Naloxone for septic shock?

ljeanmarielouise · Feb 25, 2011

Here is a link to drugs.com which states naloxone may be used to temporarily increase blood pressure. http://www.drugs.com/pro/narcan.html

annister · Feb 25, 2011

Thanks for the link.

dthfytr, ADN, LPN, RN, EMT-B, EMT-I · Feb 25, 2011

Well dip me in chocolate and call me shirley! Just when I thought I'd heard it all along comes Narcan for septic shock. Thanks for the post and the link.

GHGoonette, BSN, RN · Feb 25, 2011

Yeah, ok, but I can't see why anyone would use it instead of one of the more "accepted" substances, like ephedrine or phenylephrine. Even the article is vague...

Narcan has been shown in some cases of septic shock to produce a rise in blood pressure that may last up to several hours; however, this pressor response has not been demonstrated to improve patient survival. In some studies, treatment with Narcan in the setting of septic shock has been associated with adverse effects, including agitation, nausea and vomiting, pulmonary edema, hypotension, cardiac arrhythmias, and seizures. The decision to use Narcan in septic shock should be exercised with caution, particularly in patients who may have underlying pain or have previously received opioid therapy and may have developed opioid tolerance.
Because of the limited number of patients who have been treated, optimal dosage and treatment regimens have not been established.

I'd be very wary of any dr who wanted to use it, as it would smell like experimentation to me....

GilaRRT · Feb 25, 2011

Yeah, ok, but I can't see why anyone would use it instead of one of the more "accepted" substances, like ephedrine or phenylephrine. Even the article is vague...
I'd be very wary of any dr who wanted to use it, as it would smell like experimentation to me....

Nobody is saying we should use naloxone in lieu of standard therapies. Even the link states that naloxone may be considered as adjunctive therapy. The OP did not say anything about using naloxone as a sole agent either. So, if an experienced physician was wanting to consider it on a patient in septic shock, I would not necessarily have a problem considering using it.

CCL RN, RN · Feb 25, 2011

Gila, thats a good point.

I guess if you were at the point where you were *thinking* of narcan, then I'd use it too, because it must mean we are running out of options. And everyone knows once that happens in septic shock, it's a quick downward spiral. So once we are at the point of all pressers being used, then why not?

GHGoonette, BSN, RN · Feb 25, 2011

Nobody is saying we should use naloxone in lieu of standard therapies. Even the link states that naloxone may be considered as adjunctive therapy. The OP did not say anything about using naloxone as a sole agent either. So, if an experienced physician was wanting to consider it on a patient in septic shock, I would not necessarily have a problem considering using it.

Gila, thats a good point.
I guess if you were at the point where you were *thinking* of narcan, then I'd use it too, because it must mean we are running out of options. And everyone knows once that happens in septic shock, it's a quick downward spiral. So once we are at the point of all pressers being used, then why not?

I didn't have time to read the whole article, so I presume the piece you're referring to re "adjunctive therapy" comes further down in the text. I will go back and read the entire article relating to Naloxone's use as pressor therapy at my leisure. It's definitely something I need to know more about before some gung-ho anaesthesiologist decides to try it out for low BP.

If you're looking at last resorts, the most important thing is to save the patient's life. I'm just wary of those doctors with the cowboy mentality-and I'm sure we've all encountered them-who have heard about this or that interesting new treatment and want to try it out at the earliest opportunity. The fact that, as yet,

optimal dosage and treatment regimens have not been established.

, makes it, in my book at least, a very risky option. If it was a doctor I fully trusted, who I knew had taken time out to study and consider all the pros and cons, I would at least feel more comfortable with it, but I still think more study of the effect is needed.

All new drugs are put through exhaustive tests to establish safety, efficiency, dosages etc before being allowed onto the market; the only time when you'll find non-approved substances being used is when they are undergoing clinical trials. This is not the case with Naloxone. It is on every emergency trolley, in every unit, and it has not yet gone through the necessary trials for this application.

annister · Feb 25, 2011

Just to clarify a few things...I do not work in an intensive care setting, and was being fed the line "we don't have any unit beds", as well as "she's just tired from dialysis, she did this last week".(by adon/ccrns) This doctor does not typically deviate from standard treatment, which is why I was so baffled about the narcan thought, prompting me to look into it on my own time. I don't know the last thing about pressors, but here is some more insight. She developed afib with rvr @ 180-200, sbp was 70-80's when I could get one, she had been dialyized that afternoon, and he was requesting a cardizem gtt. I hate to open up a can of worms, but if my hospital was more proactive and relied less on hindsight, I don't think this would have been such an issue-she would have been in icu with constant monitoring. I really think the MD was, under these circumstances, trying to stretch out time to get her to the unit and maybe thought the narcan would hold her pressure until then? It was a bad situation, with a bad outcome I might add.

