Question about fent OD?

dishes, BSN, RN · Jul 21, 2016

Have you asked the physicians if her liver cirrhosis made her higher risk for adverse event and/or toxity?

MunoRN, RN · Jul 21, 2016

My first question would be what her ammonia level is, CO2 level as well. Short bypass times are particularly important in liver failure patients in order to reduce post-bypass liver failure exacerbations which would produce ammonia levels well above baseline. The national average for bypass time in mitral valve surgery is just over 2 hours, so 12 hours is ridiculously long. The confusion and restless is not all that unusual for any post-OHS patient, but the obtundation that doesn't respond to reversal agents would narrow it down to either ammonia or CO2 level.

Lev, MSN, RN, NP · Jul 21, 2016

Hows much narcan did she get? Sometimes 4-5 doses are needed to get a response. Fentanyl is short acting so the dose doesnt seem too exorbitant. Did they scan her chest and her head for a clot?

offlabel · Jul 21, 2016

The liver is pretty resilient to insult, even cirrhotic ones...my thought is that if this patient were suffering from hepatic encephalopathy 2/2 an ischemic liver there'd be a lot of other stuff that was off that would be picked up routinely like lactate, glucose and coags for starters. Routinely were I am though, not this place...Hopefully NH3 would just be part of an ALOC workup...like the head CT that, according to OP didn't happen.

NotAllWhoWandeRN, ASN, RN · Jul 22, 2016

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.

Lots of good things have been said, but I'm also going to zero in on this timeline. They left her unresponsive an entire shift before they tried to do something about it? Something is rotten in Denmark.

dec2007 · Jul 22, 2016

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!

I seriously doubt this had anything to do with receiving too much fentanyl. If narcan didn't reverse it, there is little chance it was narcotic-related. Our hospital policy for PCA use is for a max of 250 mcg per HOUR. In 4 hours that would be 1000 mcg. There are lots of parameters in this scenario that could cause mental status changes, and some surgeons will throw anyone under the bus (including the patient) to protect their statistics. Personally, I had a patient a few years ago S/P MVR with an air embolus to the brain. He was unresponsive the next day too. And believe me when I tell you that it was the surgeon's fault, not the nurse.

OnceMorewithFeeling · Jul 22, 2016

Based on the information you have provided, I do not think a fentanyl overdose is the culprit here.

But, I am concerned about the management of this patient.

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.
My understanding is that an abdominal scan showed that the cause of the sharp drop in her Hgb was a nick to the liver that was now resolved. Did further H/H checks confirm that the bleed was resolved?
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.
A change from AAOx3 to obtunded is alarming, and requires investigation. I cannot tell from your post what investigating you did. Did you run ABGs? (is that why you decided on the bipap?) Did you alert the MD to the change in mental status? Did you run another H/H or (as others have suggested), an ammonia level? How was her neuro exam?
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.
Restlessness can certainly be a sign of pain, in which case pain medication is the answer. But in this patient, based on the post-surgical course you describe, you should be looking for other causes. Again, ABGs, H/H, neuro exam? Again, did you call to alert the MD of this change?

Based on the very limited information provided in your post, it seems that this patient was having significant neurological changes at the beginning of your shift and throughout your shift, and that by giving fentanyl boluses you were simply masking the signs of these changes.

benmca13 · Jul 22, 2016

Hey guys. I'm just getting info from people at work. I'm not sure how her mental status is today but I know they did an ammonia level and it was high. So they're thinking that. The bleed in the abd was proved by CT scan. Her hemoglobin had stabilized the next day. She wasn't unresponsive when I had her. Very obtunded, lethargic, so that's why I called and got bipap.

MaxAttack, BSN, RN · Jul 22, 2016

There is a massive amount of information missing here but, long story short, it wasn't the fentanyl.

Where I would start:

Post-op patient with cirrhosis - bleed or elevated ammonia. s/p extubation - hypercapnic respiratory failure.

It sounds like the surgeon is clearly more interested in passing the blame than solving this, however. Gotta love those type.

sbeeso3 · Jul 22, 2016

how could her bleeding have been "controlled" if her HGB was dropping quickly to such levels?

cmclrn · Jul 22, 2016

Not a lot of fentanyl, BUT could've needed more narcan like stated above? And I also wonder about her ABG... Also, with her pressure 190's systolically with issues with her liver (clotting etc.), her H/H and possibly PLT.. could've had a head bleed leaving her obtunded. Our neurosurgeons really like to keep the pressure under 140 systollically if they have a hx of bleeding or liver fxn issues, etc.

offlabel · Jul 22, 2016

Hey guys. I'm just getting info from people at work. I'm not sure how her mental status is today but I know they did an ammonia level and it was high. So they're thinking that. The bleed in the abd was proved by CT scan. Her hemoglobin had stabilized the next day. She wasn't unresponsive when I had her. Very obtunded, lethargic, so that's why I called and got bipap.

MunoRN kind of called it!