Fentanyl
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Respiratory insufficiency in an elderly patient: case report A 78-year-old woman developed respiratory insufficiency after receiving fentanyl following elective repair of an abdominal aortic aneurysm. The woman, who had a BMI of 35.7 kg/m2, had an uneventful surgery. After an initial bolus of IV morphine, patient-controlled analgesia with fentanyl was initiated. The machine was programmed to deliver fentanyl in a 20µg bolus, with a 5-minute lockout time interval, and was used every hour. By the next morning, 16 hours after the operation, she had received a total dose of fentanyl 600µg. That morning, she was found to be unusually drowsy and difficult to rouse. A neurological examination yielded a Glasgow Coma Scale score of 11 (E3 + M4 + V4) with bilateral upgoing plantar reflexes and flaccid limbs. She was suspected to have had a stroke. A CT scan was performed with normal results. Her BP was 170/70mm Hg and her respiratory rate was 12 breaths/min. Arterial blood gas analysis revealed respiratory acidosis, with the following results: pH 7.17, PCO2 81mm Hg, PO2 140mm Hg, bicarbonate 29 mmol/L, base excess –2 mmol/L, O2 saturation 98% and anion gap 12. The woman was transferred to the high-dependency unit (HDU). She received ventilatory support and naloxone. Her BP remained at 170/70mm Hg, her pulse rate was 75 beats/min and her CVP was 7cm H20. Her creatinine level was 167 µmol/L (90 µmol/L at baseline). On postoperative day 2, she had an episode of rapid atrial fibrillation, which resolved after she received IV amiodarone. She had a small rise in troponin level to 0.9 µg/L. She remained in the HDU for 2 days and showed progressive improvement on ventilatory support. Questioning revealed a history of disturbed sleep with many awakenings, snoring and being unrefreshed in the morning. She frequently fell asleep during the day. A provisional diagnosis of obstructive sleep apnoea was made and was later confirmed with sleep studies. She was weaned to a face mask and discharged on room air. Ahmad JDR, et al. PCA-induced respiratory depression simulating stroke following endoluminal repair of abdominal aortic aneurysm: a case report. Journal of Medical Case Reports 1: Online first [8 pages], No. 45, 10 Jul 2007. Available from: URL: 801090527 http://www.jmedicalcasereports.com - Australia
0114-9954/10/1162-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 28 Jul 2007 No. 1162
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