Question about fent OD?

[benmca13]

So this is going to be a bit of a long post but I'm just trying to figure this whole situation out.

Long story short. My patient was 60 something years old. Had MVR done. Wanted to be on the transplant list due to non alcoholic liver cirrhosis stage 3. Was on pump for about 12 hours. Post op was rough for her her first night. Still intubate. Scv02 was high 30s to low 50s. Hemoglobin at 10 pm was 10.5 after 2 PRBCs given after her first hemoglobin came back at 8.0. Overnight her huge belly became a tad more firm (could hardly tell because it was already firm from cirrhosis). Hemoglobin was 6.3 and it showed a bleed but it was controlled and nothing was needed to be done. Had her the next night (extubated at 1630). She was A/O x3 on days but when I came on she could hardly answer any questions. Got her on bipap overnight.

About 3 am she became super restless. Pressure in the 190s on 150mcg/min of nitro and 2mcg of nipride. Gave her 50 of fent. Worked wonderful. She calmed down, pressure came down. Ended up giving her 300mcg fent total over about 4-5 hours. I'd only give it to her after when I had thought the fent had worn off. I'd only give it when her husband was there holding her arms down bc she kept trying to pull stuff out and getting out of bed. I gave her a dose right before I left. That night I got a text and apparently she has been completely unresponsive all day. Gave her a dose of narcan and she still didn't wake up. Now over the past 2 days and still hasn't woken up and the surgeons is blaming me for an overdose.

I obviously think I gave too much fent. But is she really unresponsive bc she had 300 fent over 4-5 hours when she was continuously trying to climb out of bed and wasn't neuro intact?

Why wouldn't the narcan have woken her back up if that was the case?

Thanks so much for all your help!

[suga_junkie, BSN, RN]

If the narcan didn't work then it wasn't the fentanyl. Sounds like the surgeon is trying to deflect responsibility for post op complications. Has she had any scans?

[benmca13]

No neuro scans yet. CT scan showed the bleed though. I'm going to call my educator today and ask why would it be a fent OD if the narcan didn't work? How do you feel about the amount I gave her?

[suga_junkie, BSN, RN]

300mcgs in 4-5 hrs doesn't sound excessive to me. It's not like you gave it in one go. I assume you were assessing her and she wasn't becoming really sedated/ showing signs of respiratory depression. Fentanyl had a fairly short half life also.

[benmca13]

She became sedated when I gave it to her. But then half hour later she was awake and restless again, rolling around in bed. Husband was holding her arms down bc she was trying to pull off her bipap (which I got an order for about 8 hours prior for prevention).

[Wuzzie]

When you say "bleed" what type of bleed are you specifically referring to? If I'm understanding this correctly she had a mitral valve replacement? The acute onset of restlessness is concerning. She needs her head scanned. Although I doubt the Fentanyl had anything to do with it how was it ordered? Hate to say this but you might want to contact your malpractice insurance company ASAP. Sounds like you are being thrown under the bus. This could get ugly.

[benmca13]

They think they knicked her liver when they put in pacing wires.

[Wuzzie]

They think they knicked her liver when they put in pacing wires.

Okay thank you for the clarification. Now, are they scanning her head or still blaming you? If they're still blaming you then you need to stop posting ANY details about this and ask the mods to remove your post entirely.

[Here.I.Stand, BSN, RN]

But they're not concerned about a hgb drop from 10 to 6.3? How is that controlled bleeding...or did a scan reveal a cessation of active bleeding? That drop, with the agitation, would be very concerning to me. I agree that that amount of fentanyl doesn't sound unreasonable, and wonder why she didn't experience a reversal of decreased LOC with the narcan, if she was overnarcotized.

[Wuzzie]

But they're not concerned about a hgb drop from 10 to 6.3? How is that controlled bleeding...or did a scan reveal a cessation of active bleeding? That drop, with the agitation, would be very concerning to me. I agree that that amount of fentanyl doesn't sound unreasonable, and wonder why she didn't experience a reversal of decreased LOC with the narcan, if she was overnarcotized.

I agree. I seriously cannot fathom that they did not do SOME kind of head CT to rule out a bleed. It's a good bet her platelets dropped as well and her acute agitation followed by un-responsiveness is really, really concerning.

[offlabel]

No neuro scans yet. CT scan showed the bleed though. I'm going to call my educator today and ask why would it be a fent OD if the narcan didn't work? How do you feel about the amount I gave her?

Taking everything you've said at face value (although, odds are there is more to the story that you're not aware of, behind the scenes with the physicians on the case)...If you really mean that the patient was on full bypass for 12 hours (and not just in the OR, which would be bad enough) and the surgeon got the liver with the pacing wires, I'd say the surgeon is a clown and you shouldn't worry about anything he says about your care because he's got way bigger problems than that.

No head scan but a belly scan? In a comatose patient with unknown etiology? More to that story too if that is the case, although the last thing I'd want to do when blaming a coma on narcotics is get a head CT that might show a big bleed. That would lead to a different line of questions directed at me.

If she had a fall in her liver function, you could make the case that the fentanyl accumulated and obtunded her over time, but the narcan would have ruled that out. It wasn't your fentanyl.

Your CT service sounds like an awful mess.

[SororAKS, ADN, RN]

The patient has problems that have nothing to do with Fentanyl. It isn't long acting at all. Something else is afoot.