Journal of Clinical Monitoring and Computing

https://doi.org/10.1007/s10877-019-00293-0

ORIGINAL RESEARCH

Postoperative desaturation and bradypnea after general anesthesia

in non-ICU patients: a retrospective evaluation
Masashi Ishikawa1   · Atsuhiro Sakamoto1

Received: 2 June 2018 / Accepted: 27 February 2019

© Springer Nature B.V. 2019

Abstract
Respiratory depression, presenting as desaturation and bradypnea, is common during the early postoperative period. How-
ever, it has not been evaluated by appropriate monitoring. The purpose of the present study was to identify the incidence
and predictors of desaturation and bradypnea following general anesthesia, using a continuous and centralized monitoring
system, in non-ICU patients who did not have serious complications and did not undergo major surgery. Patients were con-
nected to a continuous and centralized monitoring system via a pulse oximeter and respiratory rate sensor for at least 8 h after
extubation. We assessed the incidence and risk factors for desaturation (SpO2 < 90% for > 10 s) and bradypnea (respiratory
rate < 8 breaths/min for > 2 min) events. We retrospectively collected the clinical data of 1064 adult patients in the study. The
incidences of desaturation and bradypnea were 12.1% and 5.1%, respectively. Most desaturation events occurred after the
termination of oxygen administration. The greatest incidence of bradypnea was within the first hour after surgery, reducing
over time. Analysis revealed that age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.03–1.06; p < 0.001), BMI (OR
1.12, 95% CI 1.06–1.18; p < 0.001) and current smoking (OR 1.91, 95% CI 1.12–3.42; p = 0.023) were significant risk factors
for desaturation. Sleep apnea syndrome (OR 4.23, 95% CI 1.09–13.5; p = 0.021) and postoperative opioid administration
(OR 2.76, 95% CI 1.44–5.20; p = 0.002) were significantly associated with bradypnea. Age (OR 1.04, 95% CI 1.01–1.07;
p = 0.010) and postoperative opioid administration (OR 3.16, 95% CI 1.22–7.87; p = 0.019) showed a significant association
with the occurrence of both desaturation and bradypnea. This study demonstrated the incidence and predictors of postopera-
tive desaturation and bradypnea, and suggests the need for monitoring oxygen saturation and respiratory rate for at least 8 h
after surgery in non-ICU patients. Use of monitoring systems might provide a safety net for postoperative patients.

Keywords  Postoperative desaturation · Bradypnea · General anesthesia · Non-ICU

1 Introduction and simultaneously decreasing the ventilatory response to

Respiratory depression following general anesthesia, pre-
senting as desaturation and bradypnea, is common during
the early postoperative period [1]. Analysis of anesthesia-
related closed claims demonstrated that delayed detection
of bradypnea, resulting in desaturation, was a major cause
of morbidity and mortality during and following proce-
dures under general anesthesia [2]. Fifty percent of cases
of respiratory depression requiring cardiopulmonary resus-
citation in hospitals are due to opioid administration [3].
Opioids induce hypercapnia by reducing respiratory rate
* Masashi Ishikawa
masashi‑i@nms.ac.jp
1
Department of Anesthesiology, Nippon Medical School,
1‑1‑5 Sendagi, Bunkyo‑ku, Tokyo 113‑8603, Japan
both hypercapnia and hypoxemia [4, 5]. Although provid-
ing supplemental oxygen to patients after general anesthesia
improves their oxygenation, the opioid-induced bradypnea
persists [6, 7]. In a previous study, the majority of postop-
erative respiratory depression events were judged as pre-
ventable with better monitoring and responses [8]. Although
intermittent postoperative monitoring of the patients’ cardi-
orespiratory parameters is performed by nurses, detection
of respiratory depression using common clinical signs has
been shown to be difficult [9, 10], suggesting that continu-
ous monitoring of oxygen saturation and respiratory rate
can improve patient safety during the postoperative period.
Previous studies recommended continuous and centralized
monitoring of oxygen saturation and respiratory rate for all
patients in the early phase following general anesthesia [8,
11]. However, the barriers to implementation of continuous

