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Postoperative Monitoring for Clinical Deterioration

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Patient Safety in Surgery
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Abstract

Approximately 40 million surgeries take place annually in the United States, many of them requiring overnight or lengthier postoperative stays from the 5,000 or more hospitals that comprise our acute healthcare system. Throughout the twentieth century patients assumed that being surrounded by well trained nurses and physicians in hospitals guaranteed safety. That bubble burst with the Institute of Medicine’s 1999 report: To Err Is Human, followed closely by its 2001 report: Crossing the Quality Chasm. For the first time, the US public was put on notice regarding the high likelihood of mistakes and error occurring while hospitalized. Nearly all aspects of hospital care since then have been closely scrutinized and re-engineered to optimize risk reduction, except for one. This remaining aspect comprises the risk of having unexpected serious complications, especially immediately following surgery while recovering on hospital general care floors (GCF). This chapter entitled: “Postoperative Monitoring for Clinical Deterioration, Postoperative Care and Managing Rapidly Evolving Clinical Cascades,” explores in detail this remaining problem with its readers, taking the time to explain in clear, easily understood prose:

  • Why these problems continue occurring

  • What has and has not been done about it, and why

  • How care will be transformed in the near future to prevent these problems

  • What can be done immediately with current resources to begin a safe transition.

The author has over 40 years’ experience with this clinical issue and second curve innovation that must be applied to transform today’s hospital care into the safe care we expect and deserve.

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References

  1. Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Saf Surg. 2011;5:3. URL link (Ctrl + click to follow link) http://www.pssjournal.com/content/5/1/3.

  2. Curry JP, Lynn LA. Threshold monitoring, alarm fatigue, and the patterns of unexpected hospital death. APSF Newsl. 2011;26(2):32–5.

    Google Scholar 

  3. Gravenstein N. No patient shall be harmed by opioid-induced respiratory depression. APSF Newsl. 2011;26(2):21.

    Google Scholar 

  4. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. 2011;112(6):1392–402.

    Article  PubMed  Google Scholar 

  5. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242(3):326–41; discussion 341–3.

    PubMed Central  PubMed  Google Scholar 

  6. Lynn LA. The diagnosis of sepsis revisited – a challenge for young medical scientists in the 21st century. Patient Saf Surg. 2014;8(1):1.

    Article  PubMed Central  PubMed  Google Scholar 

  7. Hajiha M, DuBord M-A, Liu H, Horner RL. Opioid receptor mechanisms at the hypoglossal motor pool and effects on tongue muscle activity in vivo. J Physiol. 2009;587(11):2677–92.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  8. White. Opioid-induced suppression of genioglossal muscle activity: is it clinically important? J Physiol. 2009;587(14):3421–2.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  9. VanDercar DH, Martinez AP, DeLisser EA. Sleep apnea syndromes: a potential contraindication for patient-controlled analgesia. Anesthesiology. 1991;74(3):623–4.

    Article  CAS  PubMed  Google Scholar 

  10. Berry RB, Kouchi K, Bower J, Prosise G, Light RW. Triazolam in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 1995;151(2 Pt 1):450–4.

    Article  CAS  PubMed  Google Scholar 

  11. Wieczorek PM, Carli F. Obstructive sleep apnea uncovered after high spinal anesthesia: a case report. Can J Anaesth. 2005;52(7):761–4.

    Article  PubMed  Google Scholar 

  12. Wilkinson MH, Berger PJ, Blanch N, Brodecky V. Effect of venous oxygenation on arterial desaturation rate during repetitive apneas in lambs. Respir Physiol. 1995;101(3):321–31.

    Article  CAS  PubMed  Google Scholar 

  13. Khoo SM, Mukherjee JJ, et al. Obstructive sleep apnea presenting as recurrent cardiopulmonary arrest. Sleep Breath. 2009;13:89–92.

    Article  PubMed  Google Scholar 

  14. Dyken ME, Yamada T, Glenn CL, Berger HA. Obstructive sleep apnea associated with cerebral hypoxemia and death. Neurology. 2004;62(3):491–3.

    Article  PubMed  Google Scholar 

  15. Lofsky A. Sleep apnea and narcotic postoperative pain medication: a morbidity and mortality risk. APSF Newsl. 2002;17(2):24–5.

    Google Scholar 

  16. Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, Silvester W, Doolan L, Gutteridge G. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med. 2004;32:916–21.

    Article  PubMed  Google Scholar 

  17. Chan PS, Khalid A, Longmore SL, Berg AR, Kosiborod M, Spertus AJ. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA. 2008;300(21):2506–13.

    Article  CAS  PubMed  Google Scholar 

  18. Rothschild MJ, Woolf S, Finn MK, et al. A controlled trial of a rapid response system in an academic medical center. Jt Comm J Qual Patient Saf. 2008;34(7):417–25.

