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
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.