GHGoonette, BSN, RN · Feb 25, 2011

Weeelll-I'm a PACU nurse, and if I had a patient exhibiting those kind of symptoms I'd have raised holy h*ll until they made some kind of plan, even if they had to open up a single room on the ward, set it up for ICU, and hire an agency nurse to take care of her. And no way would such a patient leave my unit until such arrangements had been made! In fact, none of the ward RNs would accept a patient in that condition, and rightly so!

You don't specifically mention whether she actually was in septic shock; when was this diagnosed?

Normally with a recalcitrant hypotension the patient will have both CVP and a-line monitoring, and given the fact that the MD was trying out an uncertain factor such as Naloxone, the patient should have been in ICU. If your hospital was, for whatever reason, unwilling or unable to accommodate the patient accordingly, was it not possible for the MD to transfer her to another hospital?

GilaRRT · Feb 25, 2011

Weeelll-I'm a PACU nurse, and if I had a patient exhibiting those kind of symptoms I'd have raised holy h*ll until they made some kind of plan, even if they had to open up a single room on the ward, set it up for ICU, and hire an agency nurse to take care of her. And no way would such a patient leave my unit until such arrangements had been made! In fact, none of the ward RNs would accept a patient in that condition, and rightly so!
You don't specifically mention whether she actually was in septic shock; when was this diagnosed?
Normally with a recalcitrant hypotension the patient will have both CVP and a-line monitoring, and given the fact that the MD was trying out an uncertain factor such as Naloxone, the patient should have been in ICU. If your hospital was, for whatever reason, unwilling or unable to accommodate the patient accordingly, was it not possible for the MD to transfer her to another hospital?

Let's be realistic however. We cannot pull all these resources out of our behinds, nor can we often materialise a transfer to another facility by snapping our fingers or raising heck, let alone get a transport team that would be willing to transfer such an unstable patient with unconventional treatment modalities. Especially, when the ADON does not have your back. Without knowing about the situation or being there, it sounds like the doc was trying to navigate through a bad situation?

annister · Feb 25, 2011

Trust me, I raised h*ll, but I have no authority in such situations and I was fighting a losing battle, therefore I focused on providing what care I was capable of to this pt while incessantly calling the adon to see if anything had changed as far as icu placement (while essentially leaving my 5 other patients to fend for themselves). I honestly don't know how the issue of transporting to another facility is dealt with, as usually it is the other way around in my hospital.

The diagnosis of septic shock was never official; just a likely suspect, I suppose. Her vs, history, and the fact that she had just been to dialysis, where her TDC had been utilized all pointed in that direction. She returned from HDY with decreased LOC, but nothing concrete to justify my argument that she was in need of some sort of intervention, (at which point the MD was physically present), so I monitored her as closely as one can on a medical/oncology floor, and represented my case once I had a leg to stand on. I got orders to transfer to icu, which were immediately squashed by adon, so the MD agreed to transfer to cardiac/tele until a unit bed was available. Unfortunately, it seems I was not the only one to receive such orders and our cardiac floor had been infiltrated by ccu-worthy patients, so it took far too long to transfer her. She was shortly-thereafter made a DNR by her family and passed away that morning, so no official diagnosis was revealed to me in this matter. She was by no means in good shape to begin with, and I don't disagree that a DNR order would have been appropriate (before this situation arose), however, the fact is that her condition warranted ICU placement/monitoring, and she did not receive it. I know, I know, this is a whole other can of worms that I'm opening, but I can't help but wonder if my original question would even exist had the situation been handled properly from this standpoint.

Furthermore, I was in no position to refuse this patient, as I'd taken care of her numerous times before and, as of shift change, I had nothing more than a feeling that something wasn't right to go on. Had she been a new admit from the ER or an attempted ICU to floor transfer, you'd better believe I'd have stopped that train and raised h*ll. Sadly, that wasn't the case and I was forced to do what I could with what I had (and without any support from anyone who could offer more). I sincerely appreciate your feedback and I apologize for straying so far off topic.