- Myocardial ischemia
as a result of severe benzodiazepine and opioid
- Biswas AK, Feldman BL, Davis DH, Zintz EA.
Clin Toxicol (Phila).
- Long-term infusion of benzodiazepines and
opioids is strongly associated with dependence
and withdrawal syndromes. We report the first
case of severe benzodiazepine and opioid
withdrawal resulting in transient myocardial
- 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
- 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.
- A study of factors
that influence the severity of neonatal narcotic
- Ostrea EM Jr, Chavez CJ, Strauss ME.
- History is unreliable in assessing maternal
drug habit. Morphine was detected in significant
amounts in maternal and fetal urine regardless
of whether the mother was on a methadone program
or whether she denied any use of heroin during
the last trimester of pregnancy.
- Infants born to drug-addicted mothers were,
in general, of birthweight normal and
appropriate for gestational age (i.e., greater
that 10th percentile). The infants born to
mothers on a methadone clinic program had a
higher birthweight compared to those whose
mothers were not on any methadone program.
- In order of frequency, the signs and
symptoms of withdrawal were: central nervous
system manifestations-fist sucking,
irritability, tremors, sneezing, high-pitch cry,
hypertonia; vasomotor in the form of stuffy
nose; and gastrointestinal in the form of
sweating, diarrhea, vomiting and yawning.
Convulsions were not noted. No death occurred.
- The severity of neonatal narcotic withdrawal
did not correlate with the infant's gestational
age, APGAR, sex or race; nor with maternal age,
parity, duration of heroin addiction or duration
of methadone intake. Also, it did not correlate
with the total morphine level measured either in
infant's or mother's urine or in cord blood. The
serum levels of calcium and glucose were normal
and identical in either mild or severe
- The severity of neonatal withdrawal
correlated significantly with the methadone dose
per day of the mother (in initial, final or
average dose). A maternal methadone dose of more
than 20 mg per day was associated with a higher
incidence of moderate to severe withdrawal in
their babies. As a corollary, it was also noted
that infants whose mothers were on a high
methadone dose (i.e., greater than 20 mg per
day) had a greater postnatal weight loss despite
a significantly higher birthweight initially,
and stayed in the hospital longer.
- Finally, the modification of the environment
to reduce external stimuli to the infant born to
a drug-dependent mother, does not prevent or
diminish the severity of neonatal narcotic
withdrawal. Thus, there is no need to manage
these infants in a special nursery.