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Society for Obstetric Anesthesia and Perinatology Consensus Statement

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Society for Obstetric Anesthesia and Perinatology Consensus Statement E SPECIAL ARTICLE Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia Jeanette R. Bauchat, MD, MS, Carolyn F. Weiniger, MBChB, Pervez Sultan, MBChB, FRCA, MD, Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA, Kazuo Ando, MD, PhD,║ John J.* Kowalczyk, MD, Rie Kato, MD,† DPhil, Ronald B. George, MD, FRCPC, Craig‡ M. Palmer, MD, and Brendan Carvalho, §MBBCh, FRCA ¶ # ** †† ‡‡ The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neo- nates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression fol- lowing neuraxial morphine administration. This consensus statement promotes the use of low- dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratifica- tion and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring. (Anesth Analg XXX;XXX:00–00) PURPOSE OF THIS CONSENSUS STATEMENT women receiving neuraxial morphine for postoperative Cesarean delivery is the most commonly performed inpa- analgesia. The purpose of this document is to provide expert tient procedure in the United States with the majority of consensus recommendations on the monitoring of obstetric patients following neuraxial morphine administration. The From the Department of Anesthesiology, Vanderbilt University Medical primary aims of this document are as follows: Center, Nashville, Tennessee; Division of Anesthesiology & Critical Care & * Pain, Sourasky Medical Center, Tel Aviv, Israel; Department of Anaesthesia 1. Support the mission of the Society for Obstetric and Perioperative Medicine, University† College London Hospital, London, United Kingdom; Department of Anesthesiology,‡ Duke University School Anesthesia and Perinatology (SOAP) to improve of Medicine, Durham, North Carolina; ║Department of Anesthesiology, pregnancy-related outcomes for women and Aichi Medical University,§ Aichi, Japan; Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard neonates; Medical School, Boston, Massachusetts;¶ Division of Anesthesiology, 2. Encourage the use of a highly effective analgesic Kitasato University School of Medicine, Kanagawa, Japan; Department technique following cesarean delivery by reduc- of Anaesthesia, Pain Management and Perioperative# Medicine, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; **Department ing resource burden for unnecessary respiratory of Anesthesiology, University of Arizona College of Medicine, Tucson, monitoring; Arizona; and Department of Anesthesiology, Perioperative†† and Pain 3. Promote patient-centered care by reducing the bur- Medicine, Stanford University School of Medicine, Stanford, California. ‡‡ den of excessive respiratory monitoring in healthy Accepted for publication March 21, 2019. mothers recovering from cesarean delivery; and Funding: None. The authors declare no conflicts of interest. 4. Focus clinical vigilance and intensive respiratory Supplemental digital content is available for this article. Direct URL citations monitoring on those women at high risk for respi- appear in the printed text and are provided in the HTML and PDF versions of ratory depression following neuraxial morphine this article on the journal’s website (www.anesthesia-analgesia.org). administration. Reprints will not be available from the authors. Address correspondence to Jeanette R. Bauchat, MD, MS, Obstetric An- This writing group was appointed and selected by the esthesiology Division, Vanderbilt University Medical Center, Room 4202 SOAP board and comprised a representative group of clini- VUH (7580), 1211 Medical Center Dr, Nashville, TN 37232. Address e-mail to [email protected]. cal experts in obstetric anesthesiology who conduct research Copyright © 2019 International Anesthesia Research Society or have a special interest in respiratory monitoring or neur- DOI: 10.1213/ANE.0000000000004195 axial opioid administration. The writing group consisted of XXX 2019 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1 Copyright © 2019 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E SPECIAL Article 7 members: Jeanette R. Bauchat, Carolyn F. Weiniger, Pervez Box 1. Considerations for Use of Neuraxial Opioid Sultan, Ashraf S. Habib, Rie Kato, Ronald B. George, and Analgesia in a Low-Resource Environment Brendan Carvalho (chair). Craig M. Palmer provided valu- A physician anesthesiologist in the low-resource environment must able input into the document, and Kazuo Ando and John evaluate the appropriateness of neuraxial opioid use in their setting J. Kowalczyk conducted the SOAP member survey and including provided valuable input into the document. This statement Availability of medical providers who can evaluate underlying represents the consensus of the writing committee and was patient comorbidities and risk factors that may increase the approved by the SOAP board of directors. In generating its likelihood of respiratory depression consensus, several committee members conducted a sys- System to ensure reliable and accurate administration of 1 nonopioid multimodal medication tematic review. Selected articles from this review and any Availability of postpartum nurses who can detect respiratory additional articles identified by committee members were depression then selected based on relevance for this consensus state- Emergency response team in the event of unexpected respiratory ment. The committee reviewed systematic reviews, meta- depression, which may result from undiagnosed comorbidities analyses, randomized controlled trials, retrospective trials, and/or drug error and case reports primarily in the obstetric patient popula- tion. For topics where there are no data specific to the obstet- stratification, dosing of intrathecal or epidural morphine, as ric population, the writing group referenced best available well as modality, duration, and frequency of perioperative literature collected in nonobstetric populations. respiratory monitoring. DERIVATION OF THIS CONSENSUS DOCUMENT What Other Statements or Guidelines Are In writing a consensus document, it is recognized that Available Regarding This Topic? consensus recommendation does not mean that there was The ASA/ASRA have developed Practice Guidelines complete agreement among all writing group members. for the Prevention, Detection and Management of Email surveys and personal meetings of the entire writ- Respiratory Depression Associated with Neuraxial Opioid ing group were used to identify areas of consensus. The Administration for all surgical patients.3 These guidelines American College of Cardiology and American Heart codify recommendations to identify patients at risk for Association Clinical Practice Guideline Recommendation respiratory depression and to prevent, detect, and manage Classification System was used for classes of recommenda- respiratory depression associated with neuraxial opioids in 2 tion and strength of evidence (See details of the classifica- the general surgical population.3 However, the guidelines tion system in Supplemental Digital Content 1, Document, do not distinguish between the obstetric population receiv- http://links.lww.com/AA/C801). Authors used the class ing single-shot neuraxial morphine for postcesarean deliv- of recommendation and strength of evidence as agreed on ery analgesia and the general surgery population receiving by greater than or equal to two-third (5 of 7 members) of the neuraxial morphine for postoperative analgesia. Task Force writing group. If the class recommendation was not agreed on by greater than or equal to two-third, then we Why Was This Consensus Statement Developed? moved to a lower class of recommendation and strength of This consensus statement was developed by SOAP to pro- evidence until greater than or equal to two-third agreement vide recommendations for strategies surrounding the pre- was obtained by the Task Force writing group. vention and detection of respiratory depression associated APPROPRIATE USE OF THE CONSENSUS with neuraxial morphine specifically in the obstetric
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