February 1 was the first day we would use intranasal Fentanyl. My first shift on, I made certain I had an atomizer in my pocket. In the guidance for intranasal Fentanyl, it says “useful for patients who lack IV access or in whom IV access is not desired”. But we put nothing in the guideline that says you can’t give it to anyone. I was eager to try it out. Years ago when we first got bougies, I used bougies on all my intubations for several months, just so I could learn how to handle it, so I would be ready when it was truly needed.
My first patient was a man with intractable pain post surgery. He had no contraindications to narcotic pain management. No allergies and a stable blood pressure. He was a large man laying in bed grimacing. I asked him if I could give him some pain relief and he said yes. I drew up 50 mcgs of Fentanyl in a 1 cc syringe. I had him block one nostril. I stuck the atomizer in the other nare and told him to inhale as I briskly squirted the Fentanyl in. Then I repeated this with the second 50 mcg in the other nostril. Within a couple minutes, we were taking him downstairs in the elevator and he was chatting away with us without a care in the world. In the ambulance, I put in an IV, and eventually gave him a second dose IV. His pain was a one by the time we hit the ED.
The next day I used intranasal Fentanyl on an old woman with a hip fracture. Instead of spreading out my IV kit on the floor and strapping a tourniquet on her arm, I shot 25 mcgs up each nostril. Again, she was feeling dandy by our ED arrival.
I have been studying about Fentanyl for a presentation on the drug I am giving and here are some facts I have come upon.
IN Fentanyl should work within 3 minutes. It has a bioavailability of between 71% and 89% meaning for every 100 mcgs of Fentanyl you give them up their nose, they absorb 71 to 89 mcgs. It should last for the same length of time as IV Fentanyl. The say never give more than 1 ml at a time up a nostril and ideally only 0.5 ml. Another medic I know gave 25 mcgs up one nostril, then 50 mcgs up another and 25 mcgs back in the first, and then asked the patient which they preferred. The patient said the 25 or 0.5 ml was much more pleasant for them.
I repeated this experiment on myself using just normal saline (alas). 1 ml in one nostril and 0.5 ml up the other. My verdict. The half was much better.
So on my next patient my plan will be to give 25/ 25/ 25 and 25. Or in other words, 0.5 ml/0.5 ml/0.5 ml and 0.5 ml.
Our protocols allow for 1.5 mcg/kg with a max of 100 mcgs, followed by a repeat dose after ten minutes if necessary. If the patient still needs pain management, the last dose should be given IV.
Contraindications to IN Fentanyl therapy obviously include nasal blockages.
It is important to push briskly. On a patient where I drew up 1 ml and tried to only give half in one nostril, I pushed too tentatively and saw some of the med run out of the nose. Practicing with saline, I could see a brisk push aerosolizes the fluid quite nicely, where a less than brisk doesn’t turn it into so many tiny droplets. The tinier the droplets the more easily absorbed, and less to run out of the nose.
Now I make certain to tilt their head back and always push as briskly as possible.
I’m interested in hearing other people’s experience with IN Fentanyl.
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