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Drug Therapy Protocols: Fentanyl Disclaimer and copyright ©2016 Queensland Government All rights reserved. Without limiting the reservation of copyright, no person shall reproduce, store in a retrieval system or transmit in any form, or by any means, part or the whole of the Queensland Ambulance Service (‘QAS’) Clinical practice manual (‘CPM’) without the prior written permission of the Commissioner. The QAS accepts no responsibility for any modification, redistribution or use of the CPM or any part thereof. The CPM is expressly intended for use by QAS paramedics when performing duties and delivering ambulance services for, and on behalf of, the QAS. Under no circumstances will the QAS, its employees or agents, be liable for any loss, injury, claim, liability or damages of any kind resulting from the unauthorised use of, or reliance upon the CPM or its contents. While effort has been made to contact all copyright owners this has not always been possible. The QAS would welcome notification from any copyright holder who has been omitted or incorrectly acknowledged. All feedback and suggestions are welcome, please forward to: [email protected] Date April, 2017 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, 2020 Information security This document has been security classified using the Queensland Government Information Security Classification Framework (QGISCF) as UNCLASSIFIED and will be managed according to the requirements of the QGISF. 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, 2017 Drug class Narcotic analgesic Precautions UNCONTROLLED WHEN PRINTED 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 • Current MAOI therapy UNCONTROLLED WHEN PRINTED Indications • Significant pain Side effects • Sedation (for the maintenance of an established ETT) • Bradycardia • Autonomic dysreflexia (with systolic BP > 160 mmHg) • Hypotension • Drowsiness UNCONTROLLED WHEN PRINTED • Nausea and/or vomiting • Pin point pupils • Respiratory depression Contraindications • Muscular rigidity (particularly muscles of respiration) • KSAR or hypersensitivity to fentanyl UNCONTROLLED WHEN PRINTED Figure 4.12 QUEENSLAND AMBULANCE SERVICE 805 Fentanyl April, 2017 Presentation Special notes[4-6] UNCONTROLLED WHEN PRINTED • Fentanyl is the preferred narcotic for patients presenting with ACS. • Ampoule, 100 microg/2 mL fentanyl Onset (NAS/IV) Duration (NAS/IV) Half-life < 3 minutes 30–60 minutes 2–3 hours • 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 • 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). 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. ACP2 CCP ACP1 ACP2 CCP Intramuscular injection (IM) CCP ACP1 Subcutaneous injection (SUBCUT) ACP2 Intranasal (NAS) ACP1 UNCONTROLLED WHEN PRINTED • 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. Intraosseous injection (IO) CCP CCP Intravenous injection (IV) ACP2 UNCONTROLLED WHEN PRINTED QUEENSLAND AMBULANCE SERVICE 806 Fentanyl Adult dosages Adult dosages (cont.) CCP ACP2 ACP1 Significant pain SUBCUT QAS Clinical Consultation and Advice Line approval required in all situations. • Significant pain • Autonomic dysreflexia (with a significant BP > 160 mmHg) 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 10 minutes. Total maximum dose 100 microg. < 70 yrs – 25–100 microg Repeated at up to 50 microg every 10 minutes. Total maximum dose 200 microg. ACP2 IM < 70 yrs – 25–50 microg Repeated at up to 50 microg every 5 minutes. Total maximum dose 200 microg. CCP ACP1 UNCONTROLLED WHEN PRINTED IV 25–50 microg Repeated at up to 50 microg every 5 minutes. No maximum dose. UNCONTROLLED WHEN PRINTED ≥ 70 yrs – 25–50 microg. Repeated at up to 50 microg every 10 minutes. Total maximum dose 100 microg. < 70 yrs – 50–100 microg. Repeated at up to 100 microg every 10 minutes. Total maximum dose 200 microg. CCP NAS Sedation (for the maintenance of an established ETT) IV 25 microg. Consider administration with midazolam. Repeated PRN. No maximum dose. CCP ACP2 ACP1 • Significant pain • Autonomic dysreflexia (with a significant BP > 160 mmHg) IO 25 microg. Consider administration with midazolam. Repeated PRN. No maximum dose. ACP2 CCP UNCONTROLLED WHEN PRINTED NAS IM 25 – 100 microg Repeated every 10 minutes. No maximum dose. ≥ 70 yrs – 25–50 microg Repeated at up to 50 microg every 10 minutes. Total maximum dose 100 microg. UNCONTROLLED WHEN PRINTED 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. QUEENSLAND AMBULANCE SERVICE 807 Fentanyl Paediatric dosages (cont.) Paediatric dosages Significant pain NAS Initial dose of fentanyl is to be administered using the following scale. ACP2 ACP1 Significant pain NAS ≥ 1 year – 1.5 microg/kg Repeated once at 1 microg/kg at 10 minutes. Total maximum dose 100 microg. UNCONTROLLED WHEN PRINTED 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 < 1 year – QAS Clinical Consultation and Advice Line approval required in all situations. CCP Weight 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. UNCONTROLLED WHEN PRINTED > 30 kg 45 microg 0.9 mL 10 kg 10 microg 0.2 mL 10 – < 15 kg 10 microg 0.2 mL 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 CCP Volume ACP2 Dose ACP2 Weight ACP1 Repeated once at 1 microg/kg at 10 minutes. SUBCUT IM QAS Clinical Consultation and Advice Line approval required in all situations. ≥ 1 year – 1–2 microg/kg Single maximum dose 50 microg. Total maximum dose 2 microg/kg. UNCONTROLLED WHEN PRINTED CCP < 1 year – QAS Clinical Consultation and Advice Line approval required in all situations. < 1 year – QAS Clinical Consultation and Advice Line approval required in all situations. IM ≥ 1 year – 1–2 microg/kg Single maximum dose 50 microg. Repeated at 1 microg/kg (maximum 25 microg) at 10 minute intervals. No maximum dose. UNCONTROLLED WHEN PRINTED < 1 year – QAS Clinical Consultation and Advice Line approval required in all situations. QUEENSLAND AMBULANCE SERVICE 808 Fentanyl ACP2 Significant pain (cont.) 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. Paediatric dosages (cont.) Sedation (for the maintenance of an established ETT) CCP Paediatric dosages (cont.) IV ≥ 1 year – 1 microg/kg Single maximum dose 25 microg. Consider administration with midazolam. No maximum dose. UNCONTROLLED WHEN PRINTED < 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. 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 < 1 year – QAS Clinical Consultation and Advice Line approval required in all situations. < 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 UNCONTROLLED WHEN PRINTED QUEENSLAND AMBULANCE SERVICE 809