NaloxoneNursing considerations

Side effects by what to assess

Sources: [1][2][3][4][5][6]

Blood pressure

Why

Hypotension or hypertension after abrupt reversal

When

After reversal, closely in patients with heart disease

Normal

Below 120/80 mm Hg.

Sources: [1][2][3]

Heart rate

Why

Tachycardia and ventricular arrhythmias after abrupt reversal

When

After reversal, closely in patients with heart disease

Normal

60 to 100 beats per minute in adults at rest.

Sources: [1][2][3]

Respiratory rate

Why

Response to reversal and return of respiratory depression

When

After every dose and continuously until the opioid effect has passed

Act on

If breathing slows again, repeat the dose; assist ventilation if the response is incomplete

Normal

12 to 18 breaths per minute in adults.

Sources: [1][2][3]

High-alert status

Naloxone is not on the ISMP acute care high-alert list. The opioids it reverses are.

Sources: [1]

Narrow therapeutic index

The label does not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.

Sources: [1][2]

Boxed warning

None on the current injection or Narcan labels.

Sources: [1][2]

Antidote or reversal

Naloxone is itself the opioid antidote. Overdose of naloxone is treated with symptom-based care under close supervision; volunteers given 24 mg/70 kg showed no toxicity.

Sources: [1]

Patient teaching

• Learn the signs of overdose: cannot be woken by voice or a firm sternal rub, slow or absent breathing, pinpoint pupils, slow pulse or low blood pressure
• Give the spray right away if overdose is suspected, even when unsure; delay can cause brain damage or death
• The spray does not replace emergency care; call for help after the first dose
• Stay with the person and give another dose with a new spray if breathing slows again
• Tell family and friends where the spray is kept and how to use it
• Someone dependent on opioids may go into withdrawal after a dose

Sources: [1][2]

Sound-alike and look-alike names

• naloxone and Lanoxin
• naloxone and nalbuphine
• Narcan and Norcuron

Sources: [1]

Adult dose

Known or suspected opioid overdose, injection

0.4 to 2 mg IV. Repeat every 2 to 3 minutes if breathing does not improve. If there is no response after 10 mg, reconsider the diagnosis. IM or subcutaneous if IV is unavailable.

Postoperative opioid depression, injection

0.1 to 0.2 mg IV every 2 to 3 minutes until breathing and alertness are adequate without significant pain. Repeat doses may be needed in 1 to 2 hours.

Continuous IV infusion

2 mg in 500 mL of normal saline or D5W gives 0.004 mg/mL. Titrate the rate to response; use within 24 hours.

Opioid overdose, Narcan nasal spray

One 4 mg spray in one nostril. If there is no response or breathing slows again, give another spray with a new device every 2 to 3 minutes, alternating nostrils, until help arrives.

Sources: [1][2][3]

Renal adjustment

No specific adjustment. Safety in renal insufficiency has not been established in controlled trials, so use with caution.

Sources: [1]

Hepatic adjustment

No specific adjustment. Naloxone is cleared by liver glucuronidation, and safety in liver disease has not been established, so use with caution.

Sources: [1][2]

Mechanism

Competes with opioids at mu, kappa, and sigma receptors in the CNS, binding mu most strongly. It reverses opioid sedation, respiratory depression, and hypotension. It is a nearly pure antagonist with no opioid effect of its own and causes no tolerance or dependence. IV onset is usually within 2 minutes; IM and subcutaneous onset is slightly slower but lasts longer.

Sources: [1][2]