A 52-year-old man with fentanyl-induced muscle rigidity

Buxton, Jane A.; Gauthier, Tim; Kinshella, Mai-Lei Woo; Godwin, Jesse

doi:10.1503/cmaj.171468

Cited by 11 publications

(6 citation statements)

References 6 publications

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“…In addition, the declining proportion of successful opioid toxicity reversal post-2015, coupled with unchanged naloxone dosing at Insite provides further evidence that fentanyl overdoses may be less readily reversible at usual naloxone doses than overdoses from other opioids. Previous studies have also shown that opioid overdoses are increasingly challenging to manage in the fentanyl era potentially due to fentanyl-induced chest rigidity that impedes effective ventilations 30,31. Therefore, our data suggests that an alternative approach to naloxone dosing may be required in community settings with high fentanyl prevalence.…”

Section: Discussionmentioning

confidence: 74%

“…Previous studies have also shown that opioid overdoses are increasingly challenging to manage in the fentanyl era potentially due to fentanyl-induced chest rigidity that impedes effective ventilations. 30,31 Therefore, our data suggests that an alternative approach to naloxone dosing may be required in community settings with high fentanyl prevalence.…”

Section: Interpretation Of Findingsmentioning

confidence: 92%

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Opioid Overdose and Naloxone Dosing at Insite Supervised Injection Facility in British Columbia: A Retrospective Cohort Study

Cho

Purssell

Joe

et al. 2022

Canadian Journal of Addiction

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Objectives: We aimed to understand trends in opioid overdoses, naloxone dosing, and overdose reversal from 2014 to 2017 at Insite, a community-supervised consumption site in Vancouver, British Columbia. Methods: We performed a retrospective cohort study of patients who overdosed on opioids at Insite. We evaluated yearly trends in total overdoses, naloxone doses administered, and proportions of patients reversed (based on our definitions of “probable” and “confirmed” reversal), with particular attention to trends before and after the emergence of illicit fentanyl in 2015. Results: There was an increase in total overdoses at Insite from 2014–2015 (n=586) to 2016–2017 (n=2033). Overdose reversal data were limited by a large proportion of patients for whom there was not enough information to adjudicate whether reversal occurred, and therefore were marked “unspecified” [n=1537/2619 (58.7%)]. Within these limitations, fewer patients were reversed after 2015 (44.1% in 2016, 29.7% in 2017) than before (47.8% in 2014, 55.1% in 2015) (χ2=73.1, P<0.001). Despite this, naloxone doses remained unchanged between 2014–2015 and 2016–2017 {median: 0.4 mg [interquartile range (IQR): 0.4–0.8 mg] for both, P=0.21}. Insite staff administered higher doses to patients not successfully reversed [median: 0.8 mg (IQR: 0.4–0.8 mg)] compared with those reversed [median: 0.4 mg (IQR: 0.4–0.8 mg)] (P=0.021), and to patients offered transfer to hospital [median: 0.8 mg (IQR: 0.4–0.8 mg)] compared with those discharged home [median: 0.4 mg (IQR: 0.4–0.8 mg)] (Kruskal-Wallis H=288.7, P<0.001). Conclusion: Overdose numbers at Insite increased and fewer patients were successfully reversed following the emergence of illicit fentanyl in 2015, but naloxone doses remained unchanged, suggesting that traditional naloxone dosing does not optimally reverse overdoses caused by fentanyl. Our study supports an alternative approach to naloxone dosing in patients with suspected ultrapotent opioid toxicity and in communities with high fentanyl prevalence. Objectifs: Nous avons cherché à comprendre les tendances en matière de surdoses d’opioïdes, de dosage de naloxone et de renversement des effets de surdosage de 2014 à 2017 à Insite, un site communautaire de consommation supervisée à Vancouver, en Colombie-Britannique (C.-B.). Méthodes: Nous avons réalisé une étude de cohorte rétrospective des patients ayant fait une surdose d’opioïdes à Insite. Nous avons évalué les tendances annuelles du total des surdoses, des doses de naloxone administrées et des proportions de patients qui ont renversé les effets de surdosage (selon nos définitions de “probable” et “confirmée”), en accordant une attention particulière aux tendances avant et après l'émergence du fentanyl illicite en 2015. Résultats: Il y a eu une augmentation du nombre total de surdoses à Insite entre 2014-2015 (n=586) et 2016-2017 (n=2033). Les données sur le renversement des effets de surdosage étaient limitées par une grande proportion de patients pour lesquels il n’y avait pas assez d’informations pour juger si le renversement des effets de surdosage avait eu lieu, et ont donc été marquées “ non spécifié “ (n=1537/2619 [58,7%]). Dans le cadre de ces limitations, moins de patients ont été renversé après 2015 (44,1% en 2016, 29,7% en 2017) qu’avant (47,8% en 2014, 55,1% en 2015) (χ2=73,1, P<0,001). Malgré cela, les doses de naloxone sont restées inchangées entre 2014-2015 et 2016-2017 (médiane de 0,4 mg [IQR 0,4-0,8 mg] pour les deux, P=0,21). Le personnel d’Insite a administré des doses plus élevées aux patients dont le renversement n’a pas réussi (médiane de 0,8 mg [IQR 0,4-0,8 mg]) par rapport à ceux dont le renversement a réussi (médiane de 0,4 mg [IQR 0,4-0,8 mg] (P=0. 021), et aux patients à qui l’on a proposé un transfert à l’hôpital (médiane 0,8 mg [IQR 0,4-0,8 mg]) par rapport à ceux qui ont été renvoyés chez eux (médiane 0,4 mg [IQR 0,4-0,8 mg]) (Kruskal-Wallis H=288,7, P<0,001). Conclusion: Le nombre de surdoses à Insite a augmenté et moins de patients ont renversé les effets de surdosage avec succès après l'émergence du fentanyl illicite en 2015, mais les doses de naloxone sont restées inchangées, ce qui suggère que le dosage traditionnel de la naloxone ne renverse pas de manière optimale les surdoses causées par le fentanyl. Notre étude soutient une approche alternative au dosage de la naloxone chez les patients soupçonnés de toxicité aux opioïdes ultrapuissants et dans les communautés à forte prévalence de fentanyl.

