Cardiorespiratory Effects of Naloxone in Children

Rapid systemic uptake of naloxone after intranasal administration in children

BACKGROUND

Naloxone has a high affinity for the µ-opioid receptor and acts as a competitive antagonist, thus reversing the effects of opioids. Naloxone is often administrated intravenously, but there is a growing interest in the intranasal route in treating patients with opioid overdose, and in reversing effects after therapeutic use of opioids. As administration is painless and no intravenous access is needed, the intranasal route is especially useful in children.

AIM

The aim of this study was to investigate the uptake of naloxone 0.4 mg/ml during the first 20 min after administration as a nasal spray in a pediatric population, with special focus on the time to achieve maximum plasma concentration.

METHODS

Twenty children, 6 months-10 years, were included in the study. The naloxone dose administered was 20 µg/kg, maximum 0.4 mg, divided into repeated doses of 0.1 ml in each nostril. Venous blood samples were collected at 5, 10, and 20 min after the end of administration.

RESULTS

All patients had quantifiable concentrations of naloxone in venous blood at 5 min, and within 20 min, peak concentration had been reached in more than half of the children. At 20 min after intranasal administration, the plasma naloxone concentrations were within the range of 2-6 nanogram/ml.

CONCLUSION

This study confirms the clinical experience that the rapid effect of naloxone after intranasal administration in children was reflected in rapid systemic uptake to achieve higher peak plasma concentrations than previously reported in adults.

Reversal of Pediatric Opioid Toxicity with Take-Home Naloxone: a Case Report

BACKGROUND

Take-home naloxone, an opioid antagonist, has become part of a multimodal approach to curbing opioid-related mortality. However, there is little information about the utility of take-home naloxone in pediatric patients. We report a case of opioid toxicity after exposure to methadone in a pediatric patient, which was successfully reversed with take-home naloxone.

CASE

A previously healthy 22-month-old girl ingested an unknown amount of liquid methadone. The child became progressively somnolent. The mother administered intranasal naloxone at home with reversal of somnolence. The patient presented to the emergency department and had recurrence of symptoms. The patient was placed on a naloxone infusion and discharged from a tertiary care facility, uneventfully, 2 days after ingestion.

RESULTS

To our knowledge, we report the first case of pediatric opioid toxicity reversed by take-home naloxone. In the setting of rising opioid-related mortality, providers and public health officials should consider expanding access of take-home naloxone for children at high risk for opioid overdose.

Risk predictors of opioid-induced critical respiratory events in children: naloxone use as a quality measure of opioid safety

BACKGROUND

Opioid-induced respiratory depression (OIRD) is a life-threatening complication of opioid therapy in children. Naloxone administration triggered by OIRD has been used to monitor safety of opioid therapy in adults. We used this trigger as a quality measure of opioid safety in hospitalized children to identify risk predictors of OIRD.

METHODS

We retrospectively reviewed medical records of 38 patients identified from the hospital risk management database as requiring naloxone for critical respiratory events between January 2010 and June 2012 for demographics, comorbidities, surgery, naloxone event details, and outcomes. These data were compared with baseline prevalence in contemporary patients followed by pain service, who did not receive naloxone, to calculate unadjusted odds ratios. Thematic classification of preventable events was undertaken based on analysis of each event.

RESULTS

The incidence of naloxone use among hospital inpatients, who received opioids at-least once, was 0.06% compared with 0.23% for patients on the pain service. A majority of naloxone events occurred in postoperative patients (n = 27/38, 71.1%) within the first 24 hours of surgery (n = 20/27, 75.1%) and in the critical care unit (50%). Patients undergoing airway surgeries had higher risk for OIRD (P = 0.01). Patient risk factors for naloxone use included age <1 year (P < 0.001), obstructive sleep apnea (P < 0.001), obesity (P = 0.019), being underweight (P < 0.0001), prematurity (P < 0.001), and developmental delay (P < 0.001). Majority of events (87%) were found to be preventable, which were classified into six main themes based on type of event.

CONCLUSION

OIRD is an important, albeit mostly preventable, complication of opioid therapy in children. Naloxone use can be used as a measure to track opioid safety in children, identify contributing factors, and formulate preventive strategies to reduce the risk for OIRD.

Use of naloxone during neonatal resuscitation in Australia: compliance with published guidelines

AIMS

The aims of this study were to describe the use of naloxone during neonatal resuscitation in Australia, and to assess this against the published guidelines for use.

METHODS

The states of Queensland, South Australia and the Australian Capital Territory record the administration of naloxone in their statutory state perinatal database collections, covering all deliveries within each state. Relevant information was extracted from these databases. In addition, we interrogated the perinatal database from a single tertiary perinatal centre in Western Australia and conducted a chart review of the 100 most recent infants identified as receiving naloxone.

RESULTS

A total of 531 058 liveborn infants from 1994 through 2004 were assessed. The administration of naloxone fell from 4% to 1% of liveborn infants during this period. There was inconsistent compliance with published guidelines. Forty-two per cent of infants received naloxone without documentation of prior ventilatory support, 14% of infants received naloxone without prior administration of maternal narcotics and 80% of infants were not monitored following naloxone administration. The prevalent route of administration was intramuscular.

CONCLUSIONS

Despite a steady decrease in the use of naloxone for neonatal resuscitation, there is a considerable lack of compliance with published guidelines for use. Given the scant evidence supporting naloxone use during neonatal resuscitation and increasing documentation of potential deleterious effects, perhaps it is time to remove naloxone from our resuscitaires.

Naloxone during neonatal resuscitation: acknowledging the unknown

There are no studies to support or to refute the current recommendations regarding naloxone concentration, routes for administration, and doses in neonatal resuscitation in the delivery room. Given the lack of supporting evidence, naloxone should not be given routinely in the delivery room to depressed neonates whether or not they are exposed to opioids before delivery because no important improvement has been documented and the drug may have potential short- and long-term harmful effects.