Management of narcotic toxicity in ICU
Mohammad Hasan Othman Elmesiry;
Abstract
Opioid narcotics are a broad class of drugs including
(1) Alkaloids extracted from poppy seeds (morphine, codeine) and their semisynthetic derivatives (oxycodone, hydromorphone, oxymorphone)
(2) Synthetic phenylpiperidines (meperidine, fentanyl) and synthetic pseudopiperidines such as methadone.
The majority of opioids undergoes extensive first pass metabolism in the liver before entering the systemic circulation. Hepatic metabolism is generally intended to facilitate renal excretion through a transformation to hydrophilic substances that are easy to eliminate.
In the ICU, side effects of narcotic opioids include endocrinopathy, opioid induced hyperalgesia (OID), Cardiac toxicity, Narcotic Bowel Syndrome (NBS), Opioid-Induced Constipation (OIC), Opioid-induced respiratory depression (OIRS) and Opioid induced nausea and vomiting.
Endocrinopathy is diagnosed on the basis of clinical and laboratory assessment. Suggested management options for opioid endocrinopathy include discontinuing opioid therapy, reducing the opioid dose, switching to a different opioid or adding hormone supplementation.
Pain from OIH is not necessarily located at the source of injury or disease. Instead, pain manifests as generalized, diffuse, and ill defined. Treating OIH is often very challenging and time consuming but one option available to manage OIH includes weaning off opioids completely.Another option to manage OIH is to rotate to a different class of opioids.
For diagnosis of cardiac toxicity, Electrocardiogram (ECG) monitoring of QTc at baseline and following dose increases is appropriate in patients receiving these medications. Decreases in systemic vascular resistance and blood pressure can be treated with the administration of H1 and H2 antagonists, and may require the administration of vasopressors and intravenous fluids.
NBS is characterized by the development or worsening of abdominal pain linked to chronic or escalating doses of opioids. For treatment, a detoxification program for NBS involving inpatient medical hospitalization with careful opioid tapering using reduced intravenous morphine equivalents was suggested. Medications available included duloxetine,milnacipran, pregabalin and gabapentin.
The diagnostic criteria for OIC are often considered to be similar to chronic or functional constipation; however, OIC results directly from opioids and is thus a form of secondary constipation.The treatment of OIC is typically approached in a stepwise fashion starting with lifestyle modification. Although, it carries no risk of side effects, lifestyle modifications including increased physical activity and increased fluid intake are often infeasible due to comorbidities.
(1) Alkaloids extracted from poppy seeds (morphine, codeine) and their semisynthetic derivatives (oxycodone, hydromorphone, oxymorphone)
(2) Synthetic phenylpiperidines (meperidine, fentanyl) and synthetic pseudopiperidines such as methadone.
The majority of opioids undergoes extensive first pass metabolism in the liver before entering the systemic circulation. Hepatic metabolism is generally intended to facilitate renal excretion through a transformation to hydrophilic substances that are easy to eliminate.
In the ICU, side effects of narcotic opioids include endocrinopathy, opioid induced hyperalgesia (OID), Cardiac toxicity, Narcotic Bowel Syndrome (NBS), Opioid-Induced Constipation (OIC), Opioid-induced respiratory depression (OIRS) and Opioid induced nausea and vomiting.
Endocrinopathy is diagnosed on the basis of clinical and laboratory assessment. Suggested management options for opioid endocrinopathy include discontinuing opioid therapy, reducing the opioid dose, switching to a different opioid or adding hormone supplementation.
Pain from OIH is not necessarily located at the source of injury or disease. Instead, pain manifests as generalized, diffuse, and ill defined. Treating OIH is often very challenging and time consuming but one option available to manage OIH includes weaning off opioids completely.Another option to manage OIH is to rotate to a different class of opioids.
For diagnosis of cardiac toxicity, Electrocardiogram (ECG) monitoring of QTc at baseline and following dose increases is appropriate in patients receiving these medications. Decreases in systemic vascular resistance and blood pressure can be treated with the administration of H1 and H2 antagonists, and may require the administration of vasopressors and intravenous fluids.
NBS is characterized by the development or worsening of abdominal pain linked to chronic or escalating doses of opioids. For treatment, a detoxification program for NBS involving inpatient medical hospitalization with careful opioid tapering using reduced intravenous morphine equivalents was suggested. Medications available included duloxetine,milnacipran, pregabalin and gabapentin.
The diagnostic criteria for OIC are often considered to be similar to chronic or functional constipation; however, OIC results directly from opioids and is thus a form of secondary constipation.The treatment of OIC is typically approached in a stepwise fashion starting with lifestyle modification. Although, it carries no risk of side effects, lifestyle modifications including increased physical activity and increased fluid intake are often infeasible due to comorbidities.
Other data
| Title | Management of narcotic toxicity in ICU | Other Titles | إدارة سمية المواد المخدرة فى وحدة العناية المركزة | Authors | Mohammad Hasan Othman Elmesiry | Issue Date | 2016 |
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