title: Multimodal Analgesic Protocol and Postanesthesia Respiratory Depression During Phase I Recovery After Total Joint Arthroplasty.
abstract: BACKGROUND
  Multimodal analgesia protocols have shortened hospitalizations after total joint arthroplasty. It is unclear whether individual components of these protocols are associated with respiratory depression during phase I postanesthesia recovery.
  
  
  OBJECTIVE
  To test the hypothesis that sedating analgesics used in a multimodal protocol are associated with an increased rate of phase I postanesthesia respiratory depression.
  
  
  METHODS
  Our Department of Anesthesiology records were searched to identify patients undergoing total joint arthroplasty with a multimodal analgesia protocol, including peripheral nerve blockade, from 2008 through 2012. Patient records were reviewed for episodes of postanesthesia respiratory depression, and potential causative factors were abstracted and analyzed for potential associations. Respiratory depression was defined as apnea, hypopnea, oxyhemoglobin desaturations, or episodes of severe pain despite moderate to profound sedation.
  
  
  RESULTS
  Of 11,970 patients who underwent joint arthroplasty, 2836 (23.7%; 237 per 1000 cases; 95% confidence interval [95% CI], 214-262) had episodes of respiratory depression. A higher rate of respiratory depression was observed among patients who underwent general anesthesia (312 per 1000 cases; 95% CI, 301-323) than neuraxial anesthesia (144 per 1000 cases; 95% CI, 135-153) (P < 0.001). With both anesthetic techniques, respiratory depression was associated with preoperative use of gabapentin (>300 mg) (P < 0.001 for both anesthesia groups) and sustained-release oxycodone (>10 mg) (P = 0.01 for general anesthesia; P = 0.008 for neuraxial anesthesia).
  
  
  CONCLUSIONS
  Use of medications with long-acting sedative potential was associated with increased risk of respiratory depression during phase I anesthesia recovery. These effects were more pronounced when used in conjunction with general anesthesia than with neuraxial anesthesia.
authors.affiliation: From the Department of Anesthesiology, Mayo Clinic, Rochester, MN.
authors.forename: Toby N
authors.initials: TN
authors.lastname: Weingarten
authors.forename: Adam K
authors.initials: AK
authors.lastname: Jacob
authors.forename: Catherine W
authors.initials: CW
authors.lastname: Njathi
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Wilson
authors.forename: Juraj
authors.initials: J
authors.lastname: Sprung
mesh_terms: D000368:Aged; D000588:Amines / Q000009:adverse effects; D000700:Analgesics / Q000009:adverse effects*; D000762:Anesthesia Recovery Period; D000765:Anesthesia, Conduction / Q000009:adverse effects*; D000768:Anesthesia, General / Q000009:adverse effects*; D019643:Arthroplasty, Replacement / Q000009:adverse effects; D003509:Cyclohexanecarboxylic Acids / Q000009:adverse effects; D003692:Delayed-Action Preparations; D004305:Dose-Response Relationship, Drug; D005260:Female; D000077206:Gabapentin; D006801:Humans; D006993:Hypnotics and Sedatives / Q000009:adverse effects*; D008297:Male; D008874:Midazolam / Q000009:adverse effects; D008875:Middle Aged; D010098:Oxycodone / Q000009:adverse effects; D012131:Respiratory Insufficiency / Q000139:chemically induced* / Q000175:diagnosis; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D005680:gamma-Aminobutyric Acid / Q000009:adverse effects
chemical_list: D000588:Amines; D000700:Analgesics; D003509:Cyclohexanecarboxylic Acids; D003692:Delayed-Action Preparations; D006993:Hypnotics and Sedatives; D005680:gamma-Aminobutyric Acid; D000077206:Gabapentin; D010098:Oxycodone; D008874:Midazolam