Opioid Safety, Respiratory Compromise

Was Gary Bougie’s Post-op Gallbladder Surgery Death Preventable?

Fox 9 News recently reported on the death of Gary Bougie following routine gall bladder surgery:

Gary Bougie was two months shy of his 36th birthday when he died nearly two years ago. His family suspects he died from a condition called opioid-induced respiratory depression after going to the hospital for gallbladder surgery and they want to warn other families about how to possibly avoid a tragedy like this

Bougie had just opened his new restaurant when he went to United Hospital for surgery to remove his gallbladder back in April of 2014. He stayed overnight for observation, but his parents say learning the next morning he’d passed away from complications during the night was surreal.

While the medical examiner ruled there was no anatomical cause for Bougie’s death, his family believes the mix of pain meds he was on caused him to fall into such a deep sleep, he stopped breathing. They are suing the hospital. Their attorney says even though nurses checked on Bougie once an hour, they should have used a fingertip sensor that would have alerted them when the level of oxygen in his blood went too low.

Gary Bougie - source: http://www.bizjournals.com/twincities/news/2014/04/22/gary-bougie-dies-pizzeria-pezzo-slyce-kowalski.html

Gary Bougie – source: http://www.bizjournals.com/twincities/news/2014/04/22/gary-bougie-dies-pizzeria-pezzo-slyce-kowalski.html

The finger tip sensor referred to by Bougie’s lawyer is a pulse oximeter, which measures the oxygenation of blood.

However, according to healthcare experts, monitoring with a pulse oximeter may not have been the panacea that Bougie’s lawyer may be looking for.

In an interview with Matthew Grissinger (Director, Error Reporting Programs, Institute For Safe Medication Practices), importance of pulse oximeters may be misplaced and monitoring with capnography for adequacy of ventilation is a better indicator of respiratory depression:

… there’s too much reliance on pulse oximetry readings, which can offer a false sense of security since oxygen saturation is usually maintained even at low respiratory rates, especially if supplemental oxygen is in place. As ISMP President, Michael Cohen has said, “Capnography measures the end tidal volume of carbon dioxide, which is a more reliable indicator of respiratory depression and has previously been employed in limited areas such as critical care units.

Additionally, the Anesthesia Patient Safety Foundation (APSF) recommends continuous electronic monitoring of oxygenation and ventilation. When combined with traditional nursing assessment and vigilance, continuous electronic monitoring with pulse oximetry for oxygenation and adequacy of ventilation with capnography will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment.

“It’s time for a change in how we monitor postoperative patients receiving opioids,” declares Dr. Robert Stoelting, president of the APSF. “We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

To view the APSF video on the need for paradigm shift, please click on the image below (or go to http://apsf.org/resources/oivi/):

APSF Video

 

 

 

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