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02/19/2014 08:32AM
High Alert
fentaNYL (parenteral) (fen-ta-nil)
Severe renal, pulmonary or hepatic disease; CNS tumors;qintracranial pressure;
Head trauma; Adrenal insufficiency; Undiagnosed abdominal pain; Hypothyroidism;
Alcoholism; Cardiac disease (arrhythmias); OB, Lactation: Pregnancy and lactation.
Analgesic supplement to general anesthesia; usually with other agents (ultra– shortacting barbiturates, neuromuscular blocking agents, and inhalation anesthetics) to
produce balanced anesthesia. Induction/maintenance of anesthesia (with oxygen or
oxygen/nitrous oxide and a neuromuscular blocking agents). Neuroleptanalgesia/
neuroleptanesthesia (with or without nitrous oxide). Supplement to regional/local
anesthesia. Preoperative and postoperative analgesia. Unlabeled Use: Continuous
IV infusion as part of PCA.
Action
Binds to opiate receptors in the CNS, altering the response to and perception of pain.
Produces CNS depression. Therapeutic Effects: Supplement in anesthesia. Decreased pain.
Pharmacokinetics
Absorption: Well absorbed after IM administration.
Distribution: Unknown.
Metabolism and Excretion: Mostly metabolized by the liver, 10– 25% excreted
unchanged by the kidneys.
Half-life: Children: Bolus dose— 2.4 hr, long-term continuous infusion— 11– 36
hr; Adults: 2– 4 hr (qafter cardiopulmonary bypass and in geriatric patients).
TIME/ACTION PROFILE (analgesia*)
PEAK
IM
7–15 min
20–30 min
IV
1–2 min
3–5 min
*Respiratory depression may last longer than analgesia
⫽ Canadian drug name.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; cross-sensitivity among agents may occur;
Known intolerance.
Indications
ONSET
pg 1 # 1
Use Cautiously in: Geri: Geriatric, debilitated, or critically ill patients ; Diabetes;
Sublimaze
Classification
Therapeutic: opioid analgesics
Pharmacologic: opioid agonists
Schedule II
Pregnancy Category C
ROUTE
Plate # 0-Composite
⫽ Genetic Implication.
Adverse Reactions/Side Effects
CNS: confusion, paradoxical excitation/delirium, postoperative depression, postoperative drowsiness. EENT: blurred/double vision. Resp: APNEA, LARYNGOSPASM, allergic bronchospasm, respiratory depression. CV: arrhythmias, bradycardia, circulatory depression, hypotension. GI: biliary spasm, nausea/vomiting. Derm: facial
itching. MS: skeletal and thoracic muscle rigidity (with rapid IV infusion).
Interactions
Drug-Drug: Avoid use in patients who have received MAO inhibitors within
the previous 14 days (may produce unpredictable, potentially fatal reactions). Concomitant use of CYP3A4 inhibitors including ritonavir, ketoconazole, itraconazole, clarithromycin, nelfinavir, nefazodone, diltiazem, aprepitant, fluconazole, fosamprenavir, verapamil, and erythromycin may result inqplasma
levels andqrisk of CNS and respiratory depression. Additive CNS and respiratory depression with other CNS depressants, including alcohol, antihistamines, antidepressants, other sedative/hypnotics, and other opioid analgesics.qrisk of
hypotension with benzodiazepines. Nalbuphine, buprenorphine, or pentazocine maypanalgesia.
Drug-Food: Grapefruit juice is a moderate inhibitor of the CYP3A4 enzyme system; concurrent use mayqblood levels and the risk of respiratory and CNS depression. Careful monitoring and dose adjustment is recommended.
Route/Dosage
Preoperative Use
IM, IV (Adults and Children ⬎ 12 yr): 50– 100 mcg 30– 60 min before surgery.
DURATION
Adjunct to General Anesthesia
1–2 hr
0.5–1 hr
IM, IV (Adults and Children ⬎ 12 yr): Low dose– minor surgery— 2 mcg/kg.
Moderate dose– major surgery— 2– 20 mcg/kg. High dose– major surgery—
20– 50 mcg /kg.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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Adjunct to Regional Anesthesia
IM, IV (Adults and Children ⬎ 12 yr): 50– 100 mcg.
Postoperative Use (Recovery Room)
IM, IV (Adults and Children ⬎ 12 yr): 50– 100 mcg; may repeat in 1– 2 hr.
General Anesthesia
IV (Adults and Children ⬎ 12 yr): 50– 100 mcg/kg (up to 150 mcg/kg).
IV (Children 1– 12 yr): 2– 3 mcg/kg.
Sedation/Analgesia
IV (Adults and Children ⬎ 12 yr): 0.5– 1 mcg/kg/dose, may repeat after 30– 60
min.
IV (Children 1– 12 yr): Bolus— 1– 2 mcg/kg/dose, may repeat at 30– 60 min intervals. Continuous infusion— 1– 5 mcg/kg/hr following bolus dose.
IV (Neonates): Bolus— 0.5– 3 mcg/kg/dose. Continuous infusion— 0.5– 2
mcg/kg/hr following bolus dose. Continuous infusion during ECMO— 5– 10 mcg/
kg bolus followed by 1– 5 mcg/kg/hr, may require up to 20 mcg/kg/hr after 5 days of
therapy.
