Classification
High alert medication
Controlled and targeted substance
Synthetic opioid analgesic
Indications
ACP: Moderate to severe pain
ACP: Adjunct for awake intubation
CCP: Adjunct for rapid sequence intubation
Contraindications
- Known hypersensitivity to opioids (including morphine)
- Myasthenia gravis
- Pre-existing respiratory depression
- Acute asthma
- Upper airway obstruction
Adult dosages
ACP: Moderate to severe pain
- Loading dose: 0.5-1.0 mcg/kg IM/IV/IO; maximum single dose 100 mcg; may repeat every 5 minutes to a total dose of 300 mcg
- Loading dose: 1.5-2.0 mcg/kg IN; maximum single dose 100 mcg; may repeat every 5 minutes to a total dose of 300 mcg
- Maintenance dose for long conveyances: 50 mcg IM/IV/IO every 10 minutes; maximum total dose of 250 mcg/hour
- Maintenance dose in long conveyances: 50-100 mcg IN every 10 minutes as required; maximum total dose of 250 mcg/hour.
Consider reducing doses by half in patients > 65 years of age
If pain is insufficiently relieved after a total of 1-3 mcg/kg, consider use of ketamine
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
- Loading dose: 1.5-2.0 mcg/kg IN; maximum single dose 100 mcg
- Loading dose: 1-2 mcg/kg IV/IO; maximum single dose 50 mcg every 5 minutes as required; total maximum dose of 200 mcg
- Maintenance dose for long conveyances: 0.75-1.5 mcg/kg IN every 10 minutes as required; maximum total dose of 150 mcg/hour
- Maintenance dose in long conveyances: 0.5 mcg/kg IV/IO every 10 minutes as required; maximum total dose of 150 mcg/hour
FentaNYL is preferred for pain management over ketamine or methoxyflurane
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
- Onset: 7-15 minutes (IM); immediate (IV)
- Peak: 1-2 hours (IM); < 5 minutes (IV); 2 minutes (IN)
- Duration: 1-2 hours (IM); 30-60 minutes (IV)
Adverse Effects
- Lightheadedness, dizziness, sedation, agitation, fear, delirium, drowsiness, disorientation
- Nausea and/or vomiting
- Respiratory depression
- Laryngospasm
- Chest wall rigidity
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.
Warning And Precautions
FentaNYL is a potent opioid analgesic and carries the risk of respiratory depression whenever it is used.
Some evidence exists that suggests fentaNYL may be heat sensitive, losing some potency after 4+ weeks of storage at temperatures consistently above 40°C. Degraded medication is unlikely to be harmful to patients, but may not carry the same clinical effects, thus requiring higher doses.
Drug Interactions
Concomitant use of benzodiazepines or other central nervous system depressants can lead to significant sedation and respiratory depression.