Fentanyl - Intranasal

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS Emergency Department disclaimer.

Aim

To guide Emergency Department (ED) staff in the use of intranasal fentanyl.

Indications

• Pain relief in children in moderate to severe pain requiring opiate analgesia¹
• No IV cannula in place as of yet

Contraindications¹

• Known fentanyl hypersensitivity
• Altered conscious state: Glasgow Coma Scale (GCS) < 15
• Bilateral occluded nasal passages
• Epistaxis
• Monoamine oxidase inhibitor (MAOI) anti-depressant within last 14 days

Adverse effects¹

Adverse effects are uncommon, but may include:

• Respiratory depression
• Hypotension
• Nausea and vomiting
• Itch
• Chest wall rigidity (only reported in rapid large IV doses)

Staff competency

Authorised Staff To be deemed competent to administer Intranasal Fentanyl under this protocol staff must: be Registered Nurses who are permanent staff or regularly employed in ED and who have completed a 3-month orientation to the PCH ED. be Enrolled Nurses who have undertaken the S4R and S8 Medication competency. have successfully completed the ‘Administration of Opioids by Emergency Department Nurses’ education package and be deemed competent by the Clinical Nurse Manager, Clinical Nurse Specialist or Staff Development Nurse.

Dosage¹  

• Refer to Guidelines for Drug Dosing in Overweight and Obese Children 2 to 18 Years of Age – Medication Management Manual (internal WA Health only)
• Refer to Fentanyl Monograph – Medication Management Manual (internal WA Health only)
• Use with caution in children < 12 months and only on the advice of an ED Consultant
• 1–18 years: 1.5 micrograms/kg. Usual maximum dose is 100 micrograms due to volume
• Dose may be repeated after 5 to 10 minutes if required.
  • Consider obtaining IV access if further analgesia required after the second dose. Obtain medical review and consider alternative analgesia.

• It is acceptable to prescribe multiple doses if efficacy is adequate.

Administration²

• Draw up calculated dose of Fentanyl according to weight, plus an extra 0.1 mL in a 1 mL syringe to prime the atomiser
• Attach atomiser (MAD device WolfeTory ®) to the 1 mL syringe
• Prepare atomiser by priming with 0.1 mL of fentanyl
• Position patient either sitting up at 45° or with head to one side
• Administer dose by inserting atomiser into nostril loosely and aim for centre of nasal cavity prior to squirting
• If the dose is > 0.25 mL, split between both nostrils to prevent loss of solution by sneezing or swallowing
• Depress the plunger quickly
• Hold atomiser in place for a further 5 seconds to prevent medication from dribbling out of nostril

Observations

• Complete and record a full set of baseline observations on the Observation and Response Tool and record additional information on the Clinical Comments chart prior to administration.
• Repeat observations at the time of administration including pain score, level of sedation, respiration rate, oxygen saturation and blood pressure.
• Observe closely for adverse effects and over sedation (opioid toxicity).

Opioid Toxicity - Reversal Agent³

• Naloxone should be administered for excess sedation or respiratory depression. Refer to University of Michigan Sedation Scale (UMSS)⁶ below.

University of Michigan Sedation Scale (UMSS)
0	Awake and alert
1	Minimally sedated: tired, sleepy, appropriate response to verbal conversation and / or sound
2	Moderately sedated: somnolent / sleeping, easily aroused with light, tactile stimulation or a simple verbal command
3	Deeply sedated: deep sleep, rousable only with significant physical stimulation
4	Unarousable

Excess Sedation (difficult to rouse, University of Michigan Sedation Scale (UMSS) ≥3 (see above), respiratory depression)

• Stop opioid administration (where applicable)
• Initiate immediate senior medical / consultant review and consider moving the patient to the resuscitation bay
• Administer naloxone. Refer to Table 1 below.

Resuscitation (minimal respiration, cardiorespiratory arrest, UMSS = 4)

• Stop opioid administration (where applicable)
• Support respiration (Bag Valve Mask Ventilation)
• Initiate an ED Resuscitation call review and move the patient to the resuscitation bay
• Administer naloxone. Refer to Table 1 below.
  • Patients requiring opioid reversal may need a further prescription of naloxone charted due to the very short duration of action (20 to 60 minutes³).
  • A clear plan is to be detailed in the medical record for ongoing management (e.g. the requirement for more intensive monitoring) of opioid toxicity.
  • The treating doctor or ED Consultant should be informed if a patient has required naloxone administration for opioid toxicity and of the management.
  • In the case of a suspected opioid overdose, intravenous naloxone is to be administered (by either a Registered Medical Officer, Registered Nurse or a paediatric medication and IV competent Enrolled Nurse) in the smallest dose that will raise conscious state and respiratory rate (if applicable) to the desired level without abolishing analgesia.
  • Should the intravenous route be unavailable naloxone may be given intramuscularly.
  • Naloxone is to be prepared and administered as per the instructions detailed below.

Table 1. Recommended naloxone dose:

	Naloxone IV		Naloxone IM
Strength	400 microgram/mL	400 microgram/mL
Dilution with sodium chloride 0.9%	to 20 mL		Use Neat
Final Strength	20 microgram/mL		400 microgram/mL
Dosing Interval	Every 1 to 2 minutes3,5		Every 15 minutes4
Recommended Dose	Excess sedation: 2 microgram/kg (Maximum 100 microgram)3,4 Resuscitation: 10 microgram/kg (Maximum 400 microgram)3,4 Consider IV infusion after 2 to 3 doses.3 Continue naloxone doses every 2 to 3 minutes until infusion commenced.
If there is no immediate response to naloxone, please consider other causes than opioid toxicity for excess sedation, respiratory depression or cardiorespiratory arrest.

References

1. Australia Medicines Handbook. Fentanyl. Children’s Dosing Companion (2015) Australian Medicines Handbook Pty Ltd
2. MAD Nasal™. Intranasal Mucosal Atomization Device User Guide. Accessed May 2023 from https://www.teleflex.com/usa/en/product-areas/emergency-medicine/intranasal-drug-delivery/mad-nasal-intranasal-device/index.html
3. AMH Children’s Dosing Companion (2022) Australian Medicines Handbook Pty Ltd 2022, [Internet] Naloxone; [Modified January 2022, Cited: May 2023] Available from: Naloxone - AMH Children's Dosing Companion (health.wa.gov.au)
4. Naloxone. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Elsevier. 2022 [06 May 2023]. Available from: Naloxone Monograph - Clinical Pharmacology (health.wa.gov.au)
5. Joint Formulary Committee. British national formulary for children 2020. Available from: http://www.medicinescomplete.com.pklibresources.health.wa.gov.au/#/content/bnfc/_13150509 6?hspl=fentanyl#content%2Fbnfc%2F_131505096%23pot-interactions
6. Malviya S, Voepel-Lewis T, Tait A.R, Merkel S, Tremper K, Naughton N. Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). British Journal of Anaesthesia [Internet]. 2002 Feb [cited 2023 May 3]; 88(2): 241-245. Available from: https://www.sciencedirect.com/science/article/pii/S0007091217365352?via%3Dihub. Doi:10.1093/bja/88.2.241

Bibliography

1. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
2. A Randomized Controlled Trial Comparing Intranasal Fentanyl to Intravenous Morphine for Managing Acute Pain in Children in the Emergency Department: Meredith Borland, MBBS, FACEM Annals of Emergency Medicine  March 2007

Endorsed by:	CAHS Drug & Therapeutics Committee	Date:	June 2023
		Review date:	June 2026

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