Postoperative Opioid-induced Respiratory Failure: A Case Report

Approximately 9% of hospitalized patients will experience an unexpected adverse event resulting in transfer to the intensive care unit and/or patient harm or death (1–4). Although serious events are rare, the consequences to patients and healthcare facilities are significant (5,6). Adverse events increase the cost of patient care and cause longer lengths of stay (5, 7, 8). In recent years, evidence has increased showing that determining which patients are at higher risk along with multiparameter continuous electronic monitoring can decrease patient harm and mortality as well as costs to the healthcare system (6,9). For each hour of delay in recognizing patient deterioration, the risk of death increases by 1.5% (10). The education of the healthcare team around identifying patients at higher risk as well as the use of continuous multiparameter monitoring (respiratory rate, pulse rate, blood pressure, temperature, ventilation, and oxygenation) has been found effective in early detection of patient deterioration and decreased number of patient transfers to a higher level of care (11–14). Identifying and monitoring only those patients most at risk can avoid nurses being alerted with false, annoying alarms which result in alarm fatigue as well as help prioritize safest level of care (15–18).

How could continuous electronic monitoring have prevented a patient death? Take Sarah for example. Sarah was a 54-year-old female with a history of osteoporosis, hypothyroidism, headaches, and a seizure disorder. Sarah fell on her way into the mall. The fall resulted in a fracture of her right distal femur lateral condyle. She was taken to a local hospital where she was admitted at 11:30 p.m. She underwent open reduction and internal fixation of the right distal femur the following morning at 10:23 a.m. The surgical procedure ended successfully at 12:37 p.m. She was transferred to the recovery room at 12:45 p.m. in stable condition. Her recovery room stay was uneventful, with the exception of poorly controlled pain requiring extra doses of opioids. She was transferred to the general medical-surgical unit at 14:05 p.m. on 2 LPM of supplemental oxygen. She was found unresponsive and not breathing at 15:10 p.m. by her sister and daughter. She was pronounced dead at 15:33 p.m.

In review of the nursing care, it was apparent that the nurses who admitted her to the general floor missed signs of patient deterioration due to lack of effective assessment procedures. Sarah’s signs of respiratory compromise and lack of effective assessments included:

1. Modified Aldrete Score of 9 (Sarah required two liters per minute (LPM) supplemental oxygen to maintain SpO2 > 90%).

Aldrete score [ranges 0–10] is used by recovery room nurses to assess five parameters: respiration, circulation, consciousness, oxygen saturation, and level of activity. This score is used to determine when a post-surgical patient can be safely discharged from the recovery room. A score of nine or greater equals safe discharge from the PACU.

Rationale: As supplemental oxygen will artificially increase values of SpO2, the use of multiparameter continuous electronic monitoring is necessary (19–24). The application of capnography to the monitoring procedures is necessary to effectively assess ventilation when a patient is on supplemental oxygen (25). Sarah did not receive adequate monitoring of her ventilation once she was admitted to the general care floor. Evidence-based standards for best monitoring practices should have included the use of continuous electronic monitoring of respiratory rate, pulse, pulse oximetry, and end tidal carbon dioxide (capnography) plus nursing assessment using an evidence-based sedation scale (26).

2. The respiratory rate was 12 breaths per minute (BPM).

Normal respiratory rate for adults below 65 years of age ranges between 12–18 BPM during wake and as high as 20 BPM when asleep. The reason for the normal higher rate during sleep is that respiratory depth is diminished, thus the rate increases to maintain carbon dioxide levels. When a person is sedated, you would expect the respiratory rate to be on the higher side of normal.

Rationale: When sedated, a respiratory rate of 12 BPM could be a sign of respiratory compromise and impending carbon dioxide retention, especially when the patient’s baseline respiratory rate on admission was 18 BPM.

Sarah’s ventilation was compromised due to:

1) Still recovering from anesthesia

2) Seizure disorder in the setting of medications that can lower the seizure threshold (cause patient to be more susceptible for having a seizure)

3) Under the influence of combination of anesthesia, opioids, anti-emetics, along with phenobarbital that all increase the risk of respiratory depression.

3. The only nursing assessment was documented on admission to general care floor at 14:05 p.m.

Nursing assessments of the post-surgical patient should be, at minimum, every 15 minutes for the first four hours. There is significant evidence that documents assessing vital signs intermittently will miss signs of patient deterioration (13,27); thus, continuous electronic monitoring is necessary to occur between nursing assessments (26). In Sarah’s case, the measurement of vital signs was performed by the nursing assistant. Although the RN was in and out of the room, they did not fully assess Sarah’s respiratory and sedation status per best practices. Additionally, the measurement of vital signs was every 15 minutes, performed by a nursing assistant and not recorded in the electronic medical record, thus not available for the RN to visualize the downward trend of her ventilation.

In these times of increased use of same-day surgery procedures, hospitalizations after procedures have decreased, leaving only the sickest and most at-risk patients to be hospitalized. The reason for the hospitalization is to provide safe nursing care that includes monitoring and assessments to ensure the best patient outcomes. If they didn’t need to be monitored, most would be sent home to recover. Although post-operative patients will often be at risk of respiratory compromise, patients admitted for medical care also can present at higher risk of adverse events such as sepsis. Continuous multiparameter electronic monitoring can provide a tool that will assist nurses in identifying patient deterioration early in the trajectory of decline (25,28).

This article was sponsored by Medtronic.

In addition to support for this article, the author has received consulting and educational content development fees from Medtronic.

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