Naloxone bolus regimen

Rzasa Lynn 2018

Naloxone bolus doses are preferably administered intravenously; however, they can be given intramuscularly or intranasally if intravenous access cannot be easily established. Support of airway and breathing is the priority to prevent hypoxia while waiting for naloxone to take effect.

For adults with hypoventilation due to buprenorphine poisoning, use:

naloxone 0.4 to 2 mg intravenously, every 2 to 3 minutes according to clinical effect up to a total initial dose of 5 mg¹. Aim for a respiratory rate of greater than 10 breaths per minute and oxygen saturation greater than 92% on room air. naloxone

For children with hypoventilation due to buprenorphine poisoning, use:

naloxone 0.01 mg/kg up to 0.4 mg intravenously, every 2 to 3 minutes according to clinical effect up to a total initial dose of 5 mg¹. Aim for a normal age-appropriate respiratory rate and oxygen saturation greater than 92% on room air². naloxone

If intravenous access is not easily established, for adults and children³, initially use:

1naloxone 0.4 to 2 mg depending on the preparation and local protocols, intramuscularly⁴ naloxone

1naloxone 1.8 mg/0.1 mL nasal spray, 1 spray (1.8 mg) into one nostril⁵ Krieter 2018. naloxone

If there is a significant delay to intravenous access and the patient is still hypoventilating, a second dose of intramuscular or intranasal naloxone (using a new nasal spray into the other nostril) after 2 to 3 minutes may be beneficial.

Adequate reversal of buprenorphine toxicity is indicated by:

increased respiratory drive—normal age-appropriate respiratory rate, and oxygen saturation greater than 92% on room air
improved level of consciousness sufficient for the patient to maintain their airway (ie mildly sedated, but easily roused).

Reversing toxicity due to buprenorphine may require larger doses of naloxone than are required for other opioids. A total intravenous bolus dose of up to 5 mg of naloxone is usually sufficient to reverse buprenorphine toxicity and inadequate response to this dose suggests other causes of toxicity (eg co-ingestants). If there is inadequate response following a total intravenous bolus dose of 5 mg of naloxone, consult a clinical toxicologist or poisons information centre about whether to give further doses (up to a total bolus dose of 15 mg) or intubate and ventilate the patient. Intubation and ventilation is generally more practical than administering multiple doses of naloxone⁶.

If toxicity recurs after initial response to the naloxone bolus, repeat the naloxone bolus regimen. If the patient responds to a further titrated naloxone bolus, consider starting a naloxone infusion to prevent further recurrence of toxicity.

If naloxone supplies are insufficient, intubate and ventilate the patient.

¹ Reversing toxicity due to buprenorphine may require larger doses of naloxone than are required for other opioids. A total intravenous bolus dose of up to 5 mg of naloxone is usually sufficient to reverse buprenorphine toxicity. Consult a clinical toxicologist or poisons information centre before giving further doses up to a total bolus dose of 15 mg.Return

² See The Royal Children’s Hospital clinical guideline on Acceptable ranges for physiological variables for normal age-appropriate respiratory rates in children.Return

³ For first responders, a single dose regimen for naloxone is the safest and most appropriate approach; it is safer to give larger doses than usual to a child than to underdose them in the setting of opioid poisoning. Return

⁴ Naloxone is available as a 2 mg/2 mL prefilled syringe for intramuscular injection, intended for the treatment of opioid poisoning at home or in other nonmedical settings.Return

⁵ Naloxone is available as a concentrated 1.8 mg/0.1 mL single-use nasal spray; the concentration of naloxone preparation for injection (0.4 mg/mL) is too dilute for effective intranasal use.Return

⁶ Naloxone is available in 1 mL ampoules containing 0.4 mg/mL. The maximum total bolus dose of 15 mg is equivalent to 37.5 ampoules. Many hospital pharmacies do not routinely stock this much naloxone.Return