Fentanyl - Queensland Ambulance Service

Drug Therapy Protocols: Fentanyl
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Date
April, 2016
Purpose
Scope
Author
To ensure a consistent procedural approach to Fentanyl administration.
Applies to all QAS clinical staff.
Clinical Quality & Patient Safety Unit, QAS
Review date
April, 2018
URL
https://ambulance.qld.gov.au/clinical.html
This work is licensed under the Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0
International License. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Fentanyl
April, 2016
Drug class
Narcotic analgesic
Precautions
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Pharmacology
• Elderly patients
Fentanyl is a synthetic narcotic analgesic that acts on the central
nervous system by binding with the opioid receptors.[1-3]
• Hypotension
Metabolism
• Respiratory depression and/or failure
Hepatic metabolism and renal excretion.[1]
• Respiratory tract burns
• Known addiction to narcotics
UNCONTROLLED WHEN PRINTED
• Current MAOI therapy
Indications
• Significant pain
• Sedation (for the maintenance of an established ETT)
Side effects
• Bradycardia
• Drowsiness
UNCONTROLLED WHEN PRINTED
• Autonomic dysreflexia (with systolic BP > 160 mmHg)
• Hypotension
• Nausea and/or vomiting
• Pin point pupils
Contraindications
• Respiratory depression
• Muscular rigidity (particularly muscles of respiration)
UNCONTROLLED WHEN PRINTED
• KSAR or hypersensitivity to fentanyl
Figure 4.11
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Fentanyl
April, 2016
Presentation
Special notes[4-6]
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• Fentanyl is the preferred narcotic for patients presenting with ACS.
• Ampoule, 100 microg/2 mL fentanyl
Onset (NAS/IV)
Duration (NAS/IV)
Half-life
• Fentanyl is a rapid onset synthetic narcotic that may potentiate respiratory depression and haemodynamic instability, particularly when administered intravenously in the setting of CNS depression or hypovolaemia.
• Fentanyl administration should be considered for patients where a morphine allergy exists.
UNCONTROLLED WHEN PRINTED
< 3 minutes
30–60 minutes
2–3 hours
• When fentanyl is administered to a hypotensive patient, ACPs must call for CCP backup where available.
Schedule
• In the setting of hypotensive adult patients (SBP ≤ 90 mmHg) all incremental fentanyl doses are to be ≤ 25 microg for IV and ≤ 50 microg for IM.
• S8 (Controlled drug).
UNCONTROLLED WHEN PRINTED
ACP2
ACP2
CCP
ACP1
Intramuscular injection (IM)
CCP
Intranasal (NAS)
ACP1
Routes of administration
• There is no significant difference in the effectiveness of IV morphine to NAS fentanyl. The true benefit of paediatric NAS fentanyl administration is that it avoids painful IM or IV administration. • When administering fentanyl and midazolam to maintain sedation in the intubated patient, appropriate management is to be instituted to address any adverse side effects such as
hypotension. The addition of fentanyl in this setting will reduce
midazolam requirements, provide analgesia and ultimately
decrease the risk of hypotension. Under no circumstances are fentanyl and midazolam to be mixed in the one syringe.
CCP
CCP
Intraosseous injection (IO)
ACP2
UNCONTROLLED WHEN PRINTED
Intravenous injection (IV)
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Fentanyl
Adult dosages (cont.)
Adult dosages
ACP1
Significant pain
IM
≥ 70 yrs – 25–50 microg
Repeated at up to 50 microg every 10 minutes. Total maximum dose 100 microg.
CCP
Sedation (for the maintenance of an established ETT)
IV
25 microg. Consider administration with midazolam.
Repeated PRN. No maximum dose.
< 70 yrs – 25–100 microg
Repeated at up to 50 microg every 10 minutes.
Total maximum dose 200 microg.
• Significant pain
• Autonomic dysreflexia (with a significant BP > 160 mmHg)
CCP
UNCONTROLLED WHEN PRINTED
IO
25 microg. Consider administration with midazolam.
Repeated PRN. No maximum dose.
Paediatric dosages
Significant pain
≥ 70 yrs – 25–50 microg
Repeated at up to 50 microg every 10 minutes. Total maximum dose 100 microg.
