OB asks your opinion

[seinfeld]

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Get called in from home to do a CSection. Get my stuff all set up, see the patient, i am ready to go. Then i hear the nurses talking about another patient who is not doing well. Word on the street is she is having acute resp distress/ panic attack and the fetal heart rate is up as well. I find the OB and ask him whats going on. He tells me that the patient became acutely SOB and the fetal heart rate went to 180's. Pts BP also went from 120's to 160's. He doesnt think anything bad is going on from an OB perspective but is concerned that he doesnt know whats happening. I probe a little more and apparently she received some nubain IV just prior to this happening.

Residnets out there any guess to whats going on? How would you treat it? Whats the big game plan?

 

[SleepIsGood]

Get called in from home to do a CSection. Get my stuff all set up, see the patient, i am ready to go. Then i hear the nurses talking about another patient who is not doing well. Word on the street is she is having acute resp distress/ panic attack and the fetal heart rate is up as well. I find the OB and ask him whats going on. He tells me that the patient became acutely SOB and the fetal heart rate went to 180's. Pts BP also went from 120's to 160's. He doesnt think anything bad is going on from an OB perspective but is concerned that he doesnt know whats happening. I probe a little more and apparently she received some nubain IV just prior to this happening.

Residnets out there any guess to whats going on? How would you treat it? Whats the big game plan?

Some sort of withdrawl attack? Any history of 'use' ?

 

[narcusprince]

Here is how I would approach the situation. So your called in for PT A's c-section, and Pt B is having an acute episode of possible anaphylaxis, vs opiod withdrawal vs panic attack vs PE vs. I would first hold the elective section( how unstable is pt A). I would place bp, hr, pulse ox on Pt B. I would then probe pt B about history of narcotic abuse. I would treat moms Bp with labetalol if moms pressure does not stabilize than take her to the OR. If moms pressure stabilizes but babys HR does not stabilize I would take them to the OR. If the babys HR drops to normal range 120-160 with beat to beat variability than manage expectantly.

 

[Jeff05]

she may be in opioid/opiate withdrawal. there is a lot of literature for this, like:
http://www.ncbi.nlm.nih.gov/pubmed/7817340

this is not anaphylaxis, as she is hypertensive.
anxiety/panic attack or PE are possible - but, there is nothing to be done for this until the fetus is delivered.

 

[pgg]

Can Nubain cause pulmonary edema the way naloxone can? I would think so since it's thought to be neurogenic secondary to the catecholamine dump from sudden opioid withdrawal.

Could be just withdrawal and while I'd expect tachypnea, I wouldn't expect SOB per se from that.

 

[Bertelman]

Can Nubain cause pulmonary edema the way naloxone can? I would think so since it's thought to be neurogenic secondary to the catecholamine dump from sudden opioid withdrawal.

You just missed a great opportunity to say "Narcan can".

 

[Planktonmd]

It is very unlikely that giving Nubain to a narcotic user is going to cause the dramatic withdrawal people are imagining.
I would make sure that she is oxygenating well then treat symptomatically as an acute episode of craziness/panic/pain.

 

[IN2B8R]

It is very unlikely that giving Nubain to a narcotic user is going to cause the dramatic withdrawal people are imagining.
I would make sure that she is oxygenating well then treat symptomatically as an acute episode of craziness/panic/pain.

Agreed. Our OB's use it as a first line drug, even in those with prior history of drug abuse--I have never really seen it precipitate a withdrawal reaction as noted in the OP's story.... Not to say that Nubain would never precipitate such a reaction, just have not seen it with extensive use in such patients....

 

[gasaddict54]

Agreed. Our OB's use it as a first line drug, even in those with prior history of drug abuse--I have never really seen it precipitate a withdrawal reaction as noted in the OP's story.... Not to say that Nubain would never precipitate such a reaction, just have not seen it with extensive use in such patients....

This is why i like this forum....as i dont have alot of experience w this , i would have bet alot that this was a withdrawal issue.

