What to do for a patient on fentanyl (synthetic opioid) infusion, in comfort care, who develops tachycardia with a rate of 135 beats per minute, while already receiving 200 micrograms per minute of fentanyl?

From the Guidelines

For a patient on fentanyl infusion at 200 mcg/min for comfort care who develops tachycardia at 135 bpm, I recommend administering a bolus dose of fentanyl equal to the hourly infusion rate, which is 12,000 mcg (200 mcg/min x 60 min), every 5 min as needed to treat breakthrough pain or respiratory distress, as suggested by 1. The high fentanyl dose suggests the patient may be experiencing breakthrough pain or anxiety despite opioid therapy.

• Consider evaluating for other causes of tachycardia such as fever, hypovolemia, or hypoxia, and treat accordingly, as recommended by 1.
• Reassess the patient's comfort level and symptoms, as tachycardia may indicate inadequate symptom control despite the high fentanyl dose.
• If the patient receives two bolus doses in an hour, it is reasonable to double the infusion rate, as suggested by 1. In palliative care, the goal is symptom management rather than normalizing vital signs, so interventions should focus on patient comfort.
• If tachycardia persists but the patient appears comfortable, close monitoring may be sufficient without additional interventions. It is also important to note that opioids should be titrated to symptoms with no dose limit, as recommended by 1.
• Additionally, sedatives such as benzodiazepines can be used in combination with opioids to treat anxiety or agitation, but should only be used once pain and dyspnea are treated with opioids, as recommended by 1.

From the Research

Tachycardia Management in Fentanyl Infusion

• The patient is already receiving a high dose of fentanyl (200 micrograms per minute) and has developed tachycardia with a rate of 135 beats per minute 2.
• Increasing the fentanyl dose may not be effective in reducing the heart rate, as seen in a study where doses of up to 15 micrograms/kg were used to suppress the intubation response in cardiac patients 2.
• The use of calcium channel blockers, such as nifedipine, may be considered as an alternative therapy to attenuate opioid withdrawal syndrome symptoms, which could be contributing to the tachycardia 3.
• However, it is essential to note that the patient's tachycardia could be a sign of opioid withdrawal syndrome, as seen in a case report where a patient developed hypertension, tachycardia, tachypnea, and hyperthermia after fentanyl discontinuation 3.
• Another possible cause of tachycardia is myocardial ischemia, which can occur as a result of severe benzodiazepine and opioid withdrawal, as reported in a case study where a patient developed transient myocardial ischemia due to a sluggish central venous catheter port limiting delivery of midazolam and fentanyl 4.

Cardiac Effects of Opioid Therapy

• Long-term opioid therapy, including fentanyl, can have cardiac effects such as bradycardia, vasodilation, and decreased cardiac function, especially when used in combination with other medications 5.
• Opioids can also lead to edema, hypotension, orthostatic hypotension, and syncope when used at analgesic doses 5.
• Fentanyl-induced cardiomyopathy is a rare but possible cause of cardiac dysfunction, as reported in a case study where a patient developed cardiogenic shock due to recreational fentanyl use 6.
• The use of naloxone, a reversal agent, may be crucial in managing fentanyl toxicity and cardiomyopathy 6.