ASA Practice Guidelines for the Prevention, Detection, and Management of

Respiratory Depression Associated with Neuraxial Opioid Administration
Alexander Zlotnik MD, PhD
Professor

and Chairman,
Soroka University Medical Center,
Ben Gurion University of the Negev
Beer Sheva,
Israel

90%
hypercapnia/hypercarbia (PaCO2>50 mmHg)
TV, drowsiness, sedation, periodic apnea, cyanosis may

also provide indications of respiratory depression.

designated as either beneficial (B) or harmful (H) for the

patient;
Statistically nonsignificant findings are designated as equivocal (E).

Level 1:
The literature contains a sufficient number of RCTs to conduct meta-analysis
Level 2:
The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis
Level 3:
The literature contains a single RCT, and findings are reported as evidence.

Availability and Strength of Evidence

permit inference of beneficial or harmful relations among clinical interventions

and clinical outcomes.

Level 1:
The literature contains observational comparisons (e.g., cohort and case-control research designs) with comparative statistics.
Level 2:
The literature contains noncomparative observational studies with associative statistics.
Level 3:
The literature contains noncomparative observational studies with descriptive statistics. Level 4:
The literature contains case reports.

focused history and physical examination before administering neuraxial opioids.
Direct particular

attention should be directed toward OSA, diabetes, obesity; current medications (including preoperative opioids); and adverse effects after opioid administration.
A physical examination should include, but is not limited to, baseline vital signs, airway, heart, lung, and cognitive function.

no significant difference in the frequency of respiratory depression and

less somnolence or sedation for single injection epidural opioids compared with IM opioids (Category A1-E)

RCTs comparing patient-controlled epidural opioids (PCEAs) with IV PCA opioids are equivocal regarding respiratory depression and hypoxemia (Category A2-E)

An RCT comparing intrathecal sufentanil with IV sufentanil reports equivocal findings for respiratory depression and hypoxemia (Category A1-E).

RCTs comparing single-injection epidural opioids with IV opioids report inconsistent findings regarding respiratory depression, respiratory failure,
somnolence, or sedation (Category A2-E).

Opioids:
RCTs indicate less respiratory depression when continuous infusion of epidural

opioids are compared with IV infusion of opioids (Category A1-B).

RCTs evaluating differences in hypercarbia somnolence and sedation are equivocal (Category A2-E).

RCT reports no difference in the frequency of respiratory depression when extended release epidural morphine is compared with IV PCA morphine (Category C2-E)

RCTs report no significant differences in respiratory depression, hypoxia, and sedation or somnolence when extended-release epidural morphine is
compared with conventional (immediate-release) epidural morphine (Category C2-E)

ASA consultants agree that extended-release epidural morphine may be used in place of IV or conventional epidural morphine, although extended monitoring may be required.

parenteral opioids without altering the risk of respiratory depression or

hypoxemia.

Single-injection neuraxial fentanyl or sufentanil may be safe alternatives to single-injection neuraxial morphine.

Recommendations:

When clinically suitable, extended-release epidural morphine may be used in place of IV or conventional epidural morphine, although extended monitoring may be required.

Continuous epidural opioids are preferred to parenteral opioids for anesthesia and analgesia for reducing the risk of respiratory depression.

the frequency of respiratory depression, somnolence or sedation when single-injection

morphine is compared with single-injection fentanyl or sufentanil, administered by either an epidural or an intrathecal route (Category A2-E).

RCT findings for respiratory depression are inconsistent when comparing continuous epidural administration of morphine with fentanyl or sufentanil (Category A2-E evidence).

RCT findings for hypoxemia, hypercarbia sedation and somnolence are equivocal (Category A2-E).

fentanyl or sufentanil may be used in place of continuous

infusion of morphine or hydromorphone without increasing the risk of respiratory depression.

Recommendations:

Given the unique pharmacokinetic effect of the various neuraxially administered opioids, match the appropriate duration of monitoring with the drug.

Do not administer neuraxial morphine or hydromorphone to outpatient surgical patients.

respiratory depression is reduced when lower doses of single-injection epidural

morphine or sufentanil are compared with higher doses (Category A1-B).

Respiratory depression and sedation are equal when higher doses of continuous infusion of epidural fentanyl are compared with lower doses (Category A3-E).

Administer the lowest efficacious dose of neuraxial opioids to minimize the risk of respiratory depression.

Recommendation:

neuraxial opioids.

The concomitant administration of neuraxial opioids and parenteral opioids,

sedatives, hypnotics, or magnesium requires increased monitoring (intensity, duration, or additional methods of monitoring).

Drug Combinations.
Recommendations:

receiving neuraxial opioids for respiratory rate, SpO2, and
level of

consciousness.

Intense monitoring of prolonged duration may be warranted for patients at increased risk of respiratory depression (unstable medical condition, obesity, OSA, extremes of age,concomitant administration of opioids /hypnotics by other routes)

a minimum of 2 h after administration.

Monitor continually for the

first 20 min after administration, followed by monitoring at least once per hour until 2 h have passed.

After 2 h, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

Lipophilic Opioids.
Monitor during the entire time the infusion is in

use.

Monitor continually for the first 20 min after initiation, followed by monitoring at least once per hour until 12 h have passed.

From 12 to 24 h, monitor at least once every 2 h, and after 24 h, monitor at least once every 4 h.

After discontinuation of continuous infusion or PCEA
with neuraxial lipophilic opioids, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

Including Sustained or Extended-release Epidural Morphine).
Monitor for a minimum of

24 h after administration.
Monitor at least once per hour for the first 12 h after administration, followed by monitoring at least once every 2 h between 12 and 24h
After 24 h, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

Hydrophilic Opioids.
Monitor during the entire time the infusion is in

use.
Monitor at least once every hour for the first 12 h after initiation, followed by monitoring at least once every 2 h between 12 and 24h.
After 24 h, monitor at least once every 4 h.
After discontinuation of continuous infusion or PCEA, frequency of monitoring should be dictated by the patient’s overall clinical condition and concurrent medications.

least once every hour during the first 12 h after

administration and at least once every 2 h between 12 and 24h.

After 24 h, monitor at least once every 4 h for a minimum of 48 h.

available.

Administer supplemental oxygen to patients with altered level of consciousness,

respiratory depression, or hypoxemia and continue until the patient is alert and no respiratory depression or hypoxemia is present.

assess the efficacy of naloxone to treat respiratory depression after

neuraxial opioids, case reports suggest efficacy of naloxone in reversal of opioid-induced respiratory depression (Category B3-B).

Recommendation:

Naloxon should be available for administration to all patients with significant respiratory depression after neuraxial opioid administration.