Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants

Abstract

Even low doses of fentanyl can lead to thoracic rigidity in neonates. Additionally, we observed laryngospasm in two patients and speculate that it might be a variant of muscle rigidity.

Premedication for Nonemergency Endotracheal Intubation in the Neonate

“…8,29 A primary concern with synthetic opioid use is the risk of chest wall rigidity, but this risk can be reduced by slow administration and can be treated with either naloxone or muscle relaxants. 30 However, it is important to remember that the use of naloxone, a competitive antagonist at all opioid receptors, will also reverse the analgesic effects of these drugs.…”

“…31 When used alone, fentanyl and other synthetic opioids have been associated with acute chest wall rigidity in both preterm and term infants, which can significantly impair ventilation. 30 However, this adverse effect may be related to dose and rapid delivery and can be prevented by slow infusion of an appropriate dose and overcome with muscle relaxant 50 or reversed with naloxone. 30 Succinylcholine has been reported to have rare serious adverse effects in children, including hyperkalemia, myoglobinemia, and cardiac arrhythmias.…”

“…30 However, this adverse effect may be related to dose and rapid delivery and can be prevented by slow infusion of an appropriate dose and overcome with muscle relaxant 50 or reversed with naloxone. 30 Succinylcholine has been reported to have rare serious adverse effects in children, including hyperkalemia, myoglobinemia, and cardiac arrhythmias. Atropine seems to protect against bradyarrhythmias induced by succinylcholine.…”

Sedação e analgesia em neonatologia

“…A farmacocinética pode estar alterada na presença de aumento da pressão intra-abdominal, pois nessas situações observa-se diminuição do fluxo hepático e do débito cardíaco, permitindo o acúmulo do fentanil em locais de má perfusão e recirculação posteriormente 24 . Doses altas (acima de 5 µg.kg -1 ), quando injetadas rapidamente, podem levar à rigidez muscular, em especial da caixa torácica, dificultando a ventilação e induzindo laringoespasmo em recém-nascidos 26 . As doses recomendadas para o período neonatal são 10 : -administração intermitente de 1 a 4 µg.kg -1 por dose, a cada 2 a 4 horas, por via venosa; -administração contínua em recém-nascidos de termo de 0,5 a 3 µg.kg -1 .h -1 por via venosa e para recém-nascidos prematuros de 0,5 a 2 µg.kg -1 .h -1 por via venosa.…”

“…Its pharmacokinetics can be altered in the presence of increased intra-abdominal pressure because of decreased hepatic blood flow and cardiac output, allowing its accumulation in areas of poor perfusion and posterior recirculation 24 . Fast administration of high doses (above 5 µg.kg -1 ) could cause muscle rigidity, especially in the thorax, hindering ventilation and inducing laryngeal spasm in newborns 26 . The recommended doses for the neonatal period are 10 : -intermittent intravenous administration of 1 to 4 µg.kg -1 every 2 to 4 hours.…”