Neonatal Drug Therapy Manual

FentaNYL

Disclaimer: Official controlled document is the CHEO and Ottawa Hospital online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Updated September 10, 2024 - 11:29am

Alternate Name(s): 
Sublimaze
Classification: 
Synthetic Opioid Receptor Agonist
Original Date: 
March 1993
Revised Date: 
Sept 2024
Indications: 
  • Analgesia, anesthesia
Administration: 
  • 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.
  • SC through CLEO as continuous infusion (end of life care, alternative to IN fentanyl)
Dosage: 
  • 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 Premedication: Sedation (Ketamine OR fentanyl)
Ketamine Fentanyl
<29 weeks

Sucrose according to policy

Atropine 20 mcg/kg IV

Caffeine Load as per admission protocol

 

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. 

 IV: 0.5-1 mcg/kg over 5 minutes
>29 weeks

Sucrose according to policy

Atropine 20 mcg/kg IV

Caffeine Load as per admission protocol

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. 

IV 0.5-1 mcg/kg over 3-5 minutes

Intranasal: 1-5 mcg/kg (onset within 2-3 minutes, titrate to effect Q 15 minutes)

 

Side Effects: 
  • 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
Parameters to Monitor: 
  • BP, HR
  • ECG
  • RR
  • Urine output
Reconstitution and Stability: 

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

​​SC- CLEO:

  • ​​​Use 10 mcg/mL or 50 mcg/mL, depending on volume/hr (max 2 mL/hr for CLEO)

 

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

Compatibility: 

- Solution Compatible: D5W, 0.9% NaCl

- Y-site Compatible: cefazolin, cefotaxime, cloxacillin, dobutamine, dopamine, fluconazole, furosemide, heparin, KCl, morphine, tobramycin, SMOF, TPN, vancomycin

Notes: 
  • Rapid IV infusion may result in skeletal muscle and chest wall rigidity
References: 

-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

 

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