Clinical Practice Guidelines

Intranasal fentanyl

  • See also: Acute pain management

    Indications for use

    • Initial analgesia for children aged 1 year and older, in moderate to severe pain, with
      • Fractures and dislocations
      • Burns
      • Major lacerations
    • Painful procedures under nitrous oxide

    Contraindications

    • Known fentanyl hypersensitivity
    • Altered conscious state - Sedation Score >2
    • Bilateral occluded nasal passage
    • Epistaxis

    Prescribing Restrictions

    Requires approval by Consultant/Fellow

    Dose

    • Use 100mcg/2ml strength fentanyl solution for intravenous use
    • First dose - 1.5 mcg / kg dose
    • A second dose may be administered 10 minutes after the first to provide adequate analgesia  -  0.75 - 1.5mcg/kg
    • After 2nd dose, if further analgesia is required, review and consider alternative or additional analgesia

    Dosage schedule

    Weight estimate(kg)

    Initial dose

    (1.5mcg/kg)

    Volume - initial dose (ml)

    Top-up dose

    (0.75 - 1.5mcg/kg)

    Volume - top up dose (ml)

     7 10 mcg0.2 ml5 mcg 0.1ml 

    10

    15 mcg

    0.3 ml

    7.5 - 15 mcg

    0.15 - 0.3 ml

    12

      18 mcg

    0.35 ml

    9 - 18 mcg

    0.2 - 0.35 ml

    14

    20 mcg

    0.4 ml

    10 - 20 mcg

    0.2 - 0.4 ml

    16

    24 mcg

    0.5 ml

    12 - 24 mcg

    0.25 - 0.5 ml

    18

    27 mcg

    0.55 ml

    13.5 - 27 mcg

    0.25 - 0.55 ml

    20 - 24

    30 mcg

    0.6 ml

    15 - 30 mcg

    0.3 - 0.6 ml

    25 - 29

    37.5 mcg

    0.75 ml

    18.75 - 37.5 mcg

    0.35 - 0.75 ml

    30 - 34

    45 mcg

    0.9 ml

    22.5 - 45 mcg

    0.45 - 0.9 ml

    35 - 39

    52.5 mcg

    1.05 ml

    26.5 - 52.5 mcg

    0.5 - 1.05 ml

    40 - 44

    60 mcg

    1.2 ml

    30 - 60 mcg

    0.6 - 1.2 ml

    45 - 49

    67.5 mcg

    1.35 ml

    67.5 mcg

    0.65 - 1.35 ml

    > 50

    75 mcg

    1.5 ml

    37.5 - 75 mcg

    0.75 - 1.5 ml

    Note:    Volumes have been rounded to the nearest 0.05ml

    Administration

    • Draw up appropriate dose for weight (see table below) plus 0.1ml extra to the first dose (to account for the dead space in the device)
    • Attach Mucosal Atomiser Device (MAD300) on to the end of the syringe
    • With the child sitting at approximately 45 degrees or with head to one side, insert the device loosely into the nostril and press the plunger quickly
    • Dose should be divided between nostrils
    • Note: Do NOT draw up 0.1ml extra for second dose when re-using the delivery device (MAD)

     

     

     

    Patient monitoring

    All patients require documented baseline pain score (Faces or Visual Analogue as age appropriate) and baseline sedation score.

    Patient's receiving intranasal fentanyl will be monitored like a patient receiving IV or IM opioids such as morphine (RCH Children's Pain Management Service Guidelines):

    • Baseline set of observations prior to drug administration.
    • The patient should be awake or easily roused to voiceprior to each dose.
    • Heart rate, respiratory rate, oxygen saturation, pain score & sedation score every 5 minutes after administration. If sedated or abnormal vital signs, inform treating physician and continue observations and sedation scores until return to baseline.
    • After the last dose has been given, two further sets of observations at 5 minute intervals should be completed.
    • The effectiveness of the analgesia should be recorded in the patient's medical record and/or on the general observation chart.

     

    Side effects

    Side effects are uncommon, but may include:

    • Respiratory depression
    • Hypotension
    • Nausea and vomiting
    • Pruritis
    • Chest wall rigidity (only reported in large intravenous doses)

    Treatment of overdose includes:

    • Airway support and oxygen
    • Assist ventilation
    • Consider Naloxone bolus 0.1mg/kg IM or IV, maximum 2mg