13
Vol.:(0123456789)

and centralized monitoring and adoption of monitoring tech-
nology, and lack of staff familiarity with such monitors, are
significant, which makes use of the system in general wards
uncommon. Few reports exist regarding the incidence and
risk factors of postoperative respiratory depression in non-
ICU patients following the use of continuous and centralized
monitoring systems.
We hypothesized that postoperative desaturation and
bradypnea might occur even in non-ICU patients who did
not have serious complications and did not undergone major
surgery, making it necessary to evaluate them with a con-
tinuous and centralized monitoring system. The Patient
SafetyNet system (Masimo Corp., Irvine, CA, USA) with a
pulse oximeter and rainbow acoustic respiratory rate moni-
toring (RRa™) sensor, a non-invasive respiratory rate moni-
tor using an acoustic transducer positioned on the patient’s
throat, provides continuous and centralized monitoring of
oxygen saturation and respiratory rate. The purpose of the
present study was to identify the predictors and incidence of
desaturation and bradypnea in non-ICU patients following
general anesthesia using the Patient SafetyNet system.
2 Materials and methods
After approval by our institutional review board (No. 26-03-
428), we retrospectively analyzed consecutive adult patients
undergoing general anesthesia between January 4, 2015 and
April 30, 2015 at Nippon Medical School Hospital, a teach-
ing and acute care general hospital providing a full range
of services and with specialized units. The general surgi-
cal ward to which patients were transferred had a nurse to
patient ratio of 1:7. We collected the clinical data of 1156
patients. We excluded patients if they required intensive
care after surgery, underwent tracheostomy or required
other mechanical airway devices, had skin abnormalities at
the site of fixation of the RRa sensor, or received opioids
preoperatively.
Anesthetic management was at the discretion of the
attending anesthesiologist, including the decision to provide
regional anesthesia. No patients received anesthetic premed-
ication. Typical anesthetic management included induction
with propofol 1–2 mg/kg and fentanyl 1–2 µg/kg or remifen-
tanil 0.2–0.5 µg/kg/min, followed by rocuronium 0.6 mg/
kg. Maintenance of anesthesia was achieved with sevoflu-
rane, desflurane or propofol, and fentanyl and remifenta-
nil were administered for analgesia, as appropriate. In all
cases, sugammadex was administered for reversal of muscle
relaxation. Where necessary, patients received intravenous
patient-controlled analgesia (PCA) or patient-controlled
epidural anesthesia (PCEA). Intravenous PCA devices were
programmed to deliver a continuous background infusion of
fentanyl 15 µg/h and single fentanyl 15 µg iv bolus doses on
13
Journal of Clinical Monitoring and Computing
demand, with a lockout time of 10 min. For PCEA, 6–20 µg/
ml dosages of fentanyl and 0.06–0.2% levobupivacaine
were used, with a background infusion rate of 4 ml/h, an
on-demand bolus dose of 3 ml and a lockout time of 30 min.
All patients received oxygen with a face mask during the
postoperative period.
Patients were connected to the Patient SafetyNet system
with a pulse oximeter and an RRa sensor, which was applied
to the patient’s neck after extubation. Oxygen saturation and
respiratory rate were measured continuously for at least 8 h
following the end of surgery until 07:00 the next morning.
The system allowed continuous 24-h monitoring and data
storage, which was recorded and stored in the machine every
2 s. We assessed the incidence of desaturation (SpO2 < 90%
for > 10 s) and bradypnea (respiratory rate < 8 breaths/min
for > 2 min) [12].
Variables recorded included patient demographic infor-
mation [age, gender, body mass index (BMI), American
Society of Anesthesiologists physical status (ASA-PS),
smoking status, as well as the presence or absence of res-
piratory, renal, or hepatic dysfunction], data on the surgi-
cal procedure performed (including surgical site, duration
of surgery, and whether emergency or elective), anesthetic
management (anesthetic agents administered, type of anes-
thesia, duration of anesthesia, and dosage of opioids and
neuromuscular drugs), and postoperative management
(postoperative analgesia, oxygen administration). Cases
with missing data were excluded from statistical analysis
as described below.
2.1 Statistical analysis
Clinical data were recorded and tabulated with Excel soft-
ware (Microsoft Corp, Redmond, WA, USA). All statisti-
cal analyses were performed using JMP version 11 soft-
ware (SAS Institute. Inc, Cary, NC, USA). The results were
expressed in the form of mean ± SD or n (%). p values of
0.05 were considered indicative of statistically significant
differences between groups. Univariate analysis allowed
for the determination of variables that were significantly
different between desaturation and normal groups, and
bradypnea and normal groups, respectively. Normality of
distribution was assessed by the Shapiro–Wilk test. Con-
tinuous variables were compared between groups using the
Mann–Whitney’s U test. In case of dichotomous variables,
intergroup differences were examined using Fisher’s exact
test. Multiple logistic regression was used to identify the
risk factors associated with postoperative desaturation and
bradypnea on multivariate analysis. Data on patient demo-
graphics [age, gender, BMI, ASA-PS, current smoking,
asthma, sleep apnea syndrome (SAS), chronic obstruc-
tive pulmonary disease, liver dysfunction, renal dysfunc-
tion], duration of operation, and anesthetic management
Journal of Clinical Monitoring and Computing

