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Anesthesiology 2009; 110:218–30 Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
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*PRACTICE guidelines are systematically developed
recommendations that assist the practitioner and patient
in making decisions about health care. These
recommendations may be adopted, modified, or rejected
according to clinical needs and constraints, and
are not intended to replace local institutional policies.
In addition, practice guidelines developed by the
American Society ofAnesthesiologists (ASA) are not
intended as standards or absolute requirements, and
their use cannot guarantee any specific outcome. Practice
guidelines are subject to revision as warranted by
the evolution of medical knowledge, technology, and
practice. They provide basic recommendations that
are supported by a synthesis and analysis of the current
literature, expert and practitioner opinion, openforum commentary, and clinical feasibility data.
This document updates the “Practice Guidelines for
the Prevention, Detection and Management of Respiratory
Depression Associated with Neuraxial Opioid
Administration” adopted by ASA in 2007, and includes
new survey data and recommendations pertaining to
monitoring for respiratory depression.
A. Definitions of Neuraxial OpioidAnalgesia and
Respiratory Depression
Neuraxial opioid analgesia refers to the epidural or
spinal administration of opioids, including single-injection,
continuous- or intermittent-infusion, and patient-
controlled analgesia. For these Guidelines, respiratory
depression may be indicated by (1) reduced
respiratory rate (e.g., to  10 –12 breaths per minute),
(2) reduced oxygen saturation (e.g.,arterial oxygen
saturation  90 –92%), or (3) hypercapnia/hypercarbia
(e.g., arterial carbon dioxide tension  50 mmHg).
Other measures of respiratory function (e.g., tidal volume)
or clinical signs (e.g., drowsiness, sedation, periodic
apnea, cyanosis) may also provide indications of
respiratory depression.
B. Purposes of the Guidelines
The purposes of these Guidelines are to improve patientsafety and enhance the quality of anesthetic care by
reducing the incidence and severity of neuraxial opioid–
related respiratory depression or hypoxemia. In addition,
these Guidelines are intended to reduce the incidence
and severity of adverse outcomes related to
reduced respiratory rate or oxygen levels (e.g., cardiac
arrest, brain damage, death).
C. Focus
These Guidelines focus onthe treatment of all patients
receiving epidural or spinal opioids in inpatient
(e.g., operating rooms, intensive care units, labor and
delivery suites, postoperative surgical floors, hospital
wards) or ambulatory (e.g., stand-alone outpatient facilities)
settings. The Guidelines do not apply to patients
with chronic or cancer pain (except those with
acute postoperative pain), patients withpreexisting
implantable drug delivery systems, or patients with
contraindications to spinal or epidural opioids (e.g.,
coagulopathy, sepsis).
D. Application
These Guidelines are intended for use by anesthesiologists.
They also may serve as a resource for other
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are available inboth the HTML and PDF versions of this article. Links to the
digital files are provided in the HTML text of this article on the
Journal’s Web site (

* Developed by the American Society of Anesthesiologists Task Force on
Neuraxial Opioids: Terese T. Horlocker, M.D. (Chair), Rochester, Minnesota;
Allen W. Burton, M.D., Houston, Texas; Richard T. Connis, Ph.D.,...
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