NURSING IMPLICATIONS
Assessment
● Monitor respiratory rate and BP frequently throughout therapy. Report
●
●
●
●
significant changes immediately. The respiratory depressant effects of
fentanyl may last longer than the analgesic effects. Initial doses of other
opioids should be reduced by 25– 33% of the usually recommended
dose. Monitor closely.
Geri: Opioids have been associated with increased risk of falls in geriatric patients. Assess risk and implement fall prevention strategies.
IV, IM: Assess type, location, and intensity of pain before and 30 min after IM administration or 3– 5 min after IV administration when fentanyl is used to treat
pain.
Lab Test Considerations: May causeqserum amylase and lipase concentrations.
Toxicity and Overdose: Symptoms of toxicity include respiratory depression,
hypotension, arrhythmias, bradycardia, and asystole. Atropine may be used to
Plate # 0-Composite
pg 2 # 2
treat bradycardia. If respiratory depression persists after surgery, prolonged mechanical ventilation may be required. If an opioid antagonist is required to reverse
respiratory depression or coma, naloxone (Narcan) is the antidote. Dilute the 0.4mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg)
by direct IV push every 2 min. Pedi: For children and patients weighing ⬍40 kg,
dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL
and administer 0.5 mcg/kg every 2 min. Titrate dose to avoid withdrawal, seizures,
and severe pain. Administration of naloxone in these circumstances, especially in
cardiac patients, has resulted in hypertension and tachycardia, occasionally causing left ventricular failure and pulmonary edema.
Potential Nursing Diagnoses
Acute pain (Indications)
Ineffective breathing pattern (Adverse Reactions)
Risk for injury (Side Effects)
Implementation
● High Alert: Accidental overdosage of opioid analgesics has resulted in fatalities.
Before administering, clarify all ambiguous orders; have second practitioner independently check original order, dose calculations, route of administration, and
infusion pump programming.
● Do not confuse fentanyl with sufentanil.
● Benzodiazepines may be administered before or after administration of fentanyl to
reduce the induction dose requirements, decrease the time to loss of consciousness, and produce amnesia. This combination may also increase the risk of hypotension.
IV Administration
● pH: 4.0– 7.5.
● Direct IV: Diluent: Administer undiluted. Concentration: 50 mcg/mL. Rate:
Injections should be administered slowly over 1– 3 min. Administer doses ⬎ 5
mcg/kg over 5– 10 min. Slow IV administration may reduce the incidence and
severity of muscle rigidity, bradycardia, or hypotension. Neuromuscular blocking
agents may be administered concurrently to decrease chest wall muscle rigidity.
● Intermittent Infusion: Diluent: May be diluted in D5W or 0.9% NaCl. Concentration: Up to 50 mcg/mL. Rate: see Direct IV.
● Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, alprostadil, amikacin,
aminocaproic acid, aminophylline, amiodarone, amphotericin cholesteryl, am䉷 2015 F.A. Davis Company
CONTINUED
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Plate # 0-Composite
pg 3 # 3
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● Y-Site Incompatibility: azithromycin, dantrolene, diazoxide, pantoprazole,
CONTINUED
fentaNYL (parenteral)
Patient/Family Teaching
phenytoin, trimethoprim/sulfamethoxazole.
● Discuss the use of anesthetic agents and the sensations to expect with the patient
before surgery.
photericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban,
ascorbic acid, atracurium, atropine, azathioprine, aztreonam, benztropine, bivalirudin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium
gluconate, carboplatin, carmustine, caspofungin, cefazolin, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime,
chloramphenicol, chlorpromazine, cisatracurium, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, digoxin, diltiazem, diphenhydramine,
dobutamine, docetaxel, dopamine, doripenem, doxacurium, doxapram , doxorubicin, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin
alfa, eptifibatide, erythromycin, esmolol, etomidate, etoposide, etoposide phosphate, famotidine, fenoldopam, fluconazole, fludarabine, fluorouracil, folic acid,
furosemide, ganciclovir, gemcitabine, gentamicin, glycopyrrolate, granisetron,
heparin, hetastarch, hydrocortisone, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, insulin, irinotecan, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metaraminol, methotrexate, methoxamine, methyldopate,
methylpresnisolone, metoclopramide, metoprolol, metronidazole, midazolam,
milrinone, mitoxantrone, morphine, multivitamins, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, papaverine, pemetrexed, penicillin G,
pentamidine, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione, pipercillin/tazobactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine,
pyridoxime, quinupristin/dalfopristin, ranitidine, remifentanil, rituximab, rocuronium, sargramostim, scopolamine, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiopental, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban,
tobramycin, tolazoline, trastuzumab, trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, vitamin B complex with C, voriconazole, zoledronic acid.
⫽ Canadian drug name.
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⫽ Genetic Implication.
● Explain pain assessment scale to patient.
● Caution patient to change positions slowly to minimize orthostatic hypotension.
Geri: Geriatric patients may be a greater risk for orthostatic hypotension and,
consequently, falls. Teach patient to take precautions until drug effects have completely resolved.
● Medication causes dizziness and drowsiness. Advise patient to call for assistance
during ambulation and transfer and to avoid driving or other activities requiring
alertness for 24 hr after administration during outpatient surgery.
● Instruct patient to avoid alcohol or other CNS depressants for 24 hr after administration for outpatient surgery.
Evaluation/Desired Outcomes
● General quiescence.
● Reduced motor activity.
● Pronounced analgesia.
Why was this drug prescribed for your patient?
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.