Document Detail

Myocardial ischemia as a result of severe benzodiazepine and opioid withdrawal.
MedLine Citation:
PMID:  15902797     Owner:  NLM     Status:  MEDLINE    
CASE REPORT: A 6-month-old female born at 25 weeks gestation with severe opioid and benzodiazepine dependence resulting from multiple operative procedures and chronic ventilatory support was receiving continuous intravenous infusion of fentanyl and midazolam after trials of enteral methadone and diazepam had been unsuccessful due to gastric intolerance. On postoperative day 5 following Nissen fundoplication and gastrostomy tube placement, she acutely developed tachycardia, hypertension, agitation, loose stools, and yawning. Attempts to provide boluses of benzodiazepines and opioids revealed a very sluggish port in her subclavian central venous catheter. Prompt replacement of the catheter occurred without complication. After resuming infusions and providing additional sedatives and opioids, the loose stools, yawning, and agitation resolved. However, the tachycardia persisted. A 12-lead ECG was notable for significant ST depression in anterior leads. Laboratory studies revealed significantly elevated cardiac enzymes. The patient was transfused with packed red blood cells to optimize oxygen-carrying capacity. Echocardiography demonstrated a small region of dyskinetic apical endocardium. Cardiac enzymes normalized within 48 h. The ECG and echocardiographic findings fully resolved after approximately 70 h.
DISCUSSION: We believe that the sluggish central venous catheter port limited delivery of the midazolam and fentanyl to our patient. The resultant tachycardia and hypertension limited diastolic filling of the coronary arteries, resulting in myocardial ischemia. As the withdrawal was treated, heart rate and blood pressure returned to baseline, myocardial perfusion normalized, and the ST depression and the cardiac enzyme values normalized. This report underscores the significant morbidity associated with withdrawal syndromes and the need to recognize withdrawal early and to treat it aggressively.
Abhik K Biswas; Brian L Feldman; Daniela H Davis; Eric A Zintz
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Clinical toxicology (Philadelphia, Pa.)     Volume:  43     ISSN:  1556-3650     ISO Abbreviation:  Clin Toxicol (Phila)     Publication Date:  2005  
Date Detail:
Created Date:  2005-05-20     Completed Date:  2005-06-02     Revised Date:  2013-05-20    
Medline Journal Info:
Nlm Unique ID:  101241654     Medline TA:  Clin Toxicol (Phila)     Country:  United States    
Other Details:
Languages:  eng     Pagination:  207-9     Citation Subset:  AIM; IM    
US Navy Pediatric Critical Care Medicine, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.
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MeSH Terms
Adjuvants, Anesthesia / therapeutic use
Analgesics, Opioid / adverse effects*
Benzodiazepines / adverse effects*
Diazepam / therapeutic use
Fentanyl / adverse effects
Infant, Newborn
Infant, Premature
Methadone / adverse effects
Midazolam / therapeutic use
Myocardial Ischemia / drug therapy,  etiology*,  physiopathology
Neonatal Abstinence Syndrome* / complications*,  physiopathology
Treatment Outcome
Reg. No./Substance:
0/Adjuvants, Anesthesia; 0/Analgesics, Opioid; 12794-10-4/Benzodiazepines; 437-38-7/Fentanyl; 439-14-5/Diazepam; 59467-70-8/Midazolam; 76-99-3/Methadone

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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