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 clinical disclaimer.
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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
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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.
OR
- be Enrolled Nurses who have undertaken the S4R and S8 Medication competency.
AND
- Staff must have completed the PCH Emergency Department Stage 1 ED Intranasal Fentanyl – Nurse Administered eLearning Package and be deemed competent by the Clinical Nurse Manager, Clinical Nurse Specialist or Staff Development Nurse.
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Dosage1
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. See Appendix 2 for reference.
- 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 (if depressed too slowly the medication will drip rather than atomise)
- 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) in Appendix 1.
Excess Sedation (difficult to rouse, University of Michigan Sedation Scale (UMSS) ≥3)
- Stop opioid administration (where applicable)
- Initiate immediate senior medical / consultant review...
- Administer naloxone. Refer to Table 1.
Resuscitation (minimal respiration, cardiorespiratory arrest, UMSS = 4)
- Stop opioid administration (where applicable)
- Support respiration (Bag Valve Mask Ventilation)
- Initiate an ED Resuscitation call review...
- 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 dose3,4,5:
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Naloxone IV
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Naloxone IM
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Strength
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400 microgram/mL
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400 microgram/mL
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Dilution with sodium chloride 0.9%
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to 20 mL
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Use Neat
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Final Strength
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20 microgram/mL
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400 microgram/mL
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Dosing Interval
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Every 2 to 3 minutes
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Every 10 to 15 minutes
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| Recommended Dose |
Excess Sedation:
2 microgram/kg
(Maximum 200 microgram) |
Excess Sedation:
4 microgram/kg
(Maximum 200 microgram) |
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Resuscitation: 10 microgram/kg (Maximum 400 microgram)
Consider IV infusion after more than 2 doses. Continue naloxone doses (IV every 2 to 3 minutes) until infusion commenced.
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If there is no immediate response to naloxone, please consider other causes than opioid toxicity for excess sedation, respiratory depression or cardiorespiratory arrest.
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References
1. AMH Children’s Dosing Companion (2022) Australian Medicines Handbook Pty Ltd 2022, [Internet] Fentanyl; [Modified January 2022, cited: 13 May 2026]. Available from:
https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/fentanyl
2. MAD Nasal™. Intranasal Mucosal Atomization Device User Guide. Accessed May 2026 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: 13 May 2026] Available from:
https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/naloxone
4. Naloxone. In: Clinical Pharmacology [database on the Internet]. Tampa (FL): Elsevier. 2022 [cited 13 May 2026]. Available from:
https://www-clinicalkey-com.pklibresources.health.wa.gov.au/pharmacology/monograph/425?n=Naloxone
5. Naloxone: Paediatric Drug Information. In: Post TW, editor. UpToDate [Internet]. Waltham (MA): UpToDate Inc.; [cited 26 June 2026]. Available from:
https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/naloxone-drug-information?sectionName=Pediatric&topicId=9678&search=naloxone&usage_type=panel&anchor=F199481&source=panel_search_result&selectedTitle=1~150&showDrugLabel=true&kp_tab=drug_general&display_rank=1#F199481
Bibliography
Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S.
Philadelphia: Lippincott Williams & Wilkins, 2010.
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.
Appendix 1: University of Michigan Sedation Scale (UMSS)
University of Michigan Sedation Scale (UMSS)
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0
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Awake and alert
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1
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Minimally sedated: tired, sleepy, appropriate response to verbal conversation and / or sound
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2
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Moderately sedated: somnolent / sleeping, easily aroused with light, tactile stimulation or a simple verbal command
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| 3 |
Deeply sedated: deep sleep, rousable only with significant physical stimulation
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| 4 |
Unarousable |
Appendix 2: Image of Mucosal Atomisation Device (MAD)
| Endorsed by: |
CAHS Drug & Therapeutics Committee
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Date: |
May 2026 |
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Review date: |
May 2029 |
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