Download Fentanyl drip - Anne Arundel Medical Center

Fentanyl drip
ANNE ARUNDEL MEDICAL CENTER
CRITICAL CARE MEDICATION MANUAL
DEPARTMENT OF NURSING AND PHARMACY
Guidelines for use of intravenous
Fentanyl Citrate for Continuous Infusion
(Not Applicable to Fentanyl PCA)
Major Indications1,2
•
•
•
To provide analgesia for mechanically-ventilated intensive care unit patients (non FDA approved)
o NOTE: Intermittent fentanyl bolus administration in doses of 25-100mcg IV Push every
5-15 minutes is should be tried first over continuous infusion per Society of Critical Care
Medicine guidelines
As a comfort care/palliative care measure for hospice patients with uncontrolled pain (non FDA
approved)
As an alternative analgesic agent for patients with the following special circumstances which
prevent use of alternatives such as morphine or hydromorphone:
 Allergy
 Contraindication (e.g., renal insufficiency)
 Intolerance (e.g., hypotension, other adverse effects)
 Non-responsive pain
***Approved areas for fentanyl infusion use:
See the Critical Care Medical Manual on the Anne Arundel Medical Center Intranet,
under the document “Approved Areas for Medication”
Mechanism of Action2
•
Fentanyl is a high-potency opiate agonist acting primarily at the mu-receptors in the central
nervous system to exert its analgesic effects. Clinically, stimulation of mu-receptors throughout
the body produces analgesia, euphoria, respiratory depression, miosis, decreased gastrointestinal
motility, and physical dependence. Fentanyl also acts as an agonist at kappa-receptors, producing
analgesia, miosis, respiratory depression, dysphoria and some psychomimetic effects (e.g.,
disorientation and/or depersonalization).
Pharmacokinetics1,2
IV
Onset of Effect
1-2 minutes
Peak Effect
5 minutes
Duration of Effect
30-60 minutes
While Fentanyl has the most rapid onset and shortest duration of action of the opioids, it is a highly
lipophilic drug that redistributes into muscle and fat, which may lead to accumulation of the parent drug
and prolonged effects upon discontinuation.
Metabolism and Excretion2
•
•
Hepatic metabolism (primarily via CYP3A4) to inactive metabolites
Primarily excreted in the urine as inactive metabolite
Special Administration and Monitoring Techniques1,2,3
•
Fentanyl should be titrated to pain scale
Page 1 of 4
Updated Nov 2011
Fentanyl drip
•
•
•
•
•
•
•
Fentanyl can be used as an adjunct to sedative infusions such as lorazepam, propofol, or
midazolam
Fentanyl infusions MUST be administered through a controlled smart pump device
Patients should be regularly monitored for adequate pain relief
Do not use continuous infusion fentanyl without equipment to administer oxygen/control
respiration and an appropriate opiate antagonist order unless comfort care/hospice
Patients should have continuous respiratory monitoring
Appropriate use of pain and/or sedation scales such as the Ramsay Sedation Scale, Richmond
Agitation Sedation Scale (RASS), Confusion Assessment Method for the ICU (CAM-ICU), or
other validated sedation scale should be utilized when appropriate
Titration should also be based on vital signs (i.e heart rate, blood pressure, and respiratory rate)
Dosing2,3,4
•
Initial Dose:
Begin at dose of 25 mcg/hr and titrate as needed
*Alternatively, a bolus dose of 1-2 mcg/kg (25-100 mcg) may be administered
followed by initiation of the continuous infusion
•
Titration:
Usually titrated by 25-50 mcg increments every 30 minutes-1 hour prn to
response. A bolus dose may be indicated along with the titration.
•
Usual Dose:
25-200 mcg/hr (or 0.7-2 mcg/kg/hr)
•
Range:
The dose range for fentanyl infusions is variable. Some patients may
require higher doses, and the physician should be notified for further orders if a
maximum rate of 500 mcg/hr is achieved.
Contraindications2
•
Hypersensitivity to fentanyl or any component of the product
Precautions2,3
•
•
•
Fentanyl should be used with extreme caution in patients with pulmonary disease or in patients
with other respiratory insufficiency or hypoxemia.
