"Postoperative opioid-induced respiratory depression is a significant cause of death and brain damage in the perioperative period."

  • Potentially preventable with improvements in monitoring of ventilation, and early response and intervention, particularly within the first 24 hours postoperatively.1




CMS Center for Clinical Standards updated requirements: 

  • Emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.

  • Reflects the need for patient risk assessment and appropriate monitoring during & after medication administration, particularly for post operative pati-ents receiving IV opioid medications, in order to prevent adverse events.2


American Society of Anesthesiologists

  • Practice Guidelines for Postanesthetic Care:

    • "Particular attention should be given to monitoring oxygenation and ventilation"

  • "The Task Force emphasizes that because ventilation and oxygenation are separate though related physiologic processes, monitoring oxygen-ation by pulse oximetry is not a substitute for monitoring ventilatory function."

  • Reflects the need for patient risk assessment and appropriate monitoring during & after medication administration.

  • Particularly useful for post operative patients receiving IV opioid medications in order to prevent adverse events.3



Joint Commission Sentinel Event #49:

Safe use of opioids in hospitals.

  • Inadequate monitoring of patients on opioids identified among root causes.

  • 29% of opioid-related adverse drug events related to improper monitoring of the patient.4




"The Anesthesia Patient Safety Foundation believes that clinically significant, drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality."

  • Nearly 30% of post-operative patients and up to 7% of all Medicare patient will suffer from respiratory compromise.

  • $53,000+ cost per respiratory arrest based on Healthgrades

  • Hospital burden exceed $7 Billion annually in the U.S.5


1. Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration: An Updated Report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2016;124(3):535-552.

2. Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids. Centers for Medicare and Medicaid Services. March 14, 2014; 1-32.

3. Practice Guidelines for Postanesthetic Care. American Society of Anesthesiologists Task Force on Postanesthetic Care. 2013; 1-17.

4. Safe use of opioids in hospitals. Sentinel Event Alert. August 8, 2012;(49):1-5.

5. Weinger MB, Lee LA. No patient shall be harmed by opioid-induced respiratory depression. APSF Newsletter 2011; 26: 21, 26-8.

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