DOUBLE-EDGED SWORD: STATUS ASTHMATICUS COMPLICATIONS IN AN OPIATE TOLERANT PATIENT

TOPIC: Allergy and Airway TYPE: Medical Student/Resident Case Reports INTRODUCTION: Severe Asthma Exacerbations (SAE) in opiate tolerant patients merit consideration of non-narcotic sedation strategies. The following case illustrates unique challenges. CASE PRESENTATION: A 24-year-old male with a history asthma presented to our ED for acutely worsening shortness breath one hour. He ran out his inhaler month ago after losing insurance. His girlfriend provided more including recent IV heroin use week previous intubations asthma. They denied any fevers, sick contacts, travel, nor vaccinations. initial vitals were significant HR 129bpm, BP 147/70mmHg, SpO2 65% on 10L NRB mask. exam found him diaphoretic supraclavicular retractions, word sentences, bilateral inspiratory expiratory wheezing, multiple tender lesions hands. was advanced BiPAP, given nebulized albuterol 10mg, methylprednisolone 125mg IV, magnesium sulfate 2mg ampicillin/sulbactam 1.5g normal saline bolus 1L blood, urine, sputum cultures drawn, but he continued decline. decision made intubate ketamine 140mg succinylcholine 100mg IV. again received 10mg Initial labs leukocytosis 34.4k cells/uL (n: 5-12k), lactic acid 2.9mmol/L .7-2), ABG pH 7.13 7.35-7.45) PaCO2 89.9mmHg 35-48), urine drug screen benzodiazepines, cannabinoids opiates. escalated vancomycin piperacillin/tazobactam endocarditis concerns. trended up 6.5mmol/L warranting an additional 2L chest radiograph, CTA echocardiogram no acute pathology. required the maximum dose fentanyl sedation. On day 2, weaned extubation, increased 190/80mmHg. started morphine concerns withdrawal, normalized. culture grew haemophilus influenzae. extubated later that when stable. counselled extensively medication compliance illicit substance cessation. DISCUSSION: Expert opinion suggests potential role administration continuous infusions concomitant sedative bronchodilatory effects patients. After intubation, patient propofol, which may have exacerbated respiratory acidosis, masked withdrawal symptoms, complicated extubation. Further research enable effective management SAE Of note, reports correlate type B acidosis played reduced oxygenation patient. CONCLUSIONS: New strategies are needed manage REFERENCE #1: Mehta S, et al. COPD opioid dependency. Prim Care Respir Med. 2020;30(4). #2: Lewis LM, Ferguson I, Albuterol is associated increases serum lactate exacerbation Chest. 2014;145(1):53-9. #3: Levine M, Iliescu ME, cocaine intubation rates hospital exacerbations. 2005;128:1951–7. DISCLOSURES: No relevant relationships by Jordan Babcock, source=Web Response Adrienne Madison, Tusharkumar Pansuriya, Hytham Rashid, Mir Ali Sadat, Sivatej Sarva,