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?
The patient's history of liver Dx and a recent packed cell transfusion (old banked blood produces NH3) should have shifted the index of suspicion for the mental status changes away from the usual suspects. The coup de gras would be if someone gave this pt a decent volume of LR.
I am pretty much sure it is not fentanyl. Fentanyl metabolism is primarily hepatic, that's true, but it also means that if there is significant degree of liver failure, then it is the level of unmetabolizedfentanyl is high in serum and Narcan should solve the problem. besides this, the degree of liver failure must be profound for that to happen - with significant elevation of ammonia, bilirubin, probably developing jaundice and all the trimmings.
There are multiple causes of non-responsiveness possible on such a patient and we probably do not have the full picture, but I agree that fentanyl would be one of the last thing to blame.
Central pontine infarction causes pinpoint pupils which look just like ones caused by opioids. These are not reversible by Narcan, of course.
Wile E Coyote, ASN, RN
471 Posts
The patient's history of liver Dx and a recent packed cell transfusion (old banked blood produces NH3) should have shifted the index of suspicion for the mental status changes away from the usual suspects. The coup de gras would be if someone gave this pt a decent volume of LR.