Trouble with Narcan

mellomom · Apr 20, 2006

So does narcan always cause the delirium I saw? It seems when we've given it before, it just wakes folks up (and increases their pain...) but this was so violent... we were wondering if psych hx or anesthesia reaction played a part as well... and it turned out she did have a seizure disorder (found when family brought in all of the pill bottles, not in pmh)...

I guess I want to know what to expect next time (God forbid, but there will be one, I'm sure). I'm on a medsurg floor, so I don't usually get the od's until er is through with them; my pts who need narcan are usually othro postops, and they all have narc use/dependency for pain prior to coming in for surgery. This is the first one who went bats on me!

TazziRN, RN · Apr 21, 2006

No, it doesn't always cause that, usually if a pt has a hx of narcotic use.

Altra, BSN, RN · Apr 21, 2006

You also need to be careful about vomiting - common in opioid withdrawal. I've seen several pts. who began vomiting as soon as the Narcan kicked in and added possible aspiration to their list of problems.

Some of the most difficult medical management issues I've run into have been with frail elderly w/chronic pain who unintentionally OD on pain meds. Keeping them pain-free while maintaining the respiratory function seems just about impossible.

AmiK25 · Apr 21, 2006

Here is a Narcan tip that I have found helpful in the past...dilute the .4 mg in 9 mL of NaCl so it is .04 mg/mL and then give it very slowly 1-2 mLs at a time. Most patients do not need the entire dose of narcan to reverse respiratory depression caused by opioids. If you give small doses, you can reveres resp. depression without reversing all your analgesia and the patient is usually not as uncomfortable/agitated. By the way, Narcan can also cause HTN, severe tachycardia, and pulmonary edema. Note: This is only for resp. depression...not heroine OD (never tried it b/c I've never worked in the ER).

mamamo · Jun 22, 2006

Hi everyone I 'm new here and just want to to tell you the lasted horror story that happened in my family last month using Narcan. My 84 year old mother has been suffering from shingles since Jan. '06 that appeared the day after she had back surgery. she had been back and forth to pain management a zillion times. the doctor had written a script for 4mg dilaudid to be taken every 6 hours, It's the only pain medicine she can tolerate. she is allergic to all codeine's, condones and darvecet. She was doing pretty good on this until they introduced Lyrica which on top of the dilaudid she was really stoned and sicker than and dog. so we stopped the lyrica. Last month she was not feeling well and in a ton of pain so at AM I gave her a 4 mg dilaudid. She slept for awhile, wouldn't eat or drink and since she has a history of dehydration so I started to worry. I sat that on the bed with her trying to get her to sip water to no avail. At PM she asked for another pain pill so I gave it to her. It was the only time she hadn't spoke all morning. Common for her when she is ill. By 2 pm I had had enough worrying and called the ambulance. I explained the situation gave them a list of all her meds. and when she had them. the ems took it upon themselves to give her Narcan by the time they took us into to see her in ER, she was in cardiac arrthymia and kidney failure. she started foaming at the mouth shaking and and pooing on her self. her oxygen dropped to 80, and her blood pressure to 80 over 39. She was diagnosed with kidney failure, double pneumonia, COPD, (she has never smoked) and cardiac arrthymia and was put into ICU for ten days

When I questioned the EMS about what happened and they said they gave her narcan which was standard procedure for some one who is non responsive, on a narcotic and having difficulty breathing. The Narcan nearly killed her. They had no right to give that to a 84 year woman. She was non-responsive because she was so sick. Tell me if I'm wrong but COPD and double pneumonia would give one respiratory problems or in her case very shallow breathing.

The ER Doctor indicated that the Narcan could have called the cardiac arrthymia. Needless to say I am very upset about the use of this drug in her situation and Would like anyone's input on it:madface:

Indy, LPN, LVN · Jun 22, 2006

I'd be more worried about an 84 year old taking approximately 12 mg of dilaudid per day than anything else, imho. Of course, she's developed tolerance to it but that's a lot of meds; elderly people in general have a harder time excreting and breaking down drugs so along with tolerance and a high intake of the drug, she may have been predisposed to its toxicity.

And if you were not in the ambulance, it'd be hard to say that she didn't have a turn for the worse while there and be more unresponsive, etc. Sounds to me like narcan wasn't her only problem. Sorry to sound so blunt, but I have a hard time with the tone of the post as it seems like you want to put all the "blame" in one place. That doesn't fly with me as it could very easily be any healthcare professional, nurse, doctor, etc. besides a paramedic that might assess the patient's level of consciousness, given a history that looks like dilaudid overdose, and administer narcan.

Indy, LPN, LVN · Jun 22, 2006

Ah. Sorry, hit the button before I was done. Also, if your mother had pneumonia and COPD, those alone, at her age, could put her into ICU if she's having trouble breathing. Dilaudid certainly did not help her situation, putting respiratory depression on top of icky lung function in the first place is not good. Was she seeing a primary care doctor other than her pain doctor?