(duration of anesthesia and postoperative opioid admin- 3 Results

istration) were used in multivariable logistic regression
analysis. The strength of the association of variables with
desaturation and bradypnea was estimated by calculating
the odds ratio (OR) and 95% confidence interval (CI).
Fig. 1  Flow diagram of study enrollment
During the 4-month study period, 1156 patients who ful-
filled the study criteria received general anesthesia. Of
these, 60 cases had missing data, while monitoring was
discontinued in 3 cases due to skin itchiness or redness.
In another 29 cases, the surgical site was the same as the
RRa sensor affixation site. After excluding the above 92
patients, a total of 1064 patients were included in the study
(Fig. 1). Their demographic data and other recorded vari-
ables are presented in Tables 1 and 2. The results of mul-
tivariate analysis are shown in Table 3.
The duration and amount of postoperative oxygen
administered were 5.2 ± 2.3 h and 5.6 ± 0.8 l, respectively.
The number of patients who exhibited desaturation and
bradypnea during the observation period were 129 (12.1%)
and 54 (5.1%), respectively (Table 4). The incidence of
desaturation is shown in Fig. 2 and Table 5. There were
244 events of postoperative desaturation in 129 cases. Of
these, 244 events, 64 (26.2%) occurred while supplemental
oxygen was being administered. Most desaturation events
occurred after the termination of oxygen administra-
tion. One hundred twenty-four of the 244 events (50.8%)
occurred more than 8 h after surgery, especially from 12 to
13 h after extubation. Among patients who presented with
desaturation episodes, 2 cases required emergency surgery
for postoperative bleeding following thyroid surgery about
4 h after extubation. One case required intubation due to
laryngeal edema about 5 h after extubation. Bradypnea
was detected 112 times among 54 patients. Of these, 81
events (72.3%) occurred during oxygen supplementation.
The greatest incidence of bradypnea was within the first
hour after surgery, reducing over time thereafter (Fig. 3;
Table 5). Both desaturation and bradypnea occurred in
25 cases, including 8 instances of desaturation following

Table 1  Demographic and All cases Desaturation p value Bradypnea p value

clinical characteristics
Age, years 54.8 ± 18.5 65.6 ± 16.6 < 0.001 60.0 ± 19.2 0.034
Gender, men 451 (42.4%) 50 (38.8%) 0.341 28 (51.9%) 0.202
BMI 23.2 ± 3.8 24.6 ± 3.8 < 0.001 24.0 ± 4.5 0.206
ASA physical status 1.7 ± 0.6 1.9 ± 0.5 < 0.001 1.9 ± 0.5 0.103
Current smoking 245 (23.0%) 18 (14.0%) 0.004 12 (22.2%) 0.867
Asthma 104 (9.8%) 8 (6.2%) 0.203 7 (13.0%) 0.347
COPD 12 (1.1%) 1 (0.8%) n.s. 0 (0%) n.s.
SAS 23 (2.2%) 5 (3.9%) 0.183 4 (7.4%) 0.024
Liver dysfunction 37 (3.5%) 10 (7.8%) 0.009 2 (3.7%) 0.707
Kidney dysfunction 108 (10.2%) 21 (16.3%) 0.018 7 (13.0%) 0.48

Variables are expressed as mean (SD)

BMI body mass index, ASA American Society of Anesthesiologists, COPD chronic obstructive pulmonary
disease, SAS sleep apnea syndrome

