Medical ICU Director Wellstar West Georgia, United States
Introduction: Wooden Chest Syndrome (WCS), otherwise known as fentanyl-induced chest wall rigidity is a rare complication of intravenous fentanyl which involves chest wall muscle and diaphragm rigidity as well as laryngospasm. Although typically reported as a consequence of rapid intravenous administration, WCS can also occur with continuous infusion. With increasing utilization of fentanyl as a first line agent for pain and agitation in mechanically ventilated patients, WCS is an increasingly important consideration in the critical care setting.
Description: A 60-year-old female with chronic obstructive pulmonary disease and systolic heart failure was admitted to the critical care unit for acute hypoxic and hypercapnic respiratory failure requiring emergent intubation. Fentanyl was administered for analgesia and agitation in the usual fashion as part of the SCCM ABCDEF ICU Liberation bundle. 48 hours following initiation of continuous fentanyl, the patient was found to be increasingly agitated, rigid, and with fixed upward gaze. She was tachypneic with ventilator dyssyncronicity during this episode. Peak and plateau pressures were noted to be elevated, chest x-ray showed air trapping with no pneumothorax. Her arterial blood gas was remarkable for worsening hypercapnia. Fentanyl was discontinued and the patient was given midazolam and rocuronium with resolution of rigidity and improvement in her blood gas.
Discussion: Usage of fentanyl in mechanically ventilated patients is becoming more prevalent as analgesia is being increasingly prioritized over sedation in these patients. Therefore, WCS is an important consideration in an acutely decompensating ventilated patient on continuous or PRN fentanyl. If WCS is not promptly recognized, it can lead to unnecessary intervention and adverse patient outcomes. Therefore, a high index of suspicion for this complication is necessary.