The way I see it, she was lucky to survive, narcan or no narcan.

**canoehead, BSN, RN** · Jun 22, 2006

EMS would have been negligent not to give her Narcan.

LuvMyGamecocks · Jun 22, 2006

my pts who need narcan are usually othro postops, and they all have narc use/dependency for pain prior to coming in for surgery

Dork that I am, I've printed out all of the topics on the most excellent website created by one of allnurses.com members (Mark Hammerschmidt). There is one section called "Med Tips" that says this about Narcan:

Opiate Antagonist: Narcan (“Narcotic Antagonist”)
We used narcan last week – we got a patient with respiratory problems, apparently from her patient-controlled-analgesia (she’d had a fractured hip repaired). I guess she got too much. I’ve learned to be careful when giving narcan – if your patient is intubated and lined (or even if they’re not), you may want to think about applying restraints before giving the dose. As I understand it, Narcan pushes the opiate molecules off their receptor sites, and if the patient was in pain before, it may be worse afterwards. In other words, they may levitate, scream, shout, swear, and otherwise demonstrate an alteration in comfort level secondary to an alteration in opiate receptor status mediated by pharmacologic alteration of pain management as evidenced by, uh, screaming. (Yo, NANDA, you listening?) That’s to say, they become distressed. So narcan isn’t always a nice thing to do. The hip lady got some Narcan, which was before I came on, and I wonder how she felt – would it have been kinder to intubate her and let her “cook off” her opiates to a safe level? Risk? Benefit? Judgment call

There is also a website that gives some detailed information about administering Narcan. It is:

http://www.genesishealth.com/pdf/painbooklet.pdf

It seems to me that if I've been on opioid meds, or I've OD'ed and I'm "in trouble".....knowing that Narcan basically blows the opiates off their cell receptors....it's easy to understand physiologically why agitation and possibility of severe pain occur. The med doesn't cause the pain...it just removes what was relieving the pain.

I'm just a student, have never seen Narcan administered, have never given Narcan, so I can't comment on personal experience. If anything is off, nurses, please correct me.

rn29306 · Jun 22, 2006

Here is a Narcan tip that I have found helpful in the past...dilute the .4 mg in 9 mL of NaCl so it is .04 mg/mL and then give it very slowly 1-2 mLs at a time. Most patients do not need the entire dose of narcan to reverse respiratory depression caused by opioids. If you give small doses, you can reveres resp. depression without reversing all your analgesia and the patient is usually not as uncomfortable/agitated. By the way, Narcan can also cause HTN, severe tachycardia, and pulmonary edema. Note: This is only for resp. depression...not heroine OD (never tried it b/c I've never worked in the ER).

EXCELLENT POST! I was waiting to see all the responses before inquiring about the dose everyone was using.

40 - 80 mcg will often, like AmiK25 said, get back respiratory function without sending people through the roof. I sincerely hope, even when the MD orders full dose Narcan, that people aren't shoving the full dose. Give 40 mcg at a time, wait 2-4 minutes, and see what happens.

This is obviously for AMS and respiratory depression, not heroine OD.

40mcg at a time works extremely well in the OR for overjudicious narcotic administration. The only downside is that by using minimal dosing in order to regain respiratory function, you may indeed have to redose after a while.

Please try this on your patients in the future and I think you'll be pleasantly suprised by the outcomes.

subee, MSN, CRNA · Jun 22, 2006

I work in an inner city ER - give Narcan almost daily. You do have to be very careful with it because it can kill - it precipitates seizures. Folks with sz disorder (something you may not know in your unconcious ER pt), usually sz and can go to status quickly. With heroin OD's, you need to ensure your pt is in four point restraints PRIOR to giving Narcan if at all possible. Narcan is not a cure-all either - you may have to give more than one dose in order to keep their LOC up.

I use narcan very occasionally post anesthesia. To push a full dose of narcan is cruel, unnecessary and creating more work for yourself. Narcan in a sleepy patient need be titrated only until you obtain a satisfactory respiratory rate. We titrate doses of .05mg. to 1.0mg. A little finesse will keep everyone happy. Addicts are obnoxious and trying, but remember all those folks in successful recoveries who used to be total losers when they were using.

mamamo · Jun 22, 2006

Yes she has a primary doctor he was the one who wrote the script for dilaudid on the botlle it stakes to be taken every 4-6 hours. she had them twice a day which would be 8 mg not 12 like you mentioned. She has a high pain tolorance so when she said her shingles were an 11 on a scale from 1-10 she was obviously in pain. she was not overdosed. her pneumonia comes on very quick as she has chronic RA. When she left the house in ambulance she was breathin on her own , non responsive becasue that's how she is when she is sick. when she arrived in the hospital 15 minutes later she was as how I described her in other post. and Yes I am digusted with the EMS and asked them NEVER to give it to her again. This may be a great drug for junkies which my mother is not!