13
 Journal of Clinical Monitoring and Computing

Table 2  Surgical and anesthesia All cases Desaturation p value Bradypnea p value

data
Surgical site
 Head 3 (0.3%) 0 (0%) n.s. 0 (0%) n.s.
 Eye 44 (4.1) 4 (2.5%) 0.812 2 (3.7%) n.s.
 Face 44 (4.1%) 1 (0.8%) 0.053 3 (5.6%) 0.478
 Pharynx, neck 136 (12.8%) 16 (12.4%) 0.887 16 (29.6%) 0.002
 Back bone 29 (2.7%) 2 (1.6%) 0.566 2 (3.7%) 0.652
 Appendicular skeleton 267 (25.1%) 43 (22.2%) 0.023 16 (29.6%) 0.416
 Body surface 163 (15.3%) 19 (14.7%) n.s 4 (7.4%) 0.119
 Chest 11 (1.0%) 2 (1.6%) 0.632 1 (1.9%) 0.432
 Upper abdomen 75 (7.0%) 15 (11.6%) 0.041 2 (3.7%) 0.578
 Lower abdomen 288 (27.1%) 26 (20.2%) 0.072 8 (14.8%) 0.056
 Intravascular 4 (0.4%) 1 (0.8%) 0.401 0 (0.0%) n.s
Emergency operation 63 (5.9%) 5 (3.9%) 0.423 1 (1.9%) 0.363
Duration of operation 124.3 ± 69.7 131.1 ± 65.6 0.089 138.6 ± 58.7 0.028
Inhalation anesthesia 1041 (97.8%) 128 (99.2%) 0.346 54 (100%) 0.624
Duration of anesthesia 198.7 ± 98.2 210.2 ± 79.0 0.021 215.0 ± 71.9 0.015
Intraoperative dosage of fentanyl 0.2 ± 0.1 0.2 ± 0.1 0.336 0.2 ± 0.1 0.219
Intraoperative dosage of rocronium 58.0 ± 28.5 60.2 ± 29.5 0.438 57.2 ± 26.6 0.632
Epidural anesthesia 74 (7.0%) 12 (9.3%) 0.265 7 (13.0%) 0.088
Nerve block 53 (5.0%) 9 (7.0%) 0.276 4 (7.4%) 0.331
Postoperative opioid administration 194 (18.2%) 27 (20.9%) < 0.001 15 (27.8%) < 0.001
Postoperative oxygenation
 Duration (h) 5.2 ± 2.3 5.2 ± 2.2 0.464 5.2 ± 1.9 0.428
 Dosage (l) 5.6 ± 0.8 5.7 ± 0.7 0.481 5.7 ± 0.6 0.246

Variables are expressed as mean (SD)

Table 3  Multivariate logistic regression for desaturation and bradyp- Table 4  Incidence of desaturation and bradypnea
nea
Number of cases
Odds ratio 95% CI p value
Desaturation 129 (12.1%)
Desaturation  Total number 244
 Age 1.04 1.03–1.06 < 0.001  During postoperative oxygenation 64 (26.2%)
 BMI 1.12 1.06–1.18 < 0.001  After postoperative oxygenation 180 (73.8%)
 Current smoking 1.91 1.12–3.42 0.023 Bradypnea 54 (5.1%)
Bradypnea  Total number 112
 SAS 4.23 1.09–13.5 0.021  During postoperative oxygenation 81 (72.3%)
 Postoperative opioid administra- 2.76 1.44–5.20 0.002  After postoperative oxygenation 31 (27.7%)
tion
Both desaturation and bradypnea 25 (2.3%)
Desaturation and bradypnea
 Desaturation by bradypnea 8 (0.8%)
 Age 1.04 1.01–1.07 0.010
 Postoperative opioid administra- 3.16 1.22–7.87 0.019
tion

CI confidence interval, SAS sleep apnea syndrome
bradypnea; of these, 6 occurred after discontinuing oxygen
supplementation.
Analysis revealed that age (odds ratio [OR] 1.04, 95%
confidence interval [CI] 1.03–1.06; p < 0.001), BMI (OR
1.12, 95% CI 1.06–1.18; p < 0.001) and current smoking
(OR 1.91, 95% CI 1.12–3.42; p = 0.023) were significant
risk factors for desaturation. SAS (OR 4.23, 95% CI
1.09–13.5; p = 0.021) and postoperative opioid admin-
istration (OR 2.76, 95% CI 1.44–5.20; p = 0.002) were
significantly associated with bradypnea. Age (OR 1.04,
95% CI 1.01–1.07; p = 0.010) and postoperative opioid
administration (OR 3.16, 95% CI 1.22–7.87; p = 0.019)
were also significantly associated with the occurrence of
the combination of desaturation and bradypnea.