    PubMed  Google Scholar 

  19. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170(1):18–26.

    Article  PubMed  Google Scholar 

  20. Litvak E, Pronovost JP. Commentary: rethinking rapid response teams. JAMA. 2010;304(12):1375–6.

    Article  CAS  PubMed  Google Scholar 

  21. Pedersen T, Møller AM, Hovhannisyan K. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev. 2009;7(4):CD002013.

    Google Scholar 

  22. Ochroch EA, Russell MW, Hanson WC, Devine GA, Cucchiara AJ, Weiner MG, Schwartz SJ. The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor. Anesth Analg. 2006;102(3):868–75.

    Article  PubMed  Google Scholar 

  23. Giuliano KK, Higgins TL. New-generation pulse oximetry in the care of critically ill patients. Am J Crit Care. 2005;14(1):26–37.

    PubMed  Google Scholar 

  24. Fecho K, Freeman J, Smith FR, et al. In-hospital resuscitation: opioids and other factors influencing survival. Ther Clin Risk Manag. 2009;5:961–8.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Looi-Lyons LC, Chung FF, Chan VW, et al. Respiratory depression: an adverse outcome during patient controlled analgesia therapy. J Clin Anesth. 1996;8:151–6.

    Article  CAS  PubMed  Google Scholar 

  26. Shapiro A, Zohar E, Zaslansky R, et al. The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine. J Clin Anesth. 2005;17:537–42.

    Article  CAS  PubMed  Google Scholar 

  27. Weinger MB. No patient shall be harmed by opioid-induced respiratory depression. APSF Newsl. 2011;26(2):21.

    Google Scholar 

  28. Antic NA, Malow BA, Lange N, McEvoy RD, Olson AL, Turkington P, Windisch W, Samuels M, Stevens CA, Berry-Kravis EM, Weese-Mayer DE. PHOX2B mutation-confirmed congenital central hypoventilation syndrome: presentation in adulthood. Am J Respir Crit Care Med. 2006;174(8):923–7.

    Article  CAS  PubMed  Google Scholar 

  29. Littleton SW, Mokhlesi B. The Pickwickian syndrome – obesity hypoventilation syndrome. Clin Chest Med. 2009;30(3):467–78, vii–viii.

    Article  PubMed  Google Scholar 

  30. Casey KR, Cantillo KO, Brown LK. Sleep-related hypoventilation/hypoxemic syndromes. Chest. 2007;131(6):1936–48.

    Article  PubMed  Google Scholar 

  31. Guo F, Xu T, Wang H. Early recognition of myxedematous respiratory failure in the elderly. Am J Emerg Med. 2009;27(2):212–15.

    Article  PubMed  Google Scholar 

  32. Catling JA, Pinto DM, Jordan C, Jones JG. Respiratory effects of analgesia after cholecystectomy: comparison of continuous and intermittent papaveretum. Br Med J. 1980;281(6238):478–80.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  33. Mildh LH, Scheinin H, Kirvelä OA. The concentration-effect relationship of the respiratory depressant effects of alfentanil and fententanil. Anesth Analg. 2001;93(4):939–46.

    Article  CAS  PubMed  Google Scholar 

  34. Bouillon T, Bruhn J, Roepcke H, Hoeft A. Opioid-induced respiratory depression is associated with increased tidal volume variability. Eur J Anaesthesiol. 2003;20(2):127–33.

    Article  CAS  PubMed  Google Scholar 

  35. Wiedemann K, Diestelhorst C. The effect of sedation on pulmonary function. Anaesthesist. 1995;44 Suppl 3:S588–93.

    CAS  PubMed  Google Scholar 

  36. Yamakage M, Kamada Y, Toriyabe M, Honma Y, Namiki A. Changes in respiratory pattern and arterial blood gases during sedation with propofol or midazolam in spinal anesthesia. J Clin Anesth. 1999;11(5):375–9.

    Article  CAS  PubMed  Google Scholar 

  37. Mora CT, Torjman M, White PF. Sedative and ventilatory effects of midazolam infusion: effect of flumazenil reversal. Can J Anaesth. 1995;42(8):677–84.

    Article  CAS  PubMed  Google Scholar 

  38. Fu ES, Downs JB, Schweiger JW, Miguel RV, Smith RA. Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest. 2004;126(5):1552–8.

    Article  PubMed  Google Scholar 

  39. Barker SJ. “Motion-resistant” pulse oximetry: a comparison of new and old models. Anesth Analg. 2002;95(4):967–72.

    PubMed  Google Scholar 

  40. Goldman JM. Medical Devices and Medical Systems - Essential safety requirements for equipment comprising the patient-centric integrated clinical environment (ICE). ASTM final F-2761-2009.