Drug accumulation or prolonged duration of action can occur in patients with renal impairment,
renal failure, or hepatic disease. Use the lowest possible fentanyl dose in patients with either
hepatic or renal impairment.
Due to the effects of opiate agonists on the gastrointestinal tract, fentanyl should be used
cautiously in patients with GI disease including GI obstruction or ileus, ulcerative colitis, or preexisting constipation.
Drug Interactions2,3
•
•
•
Concomitant administration with strong/moderate CYP3A4 inhibitors may increase fentanyl
plasma concentrations (e.g., fluconazole and protease inhibitors)
Concomitant administration with CYP3A4 inducers may decrease fentanyl plasma concentrations
(e.g., carbamazepine and rifampin)
Concomitant use with other drugs that may cause CNS or respiratory depression should be
avoided or used with caution
Adverse Effects1,2,3
•
Neuromuscular: chest wall rigidity
Page 2 of 4
Updated Nov 2011
Fentanyl drip
Although rapid, high dose IV infusion of any opioid can induce chest wall rigidity, fentanyl is one
of the agents most often associated with this uncommon, life threatening adverse event.
Increased muscle tone in the chest (and sometimes abdominal) wall makes respiration difficult
and may even cause cessation of breathing. The underlying physiologic cause is unknown, but
several factors can place patients at an increased risk, including:
 Administration of high doses
 Rapid intravenous injection
 Concomitant use of nitrous oxide
 Use in the absence of muscle relaxants
 Age 65 or older
Symptoms of chest wall rigidity include difficulty breathing, complaints of chest
tightness/heaviness, decreasing respiratory rate and/or oxygen saturation, use of accessory
muscles for breathing, and nasal flaring.
Treatment of Chest Wall Rigidity:
 Turn OFF fentanyl infusion
 Oxygen via nasal cannula/mask as needed
 Administer naloxone (Narcan) per respiratory depression protocol
 Muscle relaxants may be ordered/administered to reduce muscle tone
 Provide rescue breathing if necessary, and initiate Code Blue if ineffective.
• CNS: CNS depression (dizziness/confusion/sedation)
• Cardiovascular: bradycardia, vasodilation, edema
• Respiratory: respiratory depression/dyspnea/apnea
• Gastrointestinal: constipation, nausea, vomiting
• Neuromuscular: chest wall/muscle rigidity (with high IV doses)
Discontinuation of Fentanyl Continuous Infusions: Preventing Withdrawal1,2
• Patients exposed to more than one week of high-dose opioid therapy may develop
neuroadaptation or physiological dependence.
 If the patient has received fentanyl or other high-dose opioid therapy for a prolonged
period of time (~7 days), doses should be systematically tapered to prevent withdrawal
(suggested initial decrease from the literature of 20-40%, or per prescriber’s instructions)
NOTE: This guide does NOT apply to Fentanyl PCA – see (1) SBAR for Adult fentanyl PCA and (2)
Approved Areas for IV Drip Medications (available on the AAHS Intranet).
Page 3 of 4
Updated Nov 2011
Fentanyl drip
Fentanyl Continuous Infusion Dosing Chart
Fentanyl solution for continuous infusion is available as pre-mixed 100 mL bags at concentrations of 10
and 50 mcg/mL.
Fentanyl 10 mcg/mL
Fentanyl DOSE (mcg/hr)
Fentanyl Infusion RATE (mL/hr)
10
20
25
30
40
50
60
70
75
80
90
100
1
2
2.5
3
4
5
6
7
7.5
8
9
10
Fentanyl 50 mcg/mL
Fentanyl DOSE (mcg/hr)
Fentanyl Infusion RATE (mL/hr)
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
References:
1. Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained
use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30:119141.
2. Fentanyl. Lexi-Comp OnlineTM, Lexi-Drugs Online. Hudson, Ohio: Lexi-Comp, Inc.
3. Fentanyl. DRUGDEX® System (Version 5.1) [Intranet]. Greenwood Village, CO:
Thomson Reuters (Healthcare) Inc.
4. Sessler CN, Varney K. Patient-focused sedation and analgesia in the ICU. Chest
2008; 133:552–565.
Page 4 of 4
Updated Nov 2011