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Fentanyl

Classification

High alert medication

Controlled and targeted substance

Opioid analgesic

Indications

ACP: Moderate to severe pain

Contraindications

Contraindications:

Known hypersensitivity to opioids
Known or suspected bowel obstruction
Severe respiratory depression or airway compromise (asthma/COPD)

Caution:

Hypotension
Hypovolemia
Older adults may be more sensitive to the effects of opioids - consider reducing dose by half in patients over 65
Rapid infusions can lead to skeletal muscle and chest wall rigidity

Adult dosages

ACP: Moderate to Severe Pain (E08: Pain Management)

Loading dose: IM/IV/IO: 0.5 – 1mcg/kg (Max dose 100 mcg); Usual dose: 25-50mcg q5 minutes prn (Max total: 300mcg/hour)
Loading dose: 1.5 – 2 mcg/kg IN (Max dose 100mcg); usual dose: 50-100mcg q 5 minutes prn (Max total: 300mcg/hour)
PR11: Intranasal Medication Administration

Once initial pain control is achieved, consider multimodal analgesia to support pain control

Maintenance dose for long conveyances: IM/IV/IO: 25 - 50mcg q 10 minutes prn; (Max total 250mcg/hour)
Maintenance dose for long conveyances: IN: 50 – 100mcg every 10 minutes prn; (Max total dose 250mcg/hour)

CliniCall consultation required prior to administration of higher doses

Pediatric Considerations And Dosing

Follow weight-based dosing

NB: If vascular access is unavailable, the preferred route of administration for fentanyl is intranasal – intramuscular absorption rates are inconsistent in children.

ACP: Moderate to Severe Pain (E08: Pain Management)

Loading dose: 1.5 – 2 mcg/kg IN (Max 100mcg). Do not repeat.
PR11: Intranasal Medication Administration
Loading dose: 1-2 mcg/kg IV/IO (Max 50mcg) q 5 minutes prn ; (max total 200mcg/hour)

Fentanyl is preferred over ketamine. Once initial pain control is achieved, consider multimodal analgesia to support pain control.

Maintenance dose for long conveyances: 0.75 – 1.5 mcg/kg IN q 10 minutes prn; (maximum total 150mcg/hour)
Maintenance dose in long conveyances: 0.5mcg/kg q 10 minutes prn; (max total dose 150mcg/hour)

Mechanism Of Action

Inhibits ascending pain pathways in the central nervous system, altering pain perception by binding to opiate receptors, producing analgesia and euphoria.

Pharmacokinetics

IV/IO

Onset: Immediate
Duration: 30-60 minutes

IN/IM

Onset: 7-8 minutes
Duration: 1-2 hours

Adverse Effects

• Respiratory depression
• Nausea and vomiting
• Hypotension
• Bradycardia or tachycardia
• Hypotension/hypertension
• Hallucinations
• Anxiety
• Seizures

Overdose

Provide airway management and ventilatory support. Consider the use of naloxone to reverse opioid intoxication. Naloxone should be used judiciously in patients on long-term opioid therapy to avoid precipitating acute withdrawal syndrome.

See Naloxone guideline.

Drug Interactions

Concomitant use of benzodiazepines or other central nervous system depressants can lead to significant sedation and respiratory depression.