Naloxone induced pulmonary edema

Abstract

Naloxone-induced noncardiogenic pulmonary edema is a rare but reported entity that can occur following naloxone use in the reversal of opioid overdose. Proposed mechanisms include an adrenergic crisis secondary to catecholamine surge which causes more volume shift to pulmonary vasculature, subsequently leading to pulmonary edema. It appears to be more common when higher doses of naloxone are used. We present a case of a patient with opioid overdose came with altered mental status developed early features of pulmonary edema following the administration of multiple doses of naloxone. She responded well with the administration of diuretics and oxygen supplementation. Her oxygen requirements improved and didn't require mechanical ventilation.

Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest

“…In the event of an opioid overdose, naloxone may have adverse effects, albeit clinical data indicate that serious events are rare. 3,[41][42][43][44][45][46] In case of individuals with an opioid use disorder, withdrawal symptoms may become apparent after naloxone administration; symptoms include tachycardia, mild agitation or anxiety, hypertension abdominal pain, malaise, and insomnia. 2,3,41 In extremely rare cases, abrupt reversal of opioid-induced respiratory depression by naloxone has been followed by seizures, pulmonary edema, cardiac dysrhythmias, hypertension, and cardiac arrest.…”

“…Vasoconstriction and an increase in blood pressure and the occurrence of tachyarrhythmias may be the basis of these complications, with pulmonary edema arising from a rapid fluid shift or from inspiration against a closed glottis (negative pressure pulmonary edema). 3,46 Complications may be enhanced when the patient is in a circulatory unstable condition such as low blood pressure from opioid-induced vasodilation or in case of a high vasomotor tone from (psychologic) stress, agitated delirium and/or pain. 3 In the event of complications, it is crucial to treat the different symptoms and reduce the elevated sympathetic activity with an α 2 -adrenergic receptor agonist.…”

An update on postoperative respiratory depression

“…For example, Gordon and Pellino57 reported that 21% of their patients who receive naloxone were subsequently diagnosed with another condition (eg, pneumonia, acute renal failure), which could have contributed to their clinical decline. Administration of a large dose of naloxone, especially to surgical patients, is not without risks, as catecholamine surge reverses opioid analgesia, which has been linked to pulmonary edema, and rather smaller doses of naloxone titrated to effect, if situation permits, is advisable 57,65–67. Alternatively, unresponsiveness to naloxone treatment could be in situations when RD has progressed to the point where clinical intervention with naloxone has become futile 45…”

“…36 More worrisome is that the protocols regarding the timing of these vital sign checks, especially among higher risk patients who are prescribed more frequent assessments, are often not followed. 66 In part, the inability to perform more frequent vital sign checks is driven by economic restraints, which dictate lower nursing-topatient staffing levels on general care wards. 105 While continuous electronic monitoring has been recognized as superior to intermittent vital sign checks, 36 the cost and size of such monitors have been prohibitive for widespread use on general care wards.…”

Higher-Dose Naloxone Nasal Spray (Kloxxado) for Opioid Overdose

“…Acute opioid withdrawal is associated with anxiety, piloerection, yawning, sneezing, rhinorrhea, nausea, vomiting, diarrhea, and abdominal or muscle cramps. Naloxone-induced noncardiogenic pulmonary edema has been reported rarely and appears to be more common when higher doses are used …”