 

[seinfeld]

It was an acute withdrawal of sorts. She was on Methadone maintenance. I stood at her bedside and gave 100mcg of fentanyl. When she relaxed back down and fetal heart rate returned to normal, i placed a labor epidural. Then did c-section i was called in to do. She delivered hours later without incident.

Although i agree this is rare to have such a problem my bigger question is why even try to use IV opiods in these chronic Pain/abuse pts. Newer data suggests no delay in timing of delivery whether you wait to 4cm for epidural or do it when they walk in door. (pt satisfaction may decrease as labor progress) Also given this pt was only 3cm why use nubain. Pure Mu agonists would work just as well if not better and given so early in the process risk of fetal resp depression small (if you go for stat section the peds guys can give narcan to the baby).

 

[Planktonmd]

It was an acute withdrawal of sorts. She was on Methadone maintenance. I stood at her bedside and gave 100mcg of fentanyl. When she relaxed back down and fetal heart rate returned to normal, i placed a labor epidural. Then did c-section i was called in to do. She delivered hours later without incident.

Although i agree this is rare to have such a problem my bigger question is why even try to use IV opiods in these chronic Pain/abuse pts. Newer data suggests no delay in timing of delivery whether you wait to 4cm for epidural or do it when they walk in door. (pt satisfaction may decrease as labor progress) Also given this pt was only 3cm why use nubain. Pure Mu agonists would work just as well if not better and given so early in the process risk of fetal resp depression small (if you go for stat section the peds guys can give narcan to the baby).

Can it be that she was in pain and you treated her pain with your 100mcg of Fentanyl?

 

[IN2B8R]

Can it be that she was in pain and you treated her pain with your 100mcg of Fentanyl?

Kinda of what I was thinking too, . But then again, she may have lost the high from the Methadone via the Nubain administration (doubtful, but what the heck....). Btw, most people get "more comfortable" after 100 mcg of fentanyl, especially since, in my experience, Nubain works only about 50% of the time.... Add the misery of labor on top of an inefective drug and you get a woman who thinks the world of you when you give her 100 mcg of fent...

 

[seinfeld]

Can it be that she was in pain and you treated her pain with your 100mcg of Fentanyl?

Always a skeptic.

Exactly, she was in pain, OBs gave her an antagonist and her pain got worse. Whatever it was, pain, anxiety, withdrawl, the fentanyl worked and the nubain, given how precipitously the symptoms came on after administration did something not on the up and up.

My other ?'s remain. Why screw around with agonist/antagonists in a patient with Narcotic dependance when an epidural is a clearly a better option?

 

[IN2B8R]

Always a skeptic.

Exactly, she was in pain, OBs gave her an antagonist and her pain got worse. Whatever it was, pain, anxiety, withdrawl, the fentanyl worked and the nubain, given how precipitously the symptoms came on after administration did something not on the up and up.

My other ?'s remain. Why screw around with agonist/antagonists in a patient with Narcotic dependance when an epidural is a clearly a better option?[/QUOTE]

Answer: because, more often than not, they are *****s. And I ain't talking about OB staff--nurses run the show on every OB floor.... You get my drift.

 

[Jeff05]

It is very unlikely that giving Nubain to a narcotic user is going to cause the dramatic withdrawal people are imagining.
I would make sure that she is oxygenating well then treat symptomatically as an acute episode of craziness/panic/pain.

http://www.ncbi.nlm.nih.gov/pubmed/2467983

i have managed pain patients on methadone on the floors who have gone into a clear withdrawal syndrome after the primary team gave nubain for pruritis.

not sure why you have a hard time imagining that this outcome, that has been documented in the literature and makes complete sense based on basic pharmacologic priniciples.

 

[Planktonmd]

I have seen Nalbufine unknowingly given to parturients who are narcotic dependent many times without a problem.
All I am saying is that pain, anxiety and craziness are way more common in laboring pregnant women than narcotic withdrawal caused by Nalbufine.

http://www.ncbi.nlm.nih.gov/pubmed/2467983

i have managed pain patients on methadone on the floors who have gone into a clear withdrawal syndrome after the primary team gave nubain for pruritis.

not sure why you have a hard time imagining that this outcome, that has been documented in the literature and makes complete sense based on basic pharmacologic priniciples.