CCP
< 70 yrs – 25–100 microg
Repeated at up to 50 microg every 10 minutes.
Total maximum dose 200 microg.
IM
25 – 100 microg
Repeated at up to 50 microg every 10 minutes. No maximum dose.
ACP1
ACP2
UNCONTROLLED WHEN PRINTED
IM
NAS
Initial dose of fentanyl is to be administered using the following scale.
Weight
Dose
Volume
10 kg
15 microg
0.3 mL
10 – < 15 kg
20 microg
0.4 mL
15 – < 20 kg
25 microg
0.5 mL
20 – < 25 kg
30 microg
0.6 mL
25 – 30 kg
40 microg
0.8 mL
> 30 kg
45 microg
0.9 mL
ACP2
UNCONTROLLED WHEN PRINTED
IV
≥ 70 yrs – 25 microg
Repeated at up to 25 microg every 5 minutes. Total maximum dose 100 microg.
< 70 yrs – 25–50 microg
Repeated at up to 50 microg every 5 minutes.
Total maximum dose 200 microg.
Repeated once at 1 microg/kg at 10 minutes.
Weight
Dose
Volume
10 kg
10 microg
0.2 mL
10 – < 15 kg
10 microg
0.2 mL
CCP
UNCONTROLLED WHEN PRINTED
IV
25–50 microg
Repeated at up to 50 microg every 5 minutes. No maximum dose.
15 – < 20 kg
15 microg
0.3 mL
20 – < 25 kg
20 microg
0.4 mL
25 – 30 kg
25 microg
0.5 mL
> 30 kg
30 microg
0.6 mL
< 1 year – QAS Clinical Consultation and Advice Line approval required in all situations.
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ACP2
Significant pain
NAS
≥ 1 year – 1.5 microg/kg
Repeated once at 1 microg/kg at 10 minutes.
Total maximum dose 100 microg.
Paediatric dosages (cont.)
Significant pain (cont.)
CCP
Paediatric dosages (cont.)
Fentanyl
IV
≥ 1 year – 1 microg/kg
Single maximum dose 25 microg.
Repeated at 0.5 microg/kg (maximum 25 microg) at 5 minute intervals. No maximum dose.
UNCONTROLLED WHEN PRINTED
CCP
< 1 year – QAS Clinical Consultation and Advice Line
approval required in all situations.
NAS
≥ 6 months – 1.5 microg/kg
Repeated once at 1 microg/kg at 10 minutes. Total maximum dose 100 microg
< 6 months – QAS Clinical Consultation and Advice
Line approval required in all situations.
< 1 year – QAS Clinical Consultation and Advice Line approval required in all situations.
Sedation (for the maintenance of an established ETT)
IV
≥ 1 year – 1 microg/kg
Single maximum dose 25 microg.
Consider administration with midazolam.
No maximum dose.
ACP2
≥ 1 year – 1–2 microg/kg
Single maximum dose 50 microg.
Total maximum dose 2 microg/kg.
CCP
UNCONTROLLED WHEN PRINTED
IM
< 1 year – QAS Clinical Consultation and Advice Line approval required in all situations.
IM
≥ 1 year – 2 microg/kg
Single maximum dose 50 microg.
Repeated at 1 microg/kg (maximum 25 microg) at 10 minute intervals.
No maximum dose.
CCP
CCP
< 1 year – QAS Clinical Consultation and Advice Line approval required in all situations.
IO
≥ 1 year – 1 microg/kg
Single maximum dose 25 microg.
Consider administration with midazolam.
No maximum dose.
UNCONTROLLED WHEN PRINTED
ACP2
< 1 year – QAS Clinical Consultation and Advice Line approval required in all situations.
IV
≥ 1 year – 1 microg/kg
Single maximum dose 25 microg.
Repeated at 0.5 microg/kg (maximum 25 microg) at 5 minute intervals.
Total maximum dose 2 microg/kg.
< 1 year – QAS Clinical Consultation and Advice Line approval required in all situations.
Note: QAS officers are NOT authorised to administer fentanyl to paediatric patients presenting with cardiogenic
chest pain.
UNCONTROLLED WHEN PRINTED
< 1 year – QAS Clinical Consultation and Advice Line approval required in all situations.
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