13
Journal of Clinical Monitoring and Computing

Fig. 2  Onset time of postopera-

tive desaturation. There were
244 events of postoperative
desaturation in 129 cases. One
hundred twenty-four of the 244
events (50.8%) occurred more
than 8 h after surgery

Table 5  Incidence of desaturation and bradypnea per monitored hours and centralized monitoring system. Postoperative patient
Time (h) Desaturation (%) Bradypnea (%) Patients per
care in general wards represents a high-risk situation [13].
monitored Hence, it is important to clarify risk factors for desatu-
hours ration and bradypnea, as well as providing context. The
incidence of desaturation and bradypnea in our study was
1 15 (1.41) 30 (2.82) 1064
only 12.1% and 5.1%, respectively. The low incidence of
2 7 (0.66) 20 (1.88) 1064
desaturation and bradypnea might be due to exclusion
3 7 (0.66) 11 (1.03) 1064
of serious cases requiring intensive care, avoidance of
4 6 (0.56) 11 (1.03) 1064
long-acting opioids, and reversal of muscle relaxation
5 17 (1.60) 9 (0.85) 1064
with sugammadex. Siddiqui et al. suggested that the most
6 23 (2.16) 6 (0.56) 1064
important predictor of desaturation was postoperative care
7 27 (2.54) 4 (0.38) 1064
without oxygen supplementation [14]. According to the
8 18 (1.69) 4 (0.38) 1064
results of this study, 73.8% of desaturation events occurred
9 19 (1.79) 2 (0.19) 1064
after discontinuing supplementary oxygen administration.
10 12 (1.30) 3 (0.33) 920
Hence, postoperative oxygen supplementation is important
11 15 (1.76) 5 (0.59) 851
for the prevention of postoperative desaturation.
12 15 (1.60) 1 (0.12) 812
Several risk factors have been identified as predictors
13 21 (3.12) 0 (0) 673
of postoperative desaturation and bradypnea. Moller et al.
14 20 (3.32) 2 (0.33) 603
revealed age, history of smoking and duration of anesthesia
15 6 (1.02) 1 (0.17) 589
as risk factors [15]. The risk factors for desaturation identi-
16 4 (0.94) 1 (0.23) 427
fied in our study were age, BMI and current smoking, while
17 9 (2.24) 1 (0.25) 402
the risk factors identified for bradypnea were SAS and post-
18 5 (1.32) 1 (0.26) 379
operative opioid administration. In our study, BMI was one
of the risk factors for desaturation. General anesthesia can
cause significant reduction in functional residual capacity
4 Discussion and can lead to atelectasis. Postoperative desaturation due
to atelectasis is accentuated in obese patients [16]. Eichen-
Our study indicates the incidence and predictors of post- berger et al. compared pulmonary atelectasis in non-obese
operative desaturation and bradypnea in non-ICU patients and morbidly obese patients undergoing laparoscopic sur-
after general anesthesia, determined using a continuous gery before induction, immediately post tracheal intuba-
tion, and 24 h after general anesthesia [17]. Morbidly obese