 

[IN2B8R]

90% of the patients I get on OB are nuttier than squirrel ****.

 

[Stitch]

90% of the patients I get on OB are nuttier than squirrel ****.

Because birth is natural and safe and wonderful. All of us horrible physicians are ruining her perfect natural birth experience and not listening to her perfect birth plan! Women and children never die during birth!

Remember, there's nothing more natural than natural selection...

 

[2ndyear]

It was an acute withdrawal of sorts. She was on Methadone maintenance. I stood at her bedside and gave 100mcg of fentanyl. When she relaxed back down and fetal heart rate returned to normal, i placed a labor epidural. Then did c-section i was called in to do. She delivered hours later without incident.

Although i agree this is rare to have such a problem my bigger question is why even try to use IV opiods in these chronic Pain/abuse pts. Newer data suggests no delay in timing of delivery whether you wait to 4cm for epidural or do it when they walk in door. (pt satisfaction may decrease as labor progress) Also given this pt was only 3cm why use nubain. Pure Mu agonists would work just as well if not better and given so early in the process risk of fetal resp depression small (if you go for stat section the peds guys can give narcan to the baby).

I have seen this as well, almost exact same presentation, sweaty, hypertensive, panic. Patient was on Suboxone though. It always makes me laugh at the lengths that we and mothers go to to minimize fetal exposure to drugs and 'toxins'- then you get the moms who smoke a pack a day and take narcs throughout pregnancy.

 

[DScully]

I have seen this as well, almost exact same presentation, sweaty, hypertensive, panic. Patient was on Suboxone though. It always makes me laugh at the lengths that we and mothers go to to minimize fetal exposure to drugs and 'toxins'- then you get the moms who smoke a pack a day and take narcs throughout pregnancy.

And during those times, I feel that I am violating the rules of natural selection and I am not sure if that's the most fruitful thing to do in the end. Without any intervention, mom probably wouldn't have been able to keep the baby. And the baby probably wouldn't have suffered. Or even better, the mom probably wouldn't have conceived in the first place.

 

[DScully]

http://www.ncbi.nlm.nih.gov/pubmed/2467983

i have managed pain patients on methadone on the floors who have gone into a clear withdrawal syndrome after the primary team gave nubain for pruritis.

not sure why you have a hard time imagining that this outcome, that has been documented in the literature and makes complete sense based on basic pharmacologic priniciples.

So according to Katzung's basic and clinical pharmacology 10th edition, it says "A transient, explosive abstinence syndrome - antagonist-precipitated withdrawal - can be induced in a subject physically dependent on opioids by administering naloxone or another antagonist. Within 3 minutes after injection of the antagonist, signs and symptoms similar to those seen after abrupt discontinuance appear, peaking in 10-20 minutes and largely subsiding after 1 hour. Even in the case of methadone, withdrawal of which results in a relatively mild abstinence syndrome, the antagonist-precipitated abstinence syndrome may be very severe."

 

[proman]

What Katzung refers to is true for the full antagonists like naloxone. The question are drugs like nalbuphine, which are mixed agonists/antagonists or partial agonists. Withdrawal syndromes have clearly been documented from mixed agonist/antagonists, despite PlanktonMD's anecdoctal experience.

 

[Jeff05]

What Katzung refers to is true for the full antagonists like naloxone. The question are drugs like nalbuphine, which are mixed agonists/antagonists or partial agonists. Withdrawal syndromes have clearly been documented from mixed agonist/antagonists, despite PlanktonMD's anecdoctal experience.

if you look at the study below - this is exactly what they looked at. withdrawal from methadone precipitated by nalbuphine is the same as with narcan.

"The withdrawal syndrome precipitated by nalbuphine was indistinguishable from that produced by naloxone."
http://www.ncbi.nlm.nih.gov/pubmed/2467983

 

[drf]

I've had several patients flush, get dysphoric/anxious/sweaty/goose bumps/big pupils with nalbuphine 5 mg for opioid side effects, even with only epidural Dilaudid. 2.5 mg seems to work ok.