title: Risk predictors of opioid-induced critical respiratory events in children: naloxone use as a quality measure of opioid safety.
abstract: BACKGROUND
  Opioid-induced respiratory depression (OIRD) is a life-threatening complication of opioid therapy in children. Naloxone administration triggered by OIRD has been used to monitor safety of opioid therapy in adults. We used this trigger as a quality measure of opioid safety in hospitalized children to identify risk predictors of OIRD.
  
  
  METHODS
  We retrospectively reviewed medical records of 38 patients identified from the hospital risk management database as requiring naloxone for critical respiratory events between January 2010 and June 2012 for demographics, comorbidities, surgery, naloxone event details, and outcomes. These data were compared with baseline prevalence in contemporary patients followed by pain service, who did not receive naloxone, to calculate unadjusted odds ratios. Thematic classification of preventable events was undertaken based on analysis of each event.
  
  
  RESULTS
  The incidence of naloxone use among hospital inpatients, who received opioids at-least once, was 0.06% compared with 0.23% for patients on the pain service. A majority of naloxone events occurred in postoperative patients (n = 27/38, 71.1%) within the first 24 hours of surgery (n = 20/27, 75.1%) and in the critical care unit (50%). Patients undergoing airway surgeries had higher risk for OIRD (P = 0.01). Patient risk factors for naloxone use included age <1 year (P < 0.001), obstructive sleep apnea (P < 0.001), obesity (P = 0.019), being underweight (P < 0.0001), prematurity (P < 0.001), and developmental delay (P < 0.001). Majority of events (87%) were found to be preventable, which were classified into six main themes based on type of event.
  
  
  CONCLUSIONS
  OIRD is an important, albeit mostly preventable, complication of opioid therapy in children. Naloxone use can be used as a measure to track opioid safety in children, identify contributing factors, and formulate preventive strategies to reduce the risk for OIRD.
authors.affiliation: Department of Anesthesia and Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.
authors.forename: Vidya
authors.initials: V
authors.lastname: Chidambaran
authors.forename: Vanessa
authors.initials: V
authors.lastname: Olbrecht
authors.forename: Monir
authors.initials: M
authors.lastname: Hossain
authors.forename: Senthilkumar
authors.initials: S
authors.lastname: Sadhasivam
authors.forename: John
authors.initials: J
authors.lastname: Rose
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Meyer
mesh_terms: D000293:Adolescent; D000701:Analgesics, Opioid / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009270:Naloxone / Q000627:therapeutic use*; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D015995:Prevalence; D012131:Respiratory Insufficiency / Q000139:chemically induced* / Q000453:epidemiology*; D012189:Retrospective Studies; D012306:Risk
chemical_list: D000701:Analgesics, Opioid; D009292:Narcotic Antagonists; D009270:Naloxone
keywords: Naloxone; Opioid Safety; Opioid-Induced Respiratory Depression; Pediatric; Quality Measure; Risk Factors