Hemstead, New York, United States
Preventable deaths in hospitals remain a major public health hazard worldwide. Analysis of registries for cardiopulmonary arrests (CPA) identified missed vital signs and symptoms of decompensation and spurred the development of RRT and MET teams . Although widely adopted, their impact on overall hospital morbidity and mortality remains unclear.

‘Alarm fatigue’, where poor ergonomics, integration and response to alarms on medical devices desensitizes providers to alarms was identified by the ECRI as the top health technology hazard for 2012, causing 500+ preventable deaths . The FDA, JC, AAMI, and ACCE have joined forces to remedy this patient safety hazard.

Unfortunately, alarm fatigue deaths are likely dwarfed by deaths from unrecognized respiratory depression (RD) in patients who do not receive continuous electronic monitoring. The alarm fatigue cohort was made ‘visible’ by a 1990 US law, which requires manufacturers to report medical device related deaths. Similarly, adverse events related to PCA were identified by this mechanism. But preventable deaths from unrecognized RD constitute an ‘invisible’ group. The afferent loop of the RRT, which includes monitoring, is increasingly scrutinized as a potential cause for the lack of impact of RRT’s .

Patients receiving opioids and sedatives are exposed to unrecognized RD by a standard of care that allows VS to be taken as infrequently as every 4 -12 hours, and provider education that has not kept up with the increasing acuity of in-patients and the side effects/proper dosing of new analgesics, anxiolytics, and sleep aids with RD side effects. The increasing prevalence of obesity and chronic opiate use, and associated co morbidities (OSA, obesity hypoventilation syndrome), have shifted the risk equation dramatically against the patient.

To date, there is no registry that captures preventable deaths due to undetected RD. These tragic cases are traumatic and emotional for both victims and providers, without consensus on cause, and details often sequestered behind legal firewalls. However, this set of closed legal cases typify the seemingly ‘benign’ conditions that lead to death, in my opinion, from unrecognized RD.

• 34 y.o. male; finger infection, chronic Oxycontin; I&D postop Fentanyl patch. Found unresponsive 3PM POD#2.

• 63 y.o male, BMI=33, Hx of OSA; lapar esoph hernia repair. Ambulates on POD#2; PCA and IV opioids upon return. No CPAP. Found unresponsive POD#3 at 5AM.

• Healthy 41 y.o. male ; minor congenital hand surgery; Dilaudid PCA + O2 N/C oxygen + @ 9PM. Found in CPA at 2AM w/ pink frothy lung secretions.

• 35 y.o male. Chronic pancreatitis; Suspicion of OSA. Dilaudid PCA (+basal rate) + Phenergan. Found unresponsive, apneic on day #2.

• 53. Y.o female with BMI=33; AM submandibular abscess resection. Rapid escalation of Dilaudid IV push. Patient is found in CPA at 8PM.

• Healthy 63 yo female w/ difficult airway for TKR; morphine PCA, meperidine IV push + sedatives drugs. Found in CPA at 4AM.

None of these patients received continuous monitoring. There was no evidence of PE, arrhythmias, ischemia, stroke or other etiology that explained CPA. Opioid induced ventilatory insufficiency (OIVI) , a term that describes the multiple mechanisms of respiratory decompensation more completely than RD, is the likely common pathway in the demise of these patients with and w/o risk factors (suspected OSA, chronic opioid use, difficult airway). However, the medical/surgical conditions with which these patients presented to the health system were relatively benign. A mechanism to identify and quantify deaths specifically due to OIVI needs to urgently devised.

br />Resuscitation 81 (2010) 1305-1352.

www.ecri.org/2012_Top_10_Hazards

Resuscitation 81 (2010) 375-382.

Copyright © 2012 American Society of Anesthesiologists