13

Fig. 3  Onset time of postopera-
tive bradypnea. Bradypnea was
detected 112 times among 54
patients. The greatest incidence
of bradypnea was within the
first hour after surgery, the inci-
dence reducing over time
patients showed significantly more atelectasis at all stages,
while the amount of atelectasis remained unchanged during
the examination period. Another study also suggested that
obese patients might be at further risk of SAS [18]. Further,
obese patients both with and without SAS have been shown
to exhibit episodes of desaturation following laparoscopic
bariatric surgery despite supplemental oxygen administra-
tion [19].
Continuous and centralized monitoring of oxygen satura-
tion and respiratory rate can detect respiratory depression
before it results in critical events such as cardiac arrest. Sev-
eral methods of respiratory rate monitoring are currently
used, including manual counting of breaths by a caregiver,
capnography, and transthoracic impedance measurement.
Manual counting of breaths (such as auscultation) is an
intermittent, labor-intensive and unreliable method. Cap-
nography provides accurate and continuous monitoring, but
requires a nasal or facial interface, which can be uncomfort-
able and may lead to failure if the interface is moved. Tran-
sthoracic impedance is non-invasive and can detect respira-
tory efforts, but is unable to detect alveolar hypoventilation
caused by airway obstruction [20–24]. RRa is an acoustic
monitoring device that continuously measures respiratory
rate, and is as accurate as capnography in extubated patients
[25]. Patient activities, such as talking, coughing and cry-
ing, affect the results of both RRa and capnography. The
measurement errors during these activities are, however, not
clinically relevant because they require that the patients are
awake and breathing. Further, the RRa sensor appears to be
well-tolerated and no more subject to error than capnog-
raphy [25]. RRa was found to be a reliable device and had
fewer complications in this study.
13
Journal of Clinical Monitoring and Computing
Several limitations inherent to this study warrant careful
consideration. Firstly, our findings are based on a retrospec-
tive evaluation and reflect the practice at a single center with
a relatively homogenous surgical population, which limit
their wide generalizability to other populations. Further, this
study provides no insight on the surgical site and extent of
surgeries. Further studies involving a larger number of cases
are needed for investigation of these factors. Secondly, post-
operative consciousness level was not evaluated in this study.
Since consciousness levels correlate with the incidence of
postoperative respiratory complications [26], these should
have been evaluated. Lastly, respiratory depression events
might have occurred during the artefact periods detected by
the monitor algorithms.
Although the incidences of postoperative desaturation
and bradypnea were low in this study, critical complica-
tions did occur in our patients. The Joint Commission of
the Anesthesia Patient Safety Foundation has proposed that
patients at a high risk for bradypnea following postoperative
opioid administration should receive continuous monitoring
of oxygenation and respiratory rate [27, 28]. Early detection
of desaturation in general wards leads to fewer resuscitation
scenarios and decreases the need to escalate care [29]. How-
ever, detection of desaturation and bradypnea are extremely
unreliable using clinical examination and the current moni-
toring methods. Our study suggests that use of a continuous
and centralized respiratory monitoring system for overnight
postoperatively is desirable for postoperative management
in the general ward, which would likely improve the safety
of postoperative patients, especially those with risk factors
for respiratory depression.
Journal of Clinical Monitoring and Computing
Funding  Funding support for this work was obtained solely from insti-
tutional sources.
Compliance with ethical standards  Gattinoni L. The effects of body mass on lung volumes, respira-
Conflict of interest  The authors declare that they have no conflict of
interest.
References
1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz
SR, Berry WR, Gawande AA. An estimation of the global volume
of surgery: a modelling strategy based on available data. Lancet.
2008;372(9633):139–44.
2. Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. Trends
in anesthesia-related death and brain damage: a closed claims
analysis. Anesthesiology. 2006;105(6):1081–6.
3. Overdyk FJ. Postoperative opioids remain a serious patient safety
threat. Anesthesiology. 2010;113(1):259–60.
4. Weil JV, McCullough RE, Kline JS, Sodal IE. Diminished ven-
tilatory response to hypoxia and hypercapnia after morphine in