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Section: Discussionmentioning

confidence: 74%

Section: Interpretation Of Findingsmentioning

confidence: 92%

Opioid Overdose and Naloxone Dosing at Insite Supervised Injection Facility in British Columbia: A Retrospective Cohort Study

Cho

Purssell

Joe

et al. 2022

Canadian Journal of Addiction

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show abstract

“…Such phenomena, although unusual, have been effectively managed in published cases with the use of dexmedetomidine ( Roberts & Lewis, 2018 ). Other anesthetics which have been associated with aggravation of extrapyramidal signs are fentanyl ( Buxton, Gauthier, Kinshella, & Godwin, 2018 ; Zesiewicz et al, 2009 ), alfentanil and thiopental ( Shaikh & Verma, 2011 ). Low doses of ketamine were reported to facilitate problematic airway management and tremor in PwP perioperatively ( Wright, Goodnight, & McEvoy, 2009 ).…”

Section: Severe Covid-19 Infectionmentioning

confidence: 99%

Treatment paradigms in Parkinson's Disease and Covid-19

Boura

Batzu

Dietrichs

2022

International Review of Neurobiology

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“…44,45 Opioid-induced muscle rigidity responds to neuromuscular blockade and naloxone. 46,47 The combination of meperidine and selegiline should be avoided as it can provoke agitation, muscle rigidity, and hyperthermia. 48 Non-depolarizing neuromuscular blocking agents are recommended (e.g.…”

Section: Intraoperative Anesthetic Considerationsmentioning

confidence: 99%

A Pragmatic Approach to the Perioperative Management of Parkinson’s Disease

Lenka

Mittal²,

Lamotte

et al. 2020

Can. J. Neurol. Sci.

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Patients with Parkinson’s disease (PD) may undergo several elective and emergency surgeries. Motor fluctuations, the presence of a wide range of non-motor symptoms (NMS), and the use of several medications, often not limited to dopaminergic agents, make the perioperative management of PD challenging. However, the literature on perioperative management of PD is sparse. In this descriptive review article, we comprehensively discuss the issues in the pre-, intra-, and postoperative phases which may negatively affect the PD patients and discuss the approach to their prevention and management. The major preoperative challenges include accurate medication reconciliation and administration of the dopaminergic medications during the nil per os (NPO) state. While the former can be addressed with staff education and PD-specific admission protocols, knowledge of non-oral formulations of dopaminergic agents (apomorphine, inhalational levodopa, and rotigotine transdermal patch) is the key to the management of the Parkinsonian symptoms in NPO state. Deep brain stimulation (DBS) devices should be turned off to avert potential electromagnetic interference with surgical appliances. Choosing the appropriate anesthesia and avoiding and managing respiratory issues and dysautonomia are the major intraoperative challenges. Timely reinitiation of dopaminergic medications, adequate management of pain, nausea, and vomiting, and prevention of postoperative infections and delirium are the postoperative challenges. Overall, a multidisciplinary approach is pivotal to prevent and manage the perioperative complications in PD. Administration of anti-Parkinson medications during NPO state, prevention of anesthesia-related complications, and timely rehabilitation remain the key to healthy surgical outcomes.

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A 52-year-old man with fentanyl-induced muscle rigidity

Cited by 11 publications

References 6 publications

Opioid Overdose and Naloxone Dosing at Insite Supervised Injection Facility in British Columbia: A Retrospective Cohort Study

Opioid Overdose and Naloxone Dosing at Insite Supervised Injection Facility in British Columbia: A Retrospective Cohort Study

Treatment paradigms in Parkinson's Disease and Covid-19

A Pragmatic Approach to the Perioperative Management of Parkinson’s Disease

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