Intranasal fentanyl

Indications for use

Initial analgesia for children aged 1 year and older, in moderate to severe pain, with
- Fractures and dislocations
- Burns
- Major lacerations
Painful procedures under nitrous oxide

Contraindications

Known fentanyl hypersensitivity
Altered conscious state - Sedation Score >2
Bilateral occluded nasal passage
Epistaxis

Prescribing Restrictions

Requires approval by Consultant/Fellow

Dose

Use 100 mcg/2 mL strength fentanyl solution for intravenous use
First dose - 1.5 mcg/kg dose
A second dose may be administered 10 minutes after the first to provide adequate analgesia - 0.75 - 1.5 mcg/kg
After 2nd dose, if further analgesia is required, review and consider alternative or additional analgesia

Dosage schedule

Weight estimate (kg)	Initial dose (1.5 mcg/kg)	Volume - initial dose (mL)	Top-up dose (0.75 - 1.5 mcg/kg)	Volume - top up dose (mL)
7	10 mcg	0.2 mL	5 mcg	0.1 mL
10	15 mcg	0.3 mL	7.5 - 15 mcg	0.15 - 0.3 mL
12	18 mcg	0.35 mL	9 - 18 mcg	0.2 - 0.35 mL
14	20 mcg	0.4 mL	10 - 20 mcg	0.2 - 0.4 mL
16	24 mcg	0.5 mL	12 - 24 mcg	0.25 - 0.5 mL
18	27 mcg	0.55 mL	13.5 - 27 mcg	0.25 - 0.55 mL
20 - 24	30 mcg	0.6 mL	15 - 30 mcg	0.3 - 0.6 mL
25 - 29	37.5 mcg	0.75 mL	18.75 - 37.5 mcg	0.35 - 0.75 mL
30 - 34	45 mcg	0.9 mL	22.5 - 45 mcg	0.45 - 0.9 mL
35 - 39	52.5 mcg	1.05 mL	26.5 - 52.5 mcg	0.5 - 1.05 mL
40 - 44	60 mcg	1.2 mL	30 - 60 mcg	0.6 - 1.2 mL
45 - 49	67.5 mcg	1.35 mL	32.5 - 67.5 mcg	0.65 - 1.35 mL
>50	75 mcg	1.5 mL	37.5 - 75 mcg	0.75 - 1.5 mL

Note: Volumes have been rounded to the nearest 0.05 mL

Administration

Draw up appropriate dose for weight (see table below) plus 0.1 mL extra to the first dose (to account for the dead space in the device)
Attach Mucosal Atomiser Device (MAD300) on to the end of the syringe
With the child sitting at approximately 45 degrees or with head to one side, insert the device loosely into the nostril and press the plunger quickly
Dose should be divided between nostrils
Note: Do NOT draw up 0.1 mL extra for second dose when re-using the delivery device (MAD)

Patient monitoring

All patients require documented baseline pain score (Faces or Visual Analogue as age appropriate) and baseline sedation score.

Patient's receiving intranasal fentanyl will be monitored like a patient receiving IV or IM opioids such as morphine (RCH Children's Pain Management Service Guidelines):

Baseline set of observations prior to drug administration.
The patient should be awake or easily roused to voice prior to each dose.
Heart rate, respiratory rate, oxygen saturation, pain score & sedation score every 5 minutes after administration. If sedated or abnormal vital signs, inform treating physician and continue observations and sedation scores until return to baseline.
After the last dose has been given, two further sets of observations at 5 minute intervals should be completed.
The effectiveness of the analgesia should be recorded in the patient's medical record and/or on the general observation chart.

Side effects

Side effects are uncommon, but may include:

Respiratory depression
Hypotension
Nausea and vomiting
Pruritis
Chest wall rigidity (only reported in large intravenous doses)

Treatment of overdose includes:

Airway support and oxygen
Assist ventilation
Consider Naloxone bolus 0.1 mg/kg IM or IV, maximum 2 mg

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines