Opioid toxicity

Last Updated on by FRCEM Intermediate

Clinical Features

  • miosis
  • CNS depression
  • respiratory depression
  • complications of hypoxia: seizures, dysrrhythmia, brain injury

Investigations

  • 12 lead ECG,
  • BSL,

Monitoring

  • Respiratory Rate (RR)
  • Oxygen Saturations (SpO2)
  • Heart Rate (HR)
  • Non-Invasive Blood Pressure (NIBP)
  • Sedation Score (AVPU)

should be documented with a minimum interval of 15 minutes

Management 

Resuscitation

  • appropriate use of naloxone can prevent intubation

Electrolytes and Acid-base

  • respiratory acidosis

Specific Therapy

  • Commence high-flow oxygen (15l/min) via non-rebreathe mask
  • Carefully record Respiratory Rate and Sedation Score (AVPU) – continually reassess
  • Commence continuous SpO2 monitoring

Management of Suspected Opioid Toxicity

If Respiratory Arrest? or Recreational Opioid Toxicity?

  • Ventilate with 15l/min oxygen via Bag Valve Mask at 10-12 breaths per minute
  • Give naloxone HIGH DOSE REGIME

If RR 5/min or less OR patient Unresponsive?

  • Ventilate with 15l/min oxygen via Bag Valve Mask at 10-12 breaths per minute
  • Give naloxone HIGH DOSE REGIME

If RR 6-8/min AND responding only to Pain?

  • Give naloxone LOW DOSE REGIME

If RR greater than 6/min and Alert or responding to Voice

  • Does not require naloxone at present
  • Monitor observations every 15 mins
  • Review analgesia requirements

 

Adult Naloxone HIGH DOSE REGIME 

High-Dose Regime – Use neat 400micrograms/ml naloxone as rapid intravenous boluses

Indications

1. Respiratory arrest due to opioid toxicity or recreational/intentional opioid overdose
2. Severe opioid-induced respiratory depression (RR 5 or less)
3. Reduced consciousness (U on AVPU) due to opioid toxicity

Give Naloxone 400micrograms IV ,

If NO response is seen after 60 seconds then,

Repeat Naloxone 800micrograms IV

If NO response is seen after 60 seconds then,

Repeat Naloxone 800micrograms IV

If still NO response seen after 60 seconds then,

Repeat Naloxone 2mg IV

If still no response question diagnosis of opioid toxicity Refer to critical care team for urgent review

if ‘good response‘ at any stage

Good Response

Implies improvement of both respiratory rate to >8 breaths/minute AND improvement of level of consciousness to at least V on the AVPU scale

  • Monitor
    • observations every 15 minutes should be continued for 2 hours.
    • Hourly for at least 6 hours after the last dose of naloxone for immediate release opioid preparations, 12 hours for sustained release opioid preparations and for up to 24 hours with methadone.
  • Beware of re-sedation and need for naloxone infusion- Naloxone Infusion ,may be required if patient becomes resedated as effect of naloxone bolus wears off
  • Critical Care Referral

If IV route unavailable give naloxone doses IM with 3 minute intervals between doses

 

Adult Naloxone LOW DOSE REGIME

Low-Dose Regime – Use dilute naloxone (400micrograms made up to total volume 4ml with 0.9% sodium chloride) and give as rapid intravenous boluses

Indications

  • Opioid-induced respiratory depression with reduced consciousness (P on AVPU)

Give Naloxone 100micrograms IV

If NO response is seen after 60 seconds then

Repeat Naloxone 100micrograms IV

If NO response is seen after 60 seconds then

Repeat Naloxone 200micrograms IV

If still NO response seen after 60 seconds then

Repeat Naloxone 400micrograms IV

If still no response question diagnosis of opioid toxicity, Refer to critical care team for urgent review

if ‘good response‘ at any stage

‘Good Response

implies improvement of both respiratory rate to >8 breaths/minute AND improvement of level of consciousness to at least V on the AVPU scale

  • Monitor – 15 min observations
  • Beware of re-sedation and need for naloxone infusion- Naloxone Infusion, may be required if patient becomes resedated as effect of naloxone bolus wears off
  • Critical Care Referral

If IV route unavailable give naloxone doses IM with 3 minute intervals between doses

Infusion regime

Infusion preparation:Naloxone 4mg (10 x 400 microgram ampoules) made up to 20ml with Sodium Chloride 0.9% (resulting solution 200 micrograms per ml).

The initial hourly starting rate should equal 0.6 x resuscitative cumulative bolus dose (60%) that gave an adequate clinical response

Dose Example:
1. Initial cumulative bolus producing response was naloxone
800micrograms
2. Infusion set up to run at 2.4mls per hour
3. Response is not satisfactory after 15minutes
4. Another bolus does of 400micrograms should be given and
infusion rate increased to 3ml per hour
5. Reassess the patient every 15 minutes

Underlying Cause

  • addiction counselling/ psychiatric review

Adverse Effects / Symptoms of Withdrawal

Abrupt reversal of opioid drugs in the context of chronic use has been reported to precipitate an acute withdrawal syndrome with symptoms

  • restlessness,
  • severe agitation,
  • delirium,
  • nausea and vomiting,
  • sweating,
  • shivering,
  • abdominal pain,
  • tachycardia,
  • hypertension
  • tachypnoea.

Reference

https://www.nuh.nhs.uk/download.cfm?doc=docm93jijm4n1292

 

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