Naloxone in palliative care 🧵 Naloxone can save lives in people with opioid induced respiratory failure or apnoea. It’s use only indicated when there is a fall in respiratory rate with evidence of significant ventilatory failure
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There are various parameters quoted for using naloxone which include: Resp rate <8/min with O2 sats <85% or Cyanosis In palliative care patients taking regular opioid for pain great care is needed before using naloxone
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Giving a 400microgram dose of naloxone to a patient with severe cancer pain treated with opioids will not only cause opioid withdrawal but also acutely unmask their pain. Many Patients describe this as the worst experience imaginable
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So… we need to be really sure before we give naloxone in palliative care. Here are 3 scenarios to reflect on this Firstly a 49 year old man who has been taking 40mg morphine twice daily for 2 months. He has become very drowsy and is hallucinating. RR is 12/min Sats 93% on air
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Give naloxone? His respiratory rate is reduced but he is maintaining ventilation. The answer is No but continue to monitor closely. Withhold next opioid dose, update renal function and consider parenteral hydration to aid opioid clerance
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Opioid toxicity and/or sedation are NOT indications for Naloxone unless they are accompanied by Respiratory Depression with Ventilatory failure. You will not quickly reverse opioid related confusion/delirium with Naloxone as it involves more than just opioid receptors
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Scenario 2 A 72 year old lady with lung cancer and chest wall pain is found unresponsive. Her pain has been managed using a Fentanyl patch and morphine oral solution. She has accidentally applied an extra fentanyl patch last night. RR 7/min O2 sats 84% Give Naloxone?
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This lady has respiratory depression and ventilatory failure. She is believed to have a prognosis of many months. YES give Naloxone, apply o2 and remove extra fentanyl patch. What dose of Naloxone? Do you need to fully reverse her opioid effects with 400micrograms stat?
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To avoid abrupt pain and agitation after giving Naloxone it would be better to try a smaller dose of Naloxone initially. A dose 50-100micrograms IV or IM may be enough to stimulate respiratory drive without provoking pain and full opioid withdrawal. Doses can then be repeated
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Should the small doses not work then Naloxone dose must be increased gradually and repeated until a ventilatory response is seen. With any dose of Naloxone be prepared that the patient may come round in a fearful or agitated way. Reassurance and support is vital at this time.
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Scenario 3 A 92 year old man is admitted to a hospice with widespread metastatic renal cancer. He is receiving 100mg oxycodone and 400micrograms of clonidine per day via a syringe driver for severe bone pain. He has been sleeping more over the last week and appeared comfortable.
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He has cancer cachexia and is jaundiced due to liver metastases. It is noted by a family member that his breathing has slowed and become more shallow in the last few hours. There are periods when he stops breathing for up to 20seconds. He has some myoclonic jerking of his arms.
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His RR varies between 4/min up to 12/min. Oxygen sats are 82%, his hands are cool to touch. He is unrousable. He looks comfortable. Family have asked if the morphine is causing him to present this way. Give some Naloxone? Even a small dose?
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NO definitely not! This person is dying. He is peaceful and settled. The changes in conscious level and breathing are normal signs of dying. Pauses in breathing are very common in the last hours of life. Myoclonic jerks also can occur near end of life. Reassurance is needed
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These are some of the most common scenarios that may occur. Opioids do slow down breathing and make it irregular. They act on the brainstem Pre-Botzinger complex even at safe therapeutic levels. We compensate for this by increasing tidal volume normally.
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It is only when opioid effects overwhelm this compensatory rise in tidal volume and reduce chemoreceptor sensitivity that ventilatory failure occurs. For palliative care patients established on opioids this is a very rare event! Opioid toxicity on the other hand is more common
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Remember Naloxone is not used to treat opioid toxicity Naloxone is used to treat life threatening opioid induced respiratory depression with ventilatory failure Naloxone should not be given to people who are dying peacefully
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Important Once a palliative care patient experiences naloxone reversal with acute pain, sudden fear, restlessness and agitation- it can make them fearful of ever taking opioids again, even when these drugs were providing good pain relief. This can lead to unnecessary suffering
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This article explains everything in the thread and so much more. It is vital reading for anyone who works with patients approaching end of life or receiving palliative care https://t.co/4F5sWn0mPA
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