Fentanyl*

• Fentanyl

• Sublimaze

Classification:

• Narcotic analgesic

Mechanism of Action:

• Binds to opioid receptor sites, altering perception of and emotional response to pain
• Rarely causes histamine release

Indications:

• Moderate to Severe pain
• Adjunct in RSS/RSI
• Ischemic Chest Pain

Contraindications:

• Hypersensitivity
• Hypotension Systolic < 90 mmHg
• Severe hemorrhage or shock (relative)
• MOA inhibitor therapy within last 14 days

Precautions:

• If administered to fast to pediatrics can cause stiff chest syndrome
• Use cautiously in patients with respiratory depression
• Use cautiously in patients with closed head injury or signs of increased ICP
• May exacerbate brady arrhythmias
• Use cautiously in those with hepatic or renal failure
• Use cautiously in elderly as it may cause hypotension
• Additive CNS depression with other pain, nausea, sedative medications.  Use together cautiously

Adverse Effects:

• Respiratory depression
• Apnea
• Muscle rigidity
• Bradycardia

Dose:

• 1.5 mcg/kg/dose; carefully titrate by administering 25-50 mcg IV at a time over at least 1 minute, or via nasal atomizer, q 5 minutes as needed to a max of 100 mcg q 1h.

• 1.5 mcg/kg/dose (MAX 100 mcg/dose) IN; may repeat 0.5-1 mcg/kg/dose (MAX 50 mcg/dose) after 10 min if needed.
• 1 mcg/kg/dose (MAX 50 mcg/dose) IV; may repeat q 1-2h PRN.

• IN, IV

• Patients with allergy to morphine should not expect cross-reactivity as fentanyl is a synthetic opioid.
• Fentanyl doesn’t have histamine-releasing properties like morphine; therefore, it may be preferred if hemodynamically unstable or bronchospasm. In addition, as a shorter-acting opioid, its effects may wear off quicker.
• Fentanyl has a short duration of analgesia, approximately 30-60 min, however fentanyl is highly lipophilic, with rapid distribution to highly perfused tissues (e.g., brain, heart, kidney, and GI tract) and a slower redistribution to muscle and fat. This can result in prolonged sedation after it is discontinued.
• Fentanyl has inactive metabolites and therefore may be the preferred agent in renal failure.
• Fentanyl is often used in trauma due to its quick onset time and shorter duration of action allowing for more accurate neurological assessment when it wears off. If a major trauma patient has severe hemorrhage and/or systolic blood pressure below 90, judicious careful titration of fentanyl via IV may be used if the benefits (e.g., managing pain, decreasing agitation, and keeping a patient still) outweigh the risks.
• All opioids carry risk of addiction. It is unknown what effect a bolus dose of opioid has on long term misuse. For patients with opioid use disorder on opioid agonist therapy (buprenorphine or methadone) experiencing acute pain, fentanyl may be preferred. Titrate as usual in these circumstances however higher doses than usual may be required.
• The Centers for Disease Control and Prevention (CDC) recommends non-opioid pain relievers such anti-inflammatories and acetaminophen be used as adjuncts to help reduce the amount of opioid required and thereby minimize their associated risks. Using non-opioid pain relievers such as ketorolac or acetaminophen and non-pharmacological techniques are important adjuncts which can be helpful in minimizing the amount of opioid required.
• Fentanyl is not generally the drug of choice in the palliative patient population due to its shorter duration of action (this doesn’t apply to patients with a fentanyl patch).
• Due to its shorter duration of action, fentanyl is the preferred agent for managing pain during labour; be aware of potential opioid-induced respiratory depression in the newborn.
• Pregnancy category C [if the patient will benefit from a Category C drug, it is generally used]

• Compendium of Pharmaceuticals and Specialties (CPS)