Fentanyl

Question 1

What is the presentation?

Answer 1

Fentanyl: 450mcg in 1.5ml (300mcg/ml); intra-nasal administration only
Fentanyl Citrate: 100mcg in 2ml ampoule (50mcg/ml); IV/IO only

Question 2

What is it and what does it do?

Answer 2

A short acting synthetic narcotic analgesic

Question 3

What are the indications?

Answer 3

Moderate to severe pain.

Acute Coronary Syndromes where GTN has been ineffective

Question 4

What are the contraindications?

Answer 4

Hypersensitivity to Fentanyl
Less than 1 year of age (IV / IO only)
Occluded nasal passages or epistaxis (intranasal only)

Question 5

What are the precautions?

Answer 5

Elderly patients
Respiratory depression: especially those at risk e.g. patients with severe COPD
Patients on MAO inhibitors
Caution in larger doses of women in active labour
Use of IV Ketamine as analgesic prior to minimum (age dependant) dose of IV Fentanyl requires ASMA authorisation:
Paediatric: 100mcg
Adult < 70 years old: 200mcg
Adult > 70 (or frail): 100mcg
Administer slowly
Cease administration prior to calculated dose if desired effect is obtained.
Patients under extended care (e.g. ‘ramped’ patients) who have already been administered pain relief should have careful consideration with regards to the dosages of fentanyl administered, titrating only to effect.

Question 6

What is the IV/IO dose for an adult >70 years or frail?

Answer 6

Dilute 100mcg in 2ml with 8ml NaCl 0/9% to produce10mcg/1ml

Pre-hospital loading dose: Titrate 0.5mcg/kg slow IV push (maximum single dose: 50mcg)
Subsequent dose: 25mcg to effect every 5 minutes

Ramped patients must not have loading doses administered - maintenance doses (max 25mcg IV) to effect as required.

Question 7

What is the IV/IO dose for an adult <70 years?

Answer 7

Dilute 100mcg in 2ml with 8ml NaCl 0/9% to produce10mcg/1ml

Pre-hospital loading dose: Titrate 1mcg/kg slow IV push (maximum single dose: 100mcg)
Subsequent dose: 25mcg to effect every 5 minutes.

Ramped patients must not have loading doses administered - maintenance doses (max 25mcg IV) to effect as required.

Question 8

What is the IV/IO dose for a paed?

Answer 8

Dilute 100mcg in 2ml with 8ml NaCl 0/9% to produce10mcg/1ml

Pre-hospital loading dose: Titrate 1mcg/kg slow IV push (maximum single dose: 25mcg)
Subsequent dose: 1mcg/kg (up to 25mcg) to effect every 5 minutes.

Ramped patients must not have loading doses administered - maintenance doses (max 25mcg IV) to effect as required.

Question 9

What are the IN doses for an adult?

Answer 9

Initial: 3 x 0.2ml (180mcg)

Subsequent at 5 minutes: 1 x 0.2ml (60mcg) Subsequent IV dose if necessary: 25mcg titrated to effect every 5 minutes.

Question 10

What are the IN doses for a small/elderly/frail adult?

Answer 10

Initial: 2 x 0.2ml (120mcg)

Subsequent at 5 minutes: 1 x 0.2ml (60mcg) Subsequent IV dose if necessary: 25mcg titrated to effect every 5 minutes.

Question 11

What are the IN doses for someone between 31-40kg?

Answer 11

Initial: 1 x 0.15ml (45mcg)

Subsequent at 5 minutes: 1 x 0.15ml (45mcg) Subsequent IV dose if required: 25mcg titrated to effect every 5 minutes.

Question 12

What are the IN doses for someone between 21-30kg?

Answer 12

Initial: 1 x 0.10ml (30mcg)
Subsequent at 5 minutes: 1 x 0.10ml (30mcg)
Subsequent IV dose if required: Up to 1mcg/kg titrated to effect every 5 minutes
(Maximum bolus dose 25mcg each time).

Question 13

What are the IN doses for someone <20kg

Answer 13

Initial: 1 x 0.05ml (15mcg)
Subsequent at 5 minutes: 1 x 0.05ml (15mcg)
Subsequent IV dose if required: Up to 1mcg/kg titrated to effect every 5 minutes
(Maximum bolus dose 25mcg each time)

Question 14

What are the special considerations?

Answer 14

Adopt a low threshold to engage with the ED team if pain remains difficult to control
Nausea/vomiting
Respiratory depression; monitor pulse oximetry for all patients having IV / IN Fentanyl
Cardiovascular effects:
Bradycardia
Hypotension (rare)