normal man. N Engl J Med. 1975;292(21):1103–6.
5. Berkenbosch A, Teppema LJ, Olievier CN, Dahan A. Influences
of morphine on the ventilatory response to isocapnic hypoxia.
Anesthesiology. 1997;86(6):1342–9.
6. Jones JG, Jordan C, Scudder C, Rocke DA, Barrowcliffe M. Epi-
sodic postoperative oxygen desaturation: the value of added oxy-
gen. J R Soc Med. 1985;78(12):1019–22.
7. Rosenberg J, Pedersen MH, Gebuhr P, Kehlet H. Effect of oxygen
therapy on late postoperative episodic and constant hypoxaemia.
Br J Anaesth. 1992;68(1):18–22.
8. Lee LA, Caplan RA, Stephens LS, Posner KL, Terman GW,
Voepel-Lewis T, Domino KB. Postoperative opioid-induced res-
piratory depression: a closed claims analysis. Anesthesiology.
2015;122(3):659–65.
9. Maddox RR, Williams CK, Oglesby H, Butler B, Colclasure B.
Clinical experience with patient-controlled analgesia using con-
tinuous respiratory monitoring and a smart infusion system. Am
J Health Syst Pharm. 2006;63(2):157–64.
10. Meiklejohn BH, Smith G, Elling AE, Hindocha N. Arterial oxygen
desaturation during postoperative transportation: the influence of
operation site. Anaesthesia. 1987;42(12):1313–5.
11. American Society of Anesthesiologists Task Force on Postanes-
thetic Care. Practice guidelines for postanesthetic care: a report
by the American Society of Anesthesiologists Task Force on Pos-
tanesthetic Care. Anesthesiology. 2002;96(3):742–52.
12. Gali B, Whalen FX, Schroeder DR, Gay PC, Plevak DJ. Iden-
tification of patients at risk for postoperative respiratory com-
plications using a preoperative obstructive sleep apnea screen-
ing tool and postanesthesia care assessment. Anesthesiology.
2009;110(4):869–77.
13. Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N,
Crouch R, Ineson N, Shaikh L. Incidence, location and reasons for
avoidable in-hospital cardiac arrest in a district general hospital.
Resuscitation. 2002;54(2):115–23.
14. Siddiqui N, Arzola C, Teresi J, Fox G, Guerina L, Friedman Z.
Predictors of desaturation in the postoperative anesthesia care
unit: an observational study. J Clin Anesth. 2013;25(8):612–7.
15. Moller JT, Wittrup M, Johansen SH. Hypoxemia in the pos-
tanesthesia care unit: an observer study. Anesthesiology.
1990;73(5):890–5.
16. Pelosi P, Croci M, Ravagnan I, Tredici S, Pedoto A, Lissoni A,
tory mechanics, and gas exchange during general anesthesia.
Anesth Analg. 1998;87(3):654–60.
17. Eichenberger A, Proietti S, Wicky S, Frascarolo P, Suter M,
Spahn DR, Magnusson L. Morbid obesity and postoperative pul-
monary atelectasis: an underestimated problem. Anesth Analg.
2002;95(6):1788–92.
18. Benumof JL. Obstructive sleep apnea in the adult obese patient:
implications for airway management. Anesthesiol Clin N Am.
2002;20(4):789–811.
19. Ahmad S, Nagle A, McCarthy RJ, Fitzgerald PC, Sullivan JT,
Prystowsky J. Postoperative hypoxemia in morbidly obese patients
with and without obstructive sleep apnea undergoing laparoscopic
bariatric surgery. Anesth Analg. 2008;107(1):138–43.
20. Petterson MT, Begnoche VL, Graybeal JM. The effect of motion
on pulse oximetry and its clinical significance. Anesth Analg.
2007;105(6 Suppl):78–84.
21. Wilkinson JN, Thanawala VU. Thoracic impedance monitor-
ing of respiratory rate during sedation—is it safe? Anaesthesia.
2009;64(4):455–6.
22. Cohen KP, Ladd WM, Beams DM, Sheers WS, Radwin RG,
Tompkins WJ, Webster JG. Comparison of impedance and
inductance ventilation sensors on adults during breathing, motion,
and simulated airway obstruction. IEEE Trans Biomed Eng.
1997;44(7):555–66.
23. Drummond GB, Nimmo AF, Elton RA. Thoracic impedance used
for measuring chest wall movement in postoperative patients. Br
J Anaesth. 1996;77(3):327–32.
24. Brouillette RT, Morrow AS, Weese-Mayer DE, Hunt CE. Com-
parison of respiratory inductive plethysmography and thoracic
impedance for apnea monitoring. J Pediatr. 1987;111(3):377–83.
25. Mimoz O, Benard T, Gaucher A, Frasca D, Debaene B. Accu-
racy of respiratory rate monitoring using a non-invasive
acoustic method after general anaesthesia. Br J Anaesth. 2012
May;108(5):872–5.
26. Parr SM, Robinson BJ, Glover PW, Galletly DC. Level of con-
sciousness on arrival in the recovery room and the development
of early respiratory morbidity. Anaesth Intensive Care. 1991
Aug;19(3):369–72.
27. The Joint Commission. Safe use of opioids in hospitals Sentinel
Event Alert 2012. http://www.joint​commi​ssion​.org/asset​s/1/18/
SEA_49_opioi​ds_8_2_12_final​.pdf. Accessed 15 May 2018.
28. Weinger M, Lee L. No patient shall be harmed by opioid induced
respiratory depression. APSF NewsLett. 2011;26:21–40.
29. Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse
oximetry surveillance on rescue events and intensive care unit
transfers: a before-and-after concurrence study. Anesthesiology.
2010;112(2):282–7.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13