buprenorphine and Delirium

In Japan, indications for opioid analgesics, once exclusively used as pain killers for patients suffering from malignant cancer, have been expanded for a wide range of pain. Herein we report a patient with opioid-induced delirium associated with the administration of buprenorphine patches that was well below the indicated therapeutic range limit. An 82-year-old woman was referred to us from an orthopaedic practitioner for uncontrollable behavioural problems apparently caused by the beginning of dementia; the patient had gradually developed disorientation, visual hallucinations, and delusions. Laboratory and imaging findings excluded common causes of delirium including Alzheimer's disease and diffuse Lewy body disease. Detailed questioning revealed that the patient's confused state appeared following a buprenorphine patch dose increase and subsequently disappeared after administration was stopped. Delirium has not been reported as a side-effect in clinical trials of buprenorphine patches. However, our findings in this case show that even topical opioids can precipitate the development of a delirious state in elderly patients.

Topics: Aged, 80 and over; Analgesics, Opioid; Buprenorphine; Confusion; Delirium; Dementia; Female; Hallucinations; Humans; Japan; Low Back Pain; Transdermal Patch; Treatment Outcome

Cowden syndrome is a rare syndrome of chromosome abnormalities presenting with polyposis of digestive tracts, characteristic skin eruption and neuromuscular disorders. A 56-year-old male patient with Cowden syndrome underwent upper abdominal surgery under general anesthesia followed by post-operative epidural analgesia with buprenorphine. Proposed total gastrectomy was not performed because of massive invasion of carcinoma in the abdominal cavity and gastrojejunostomy was done instead. The anesthesia was satisfactory with inhalation of nitrous oxide and enflurane with intravenous vecuronium. Neuromuscular monitoring with electric twitch-responses of the hand showed normal patterns throughout the anesthesia. The recovery from anesthesia and neuromuscular blockade was prompt. Intermittent epidural buprenorphine, twice a day (0.2 mg of buprenorphine in 9 ml of normal saline for one time) was started just after the recovery of anesthesia and continued for four days. Delirium occurred two days after beginning epidural buprenorphine and disappeared three days after its discontinuation. The patient died 52 days after the operation from obstructive jaundice and sepsis. The delirium, therefore, seems to have been caused by buprenorphine possibly due to its impaired metabolism by the liver. Although we did not experience any abnormal neuromuscular reactions to vecuronium or anesthetic agents, it is important to perform preoperative neuromuscular examinations and peri-operative monitoring in the anesthetic management of a patient with this syndrome.

Topics: Analgesia, Epidural; Anesthesia, General; Buprenorphine; Delirium; Hamartoma Syndrome, Multiple; Humans; Male; Middle Aged; Monitoring, Physiologic

Five cases of post narcotic delirium, somnolence or coma are interpreted as central anticholinergic syndromes as they were reversed by physostigmine. There is to date no information whether the drug combinations midazolam/fentanyl, benzoctamine/buprenorphine and etomidate/carticaine may act as central anticholinergic agents.

Topics: Adult; Aged; Anthracenes; Atropine; Benzodiazepines; Buprenorphine; Carticaine; Coma; Delirium; Etomidate; Fentanyl; Humans; Male; Meperidine; Midazolam; Parasympatholytics; Physostigmine; Preanesthetic Medication; Promethazine