Anesth Analg 2006;102:1596
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000215128.75157.2D
LETTER TO THE EDITOR
New JCAHO Pain Standard Bigger Threat to Patient Safety Than Envisioned
Frank Overdyk, MSEE, MD,
Rickey Carter, PhD, and
Ray Maddox, PharmD
Department of Anesthesiology, Medical University of South Carolina, Charleston, SC, overdykf{at}musc.edu
To the Editor:
We are troubled by some of the methodology and analysis described in a recent article by Vila et al. (1) on the efficacy and safety implications of the Hospital Wide Pain Management Standards mandated by Joint Commission on Accreditation of Healthcare Organizations. We doubt using a single respiratory rate obtained from retrospective chart review of cases with opioid-related adverse drug reactions (ADRs) is useful in predicting a patient's propensity for respiratory depression. The fact that 16/29 (55%) patients with opioid adverse drug reactions had respiratory rates more than or equal to 18 breaths/min (2 patients had a respiratory rate of 32 and 40 breaths/min) suggests that these events were mislabeled as opioid adverse drug reactions, involved an opioid side effect other than respiratory depression, or were measured after the patient was aroused or received naloxone. Not surprisingly, they did not observe a predictable decrease in respiratory rate before opioid-induced respiratory arrest. The difficulty of obtaining reliable "manual" respiratory rates is described by Vila in an earlier study where patients under monitored anesthesia care had prolonged periods of apnea, consistently missed by dedicated anesthesia providers using visual surveillance and oximetry (2). We are further alarmed at the suggestion that pulse oximetry alone may be "used effectively" for patients at high risk for ventilatory depression and respiratory arrest. "High risk" patients often receive supplemental oxygen, hindering the ability of oximetry to detect hypoventilation on a timely basis (3). More importantly, although oximetry may suffice as a monitor in procedural areas and recovery rooms, where these studies were performed, its delayed warning of hypoventilation may be tragically inadequate on a hospital ward where vital sign are monitored more infrequently and nurses have more patients. Finally, a recent, comprehensive, meta-analysis of 116 studies by Cashman and Dolin (4) found the incidence of respiratory depression during acute, opioid-containing, postoperative pain management (as measured by respiratory rate <10 breaths/min) in 29,607 patients to be 1.1% (95% confidence interval, 0.7%–1.7%). Although not strictly comparable, Vila et al.'s incidence of 29 cases of opioid-related adverse drug reactions (respiratory rate <12 breaths/min) in 32,019 patients (0.091%), seems greatly at odds with the Cashman and Dolin findings.
Although Vila et al. present valuable insight on patient satisfaction with pain therapy and consciousness changes with opioid adverse drug reactions, the respiratory rate data are unreliable, and hence their monitoring recommendation appears ill advised.
References
- Vila H Jr, Smith RA, Augustyniak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg 2005;101:474–80.[Abstract/Free Full Text]
- Soto RG, Fu ES, Vila H Jr, Miguel RV. Capnography accurately detects apnea during monitored anesthesia care. Anesth Analg 2004;99:379–82.[Abstract/Free Full Text]
- Fu ES, Downs JB, Schweiger JW, et al. Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest 2004;126:1552–8.[Abstract/Free Full Text]
- Cashman JN, Dolin SJ. Respiratory and haemodynamic effects of acute postoperative pain management: evidence from published data. Br J Anaesth 2004;93:212–23.[Abstract/Free Full Text]
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