    Google Scholar 

  41. Moldenhauer K, Sabel A, Chu ES, Mehler PS. Clinical triggers: an alternative to a rapid response team. Jt Comm J Qual Patient Saf. 2009;35(3):164–74.

    PubMed  Google Scholar 

  42. Taenzer AH, Blike GT. Postoperative monitoring – the Dartmouth experience. APSF Newsl. 2012;27(1):1–28.

    Google Scholar 

  43. Dean NC, Jones J, Sanz Herrero F, Jephson A, Brown S, Jones BE, Vines C. Calculating PaO2/FIO2 from SPO2 in emergency department patients with pneumonia; comparison of the Severinghaus and Rice equations in a Utah population. Am J Respir Crit Care Med. 2012;185:A1806.

    Google Scholar 

  44. Galhotra S, DeVita MA, Simmons RL, et al. Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. Qual Saf Health Care. 2007;16:260–5.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Ankichetty S, Chung F. Considerations for patients with obstructive sleep apnea undergoing ambulatory surgery. Curr Opin Anaesthesiol. 2011;24(6):605–11.

    Article  PubMed  Google Scholar 

  46. Sovik O, Thordarson H. Dead-in-bed syndrome in young diabetic patients. Diabetes Care. 1999;22 Suppl 2:B40–2.

    PubMed  Google Scholar 

  47. Society of Anesthesia and Sleep Medicine consensus recommendations for perioperative management of Obstructive Sleep Apnea. URL link (Ctrl + click to follow link) http://sasmhq.org/?page_id=2552.

  48. Lynn LA. Interpretive oximetry: future directions for diagnostic applications of the SpO2 time-series. Anesth Analg. 2002;94(1 Suppl):S84–8.

    PubMed  Google Scholar 

  49. Dempsey JA, Veasey SC, Morgan BJ, O’Donnell CP. Pathophysiology of sleep apnea. Physiol Rev. 2010;90(1):47–112.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  50. Famey RJ, Walker JM, Cloward TV, Rhonduea S. Sleep-disordered breathing associated with long-term opioid therapy. Chest. 2003;123(2):632–9.

    Article  Google Scholar 

  51. Wang D, Teichtahi H, Drummer O, Goodman C, Cherry G, Cunnington D, Kronborg I. Central sleep apnea in stable methadone maintenance treatment patients. Chest. 2005;128(3):1348–56.

    Article  PubMed  Google Scholar 

  52. Montandon G, Qin W, Liu H, Ren J, Greer JJ, Horner RL. PreBotzinger complex neurokinin-1 receptor-expressing neurons mediate opioid-induced respiratory depression. J Neurosci. 2011;31(4):1292–301.

    Article  CAS  PubMed  Google Scholar 

  53. Saper CB, Chou TC, Scammell TE. The sleep switch: hypothalamic control of sleep and wakefulness. Trends Neurosci. 2001;24:726–31.

    Article  CAS  PubMed  Google Scholar 

  54. Nelson A, Battersby BS, et al. Opioid-induced decreases in rat brain adenosine levels are reversed by inhibiting adenosine deaminase. Anesthesiology. 2009;111:1327–33.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  55. Gallagher RM, Rosenthal LJ. Chronic pain and opiates: balancing pain control and risks in long-term opioid treatment. Arch Phys Med Rehabil. 2008;89:S77–82.

    Article  PubMed  Google Scholar 

  56. Catley DM, Thornton C, Jordan C, Lehane JR, Royston D, Jones JG. Pronounced, episodic oxygen desaturation in the postoperative period: its association with ventilatory pattern and analgesic regimen. Anesthesiology. 1985;63:20–8.

    Article  CAS  PubMed  Google Scholar 

  57. Rosenberg J, Dirkes WE, Kehlet H. Episodic arterial oxygen desaturation and heart rate variations following major abdominal surgery. Br J Anaesth. 1989;63:651–4.

    Article  CAS  PubMed  Google Scholar 

  58. Anesthesia Patient Safety Foundation consensus recommendations on continuous electronic monitoring for perioperative patients receiving opioids on hospital general care floors. URL link (Ctrl + click to follow link) http://www.apsf.org/announcements.php?id=7.

  59. Weick KE. The collapse of sensemaking in organizations: the Mann Gulch disaster. Adm Sci Q. 1993;38(4):628–52.

    Article  Google Scholar 

  60. Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers. Anesthesiology. 2010;112:282–7.

    Article  PubMed  Google Scholar 

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Correspondence to J. Paul Curry MD .

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Curry, J.P. (2014). Postoperative Monitoring for Clinical Deterioration. In: Stahel, P., Mauffrey, C. (eds) Patient Safety in Surgery. Springer, London. https://doi.org/10.1007/978-1-4471-4369-7_8

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  • DOI: https://doi.org/10.1007/978-1-4471-4369-7_8

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