C53-15 Management of Iatrogenic Fentanyl Toxicity: A Case Report

Abstract Introduction Parenteral opiates are frequently administered in hospital settings. They are considered high-risk medications with potential for dangerous administration errors. Fentanyl, a highly lipophilic opioid, provides potent analgesia but can cause life-threatening effects such as respiratory depression, hemodynamic instability and chest wall rigidity, particularly with high doses or rapid infusion. Case We present a case of iatrogenic overdose in a patient admitted for hypoxemic respiratory failure secondary to Influenza A with superimposed bacterial pneumonia. Following intubation, the patient inadvertently received 2.5 mg fentanyl, instead of a desired intravenous fluid bolus. The patient improved with antibiotics and oseltamivir and was extubated two days later. However, he required reintubation for recurrent respiratory failure and impaired airway protection despite naloxone administration, potentially from a fentanyl multiple peak phenomenon. After further supportive care, he demonstrated significant clinical improvement and was extubated on hospital day six. Subsequently, he suffered a cardiac arrest, requiring reintubation. Return of spontaneous circulation was achieved, and he was successfully extubated 48 hours later. The patient was ultimately discharged on hospital day 14. Discussion Following this iatrogenic large fentanyl overdose, multiple steps were taken to prevent recurrence including multidisciplinary Quality and Safety meetings, the development of standardized practices for loading and unloading infusion pump tubing, adjustments to detachment protocols, and enhanced staff education regarding pump alarms and infusion programming errors. This case highlights the importance of implementing safeguards to prevent opioid administration errors. Additionally, the report prompts recall of the side effects of fentanyl overdose including rigid chest syndrome, respiratory depression and multiple peak phenomenon. It underscores the role of prolonged supportive therapy in patients for whom opioid reversal agents are either ineffective or clinically inappropriate. This abstract is funded by: None