Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients

Abstract

Background Opioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients. We postulate that FIRCS can occur in this setting and is likely under recognized, leading to increased morbidity and mortality. Methods Patients admitted to the intensive care unit with suspected FIRCS were included in this retrospective analysis. The objective of this analysis is to describe the clinical presentation and treatment strategies for FIRCS. Results Forty-two patients exhibiting symptoms of FIRCS were included in this analysis. Twenty-two of the forty-two patients with descriptive documentation had evidence of thoracic or abdominal rigidity on examination (52.4%). Twelve of sixteen (75%) patients treated solely with naloxone had documented ventilator compliance following intervention, compared to six of eleven (55%) managed with cisatracurium alone. Nine of twelve patients who ultimately received naloxone after initial treatment with cisatracurium had documented ventilator compliance following naloxone administration (75%). Standard interventions, including sedation optimization and ventilator adjustments were attempted to rule out and treat other potential causes of dyssynchrony. In most cases, the administration of naloxone resulted in appropriate compliance with both ventilator and patient-initiated breaths, suggesting the ventilator dyssynchrony was due to fentanyl. Conclusions This is the largest case series to date describing FIRCS in the intensive care setting. Recognition and prompt management is necessary for improved patient outcomes. Research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions.

Airway Management for the Critically Ill Patient in the Emergency Department

“…10 The dose most commonly used is 1-3 mcg/kg given over 60 seconds, its onset is roughly 30 seconds with a half-life of 2-4 hours. 11 A common concern when administering fentanyl is rigid or wooden chest syndrome. However this is rare after single doses especially under 200 mcg.…”

“…12 17 With an induction dose of 0.1-0.3 mg/kg, it has a rapid distribution with onset of 60-90 seconds and provides a sedative effect for 1-4 hours. 11 Midazolam has a synergistic effect with concomitant opioid use, which allows for a more profound effect with a lesser dose when administered appropriately. However, this synergy can also lead to severe respiratory and cognitive depression when not accounted for.…”

“…However, this synergy can also lead to severe respiratory and cognitive depression when not accounted for. 17 In addition to intravenous (IV) administration, midazolam can also be administered intramuscularly (with a delayed onset of roughly 15 minutes) which might be advantageous when intravenous access is unavailable 11 . Midazolam should be used with caution in patients with impaired hepatic and renal metabolism and should be avoided in all pregnant patients (category D).…”

“…Midazolam should be used with caution in patients with impaired hepatic and renal metabolism and should be avoided in all pregnant patients (category D). 11,17 Etomidate is a GABA receptor agonist and provides sedation and amnesia without analgesia. 18 The dose for induction most used is 0.3 mg/kg, the onset of action is 30-60 seconds, peak effect of 1 minute, and half-life is 2.5-3.5 hours.…”

“…Unlike propofol and midazolam, it has decreased rates of hypotension in patients over the age of 50 years. 11,21 At the correct dose ketamine can cause amnesia and analgesia as well as an added benefit of bronchodilation. Ketamine does not negatively affect cardiac output and is not associated with hypotension.…”