• Carolyn F Weiniger, Seden Akdagli, Elliot Turvall, Lisa Deutsch, and Brendan Carvalho.
• From the Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
• Anesth. Analg. 2019 Mar 1; 128 (3): 513-522.

BackgroundIntrathecal morphine provides excellent analgesia after cesarean delivery; however, respiratory events such as apnea, bradypnea, and hypoxemia have been reported. The primary study aim was to estimate the number of apneas per subject, termed "apnea alert events" (AAEs) defined by no breath for 30-120 seconds, using continuous capnography in women who underwent cesarean delivery.MethodsWe performed a prospective, observational study with institutional review board approval of women who underwent cesarean delivery with spinal anesthesia containing 150-µg intrathecal morphine. A STOP-Bang obstructive sleep apnea assessment was administered to all women. Women were requested to use continuous capnography and pulse oximetry for 24 hours after cesarean delivery. Nasal sampling cannula measured end-tidal carbon dioxide (EtCO2) and respiratory rate (RR), and oxygen saturation (SpO2) as measured by pulse oximetry. Capnography data were defined as "valid" when EtCO2 >10 mm Hg, RR >5 breaths per minute (bpm), SpO2 >70%, or during apnea (AAE) defined as "no breath" (EtCO2, <5 mm Hg) for 30-120 seconds. Individual respiratory variable alerts were 10-second means of EtCO2 <10 mm Hg, RR <8 bpm, and SpO2 <94%. Nurse observations of RR (hourly and blinded to capnography) are reported.ResultsWe recruited 80 women, mean (standard deviation [SD]) 35 (5) years, 47% body mass index >30 kg/m2/weight >90 kg, and 11% with suspected obstructive sleep apnea (known or STOP-Bang score >3). The duration of normal capnography and pulse oximetry data was mean (SD) (range) 8:28 (7:51) (0:00-22:32) and 15:08 (6:42) (1:31-23:07) hours:minutes, respectively; 6 women did not use the capnography. There were 198 AAEs, mean (SD) duration 57 (27) seconds experienced by 39/74 (53%) women, median (95% confidence interval for median) (range) 1 (0-1) (0-29) per subject. Observation of RR by nurses was ≥14 bpm at all time-points for all women, r = 0.05 between capnography and nurse RR (95% confidence interval, -0.04 to 0.14). There were no clinically relevant adverse events for any woman. Sixty-five women (82%) had complaints with the capnography device, including itchy nose, nausea, interference with nursing baby, and overall inconvenience.ConclusionsWe report 198 AAEs detected by capnography among women who underwent cesarean delivery after receiving intrathecal morphine. These apneas were not confirmed by the intermittent hourly nursing observations. Absence of observer verification precludes distinction between real, albeit nonclinically significant alerts with capnography versus false apneas. Discomfort with the nasal sampling cannula and frequent alerts may impact capnography application after cesarean delivery. No clinically relevant adverse events occurred.

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