Fentanyl - Intranasal


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. 

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To guide staff in the use of intranasal fentanyl.


  • Pain relief in children in moderate to severe pain requiring opiate analgesia
  • No IV cannula inserted


  • Known fentanyl hypersensitivity
  • Altered conscious state: GCS < 15
  • Bilateral occluded nasal passages
  • Epistaxis
  • MAOI anti-depressant within 14 days

Adverse effects

Adverse effects are uncommon, but may include:
  • Respiratory depression
  • Hypotension
  • Nausea and vomiting
  • Itch
  • Chest wall rigidity (only reported in rapid large IV doses)


  • Age: 1–18 years (Use with caution in children < 12 months)
  • Dose: 1.5 micrograms/kg per dose, intra-nasally
  • Maximum dose 100 micrograms
  • Repeat after 5 -10 minutes, if required
  • If further analgesia required after the second dose, obtain medical review and consider alternative analgesia
  • It is acceptable to prescribe multiple dosages if efficacy is good


  • Draw up calculated dose of Fentanyl according to weight, plus an extra 0.1ml in a 1ml syringe to load atomiser.
  • Attach atomiser (MAD device WolfeTory ®) to the 1ml syringe.
  • Prepare atomiser by priming with 0.1ml of fentanyl.
  • Position patient either sitting up at 45° or with head to one side.
  • Administer dose by inserting into nostril loosely and aim for centre of nasal cavity prior to squirting.
  • If the dose is > 0.25mL, 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.


  • Time of administration
  • Baseline pre-narcotic observations if possible: HR, RR, BP, oxygen saturations
  • Observe closely for adverse effects and over sedation

Treatment of overdose

  • Support airway
  • Oxygen
  • Assist ventilation
  • Consider Naloxone as a reversal agent:
    • Naloxone is available in the resuscitation room
    • Should be administered for excess sedation or respiratory depression
    • Dose: 1-5 micrograms/kg IV, maximum dose of 100 micrograms, may be repeated every 2-3 minutes if required
    • Has short duration of action – approximately 30 minutes, may necessitate repeat doses or infusion.


  1. AMH Children’s Dosing Companion (2015) Australian Medicines Handbook Pty Ltd
  2. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
  3. 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

Reviewer/Team: Meredith Borland (ED Director), Dennis Chow (ED Consultant), Deirdre Speldewinde (ED Consultant), Gabrielle Anstey (ED CNS), Craig Hasler (ED CNM)
Last reviewed: Mar 2018

Review date: Mar 2019
Endorsed by:

Director, Emergency Department Date:  Apr 2018

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