- Analgesia, anesthesia
- IV direct: over 3 - 5 minutes
- IV continuous infusion
- Intranasal (IN)
- Administer injection solution intranasally using Mucosal Atomization Device (MAD). Larger volumes should be divided between both nostrils.
- Ensure to account for the deadspace volume in the MAD (approx 0.06 mL for the MAD300 model). Either draw up extra medication for this volume, OR draw back on the syringe after administration of dose and then empty the air into the nostril so no drug remains in the MAD.
- Analgesia:
- IV direct: 0.5 - 4 mcg/kg/dose Q2-4h PRN
- IV continuous infusion: 0.5 - 4 mcg/kg/hr
- Rapid sequence intubation: 2 mcg/kg/dose
- Intranasal: 1.5 mcg/kg/dose
- Palliative Care Symptom Management Protocol
Birthweight Fentanyl intranasal dose (using 10 mcg/mL fentanyl) < 500 g - < 1000g 1 mcg (0.1 mL) q5min prn > 1000 g - < 3000 g
2.5 mcg (0.25 mL) q5min prn > 3000 g - > 4000 g 5 mcg (0.5 mL) q5min prn > 4000 g 5 mcg (0.5 mL) q5min prn
- MIST Protocol
| Gestational Age | Premedication | Ketamine Dosing* |
| Less than 29 weeks |
Sucrose according to policy Atropine 20 mcg/kg IV Caffeine Load as per admission protocol Optional: Fentanyl 0.5-1 mcg/kg over 5 minutes OR ketamine* |
IV: 0.5 mg/kg over 5 minutes Intranasal: 1-4 mg/kg, titrate by 0.5-1 mg/kg Buccal/Sublingual: 0.5 mg/kg, given 10-20 minutes before MIST. Repeat Q 7-10 minutes to clinical effect, max 4 doses. |
| 29 weeks or greater |
Sucrose according to policy Atropine 20 mcg/kg IV Caffeine Load as per admission protocol Optional: Fentanyl 0.5-1 mcg/kg over 3-5 minutes OR ketamine* |
IV: 1 mg/kg over 5 minutes Intranasal: 2-5 mg/kg, titrate by 0.5-1.5 mg/kg Buccal/Sublingual: 1 mg/kg, given 10-20 minutes before MIST. Repeat Q 15 minutes to clinical effect, max 2 doses. |
- CNS: coma, seizures, sedation, restlessness
- CVS: bradycardia, hypotension, flushing
-
Dermatology: erythema, pruritus, rash
-
GU: urinary retention
-
Miscellaneous: sweating, physical dependency, may require dose reduction regimen. Tolerance with prolonged use
- Respiratory: depression, respiratory muscle stiffness
- BP, HR
- ECG
- RR
- Urine output
CHEO:
IV direct:
- Use fentanyl 10 mcg/mL - 3 mL prefilled syringe prepared by pharmacy
- If patient receiving fentanyl by continuous infusion, use appropriate setting on pump to administer bolus dose
IV continuous infusion:
- Use 10 mcg/mL, 20 mL prefilled syringe prepared by pharmacy
Intranasal:
-
If fentanyl 10 mcg/mL is not readily available:
-
Withdraw 2 mL (100 mcg) of fentanyl 50 mcg/mL and add to 8 mL of normal saline.
Final concentration: 10 mcg/mL
-
TOH:
IV direct:
- Fentanyl 50 mcg/mL
- Take 1 mL (50 mcg) and add to 9 mL 0.9% NaCl
- Final concentration: 5 mcg/mL
IV continuous infusion:
- Fentanyl 50 mcg/mL
- Take 0.4 mL (20 mcg) and add to 19.6 mL D5W
- Final concentration: 1 mcg/mL
- Fentanyl 50 mcg/mL
- Take 0.8 mL (40 mcg) and add to 19.2 mL D5W
- Final concentration: 2 mcg/mL
- Fentanyl 50 mcg/mL
- Take 2 mL (100 mcg) and add to 18 mL D5W
- Final concentration: 5 mcg/mL
- Fentanyl 50 mcg/mL
- Take 4 mL (200 mcg) and add to 16 mL D5W
- Final concentration: 10 mcg/mL
-
Intranasal:
Withdraw 2 mL (100 mcg) of fentanyl 50 mcg/mL and add to 8 mL of normal saline.
Final concentration: 10 mcg/mL
- Solution Compatible: D5W, 0.9% NaCl
- Y-site Compatible: cefazolin, cefotaxime, cloxacillin, dobutamine, dopamine, fluconazole, furosemide, heparin, KCl, morphine, tobramycin, SMOF, TPN, vancomycin
- Rapid IV infusion may result in skeletal muscle and chest wall rigidity
-Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook 22nd Edition. Hudson: Lexi-Comp Inc.; 2015
- American Society of Health-System Pharmacists (ASHP). Handbook on Injectable Drugs. 19th Edition. Bethesda: ASHP 2017
- Harlos MS, Stenekes S, Lambert D, Hohl C, Chochinov HM (2013). Intranasal fentanyl in the palliative care of newborns and infants. Journal of Pain and Symptom Management, 46 (2), 265-274