Drug Therapy Protocols: Fentanyl

1 Drug Therapy Protocols: Fentanyl While the QAS has attempted 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: The Digital Clinical Practice Manual is expressly intended for use by appropriately qualified QAS clinicians when performing duties and delivering ambulance services for, and on behalf of, the QAS. The QAS disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this manual, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. State of Queensland (Queensland Ambulance Service) work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives International LicenseYou are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the State of Queensland, Queensland Ambulance Service and comply with the licence terms.

2 If you alter the work, you may not share or distribute the modified work. To view a copy of this license, visit copyright permissions beyond the scope of this license please contact: codeDTP_FEN_0722 DateJuly, 2022 PurposeTo ensure a consistent procedural approach to Fentanyl to all Queensland Ambulance Service (QAS) clinical care settingPre-hospital assessment and to all ages unless specifically of fundingInternal 100%AuthorClinical Quality & Patient Safety Unit, QASR eview dateJuly, 2024 Information securityUNCLASSIFIED Queensland Government Information Security Classification AMBULANCE SERVICE IndicationsDrug class [1,2]Narcotic analgesicPharmacologyFentanyl is a synthetic narcotic analgesic that acts on the central nervous system by binding with the opioid receptors.[1-2]MetabolismHepatic metabolism and renal excretion.[1]FentanylNOTE: Morphine is the preferred narcotic agent except under the following circumstances: allergy AND/OR Adverse Drug Reaction to morphine; haemodynamic instability; known/suspected kidney disease; when NAS narcotic administration is thepreferred treatment; AND/OR suspected ACS.

3 Side effects Bradycardia Drowsiness Hypotension Nausea and/or vomiting Pin point pupils Respiratory depression Muscular rigidity (particularly muscles of respiration) Contraindications Allergy AND/OR Adverse Drug Reaction Precautions Hypotension Respiratory tract burns Respiratory depression and/or failure Known addiction to narcotics Current MAOI therapyJuly, 2022 Figure Significant pain Sedation Autonomic dysreflexia (with a systolic BP > 160 mmHg) Induction for Rapid Sequence Intubation (RSI)UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED1005 QUEENSLAND AMBULANCE SERVICE Presentation Ampoule, 100 microg/2 mL fentanylSchedule S8 (Controlled drugs).Onset DurationHalf-life30 60 minutes < 3 minutes2 3 hours Special notes [1-5] Ambulance officers must only administer medications for the listed indications and dosing range. Any consideration for treatment outside the listed scope of practice requires mandatory approval via the QAS Clinical Consultation and Advice Line.

4 A Morphine Milligram Equivalent (MME) dose of Fentanyl can be calculatedusing the following formula: 100 microg Fentanyl = 10 mg MME. In the rare situation when combined narcotic (morphine AND Fentanyl ) Therapy is administered, the Total maximum dose must be calculated using a combination of all morphine AND Morphine Milligram Equivalent (MME) medication ( Fentanyl ). For example, 10 mg morphine AND 100 microg Fentanyl would equal the ACP total maximum dose of 20 mg MME. Fentanyl is a rapid onset synthetic narcotic that may potentiate respiratorydepression and haemodynamic instability, particularly when administeredintravenously in the setting of CNS depression of hypovolaemia. When Fentanyl is administered to a hypotensive patient, ACPs must call for CCP backup where available. In the setting of hypotensive adult patients (SBP 90 mmHg) all incremental Fentanyl doses must be no greater than 25 microg for IV and no greater than 50 microg for IM.

5 There is no significant difference in the effectiveness of IV morphine to NASfentanyl. The true benefit of paediatric NAS Fentanyl administration is thatit avoids painful IM or IV Routes of administrationIntranasal (NAS)Subcutaneous injection (SUBCUT)Intramuscular injection (IM)Intravenous injection (IV)Intraosseous injection (IO)CCPACP2 CCPACP2 CCPACP1 ACP2 CCPACP1 ACP2 CCPUNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED1006 QUEENSLAND AMBULANCE SERVICESUBCUTQAS Clinical Consultation and Advice Line approval required in all 70 yrs/cachectic or frail 25 50 microgRepeated at up to 50 microg every 10 minutes. Total maximum dose 100 microg (or MME).< 70 yrs 25 100 microgRepeated at up to 50 microg every 10 minutes. Total maximum dose 200 microg (or MME).NAS 70 yrs/cachectic or frail 25 50 at up to 50 microg every 10 maximum dose 100 microg (or MME).

6 < 70 yrs 50 100 at up to 100 microg every 10 maximum dose 200 microg (or MME).NAS25 100 microgRepeated every 10 maximum 70 yrs/cachectic or frail 25 50 microgRepeated at up to 50 microg every 10 minutes. Total maximum dose 100 microg (or MME).< 70 yrs 25 100 microgRepeated at up to 50 microg every 10 minutes. Total maximum dose 200 microg (or MME).IM25 100 microg Repeated at up to 50 microg every 10 minutes. No maximum dosages [1,2,4]ACP2 FentanylCCPCCP Significant pain Autonomic dysreflexia (with systolic BP > 160 mmHg)Significant painACP1 ACP2 CCPACP1 SedationSedation SedationIV/IO25 microg. Consider administration with midazolam. Repeated PRN. No maximum 70 yrs/cachectic or frail 25 microgRepeated at up to 25 microg every 5 minutes. Total maximum dose 100 microg (or MME).< 70 yrs 25 50 microgRepeated at up to 50 microg every 5 minutes. Total maximum dose 200 microg (or MME).

7 IV25 50 microgRepeated at up to 50 microg every 5 minutes. No maximum dosages (cont.) Significant pain Autonomic dysreflexia (with systolic BP > 160 mmHg)ACP2 CCPCCP Induction for RSII nduction for RSII nduction for RSIIV/IOQAS Clinical Consultation and Advice Lineapproval required in all 5 microg/kgSingle dose WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED1007 QUEENSLAND AMBULANCE SERVICE Significant painSignificant painSignificant painNAS NAS 6 months microg/kgSingle maximum dose 50 once at 1 microg/kg at 10 minutes. Total maximum dose 100 microg (or MME).< 6 months QAS Clinical Consultation and Advice Line approval required in all Clinical Consultation and Advice Line approval required in all 1 year 1 2 microg/kgSingle maximum dose 50 maximum dose 2 microg/kg (or MME).< 1 year QAS Clinical Consultation and Advice Line approval required in all 1 year 1 2 microg/kgSingle maximum dose 50 at 1 microg/kg (maximum 25 microg) at 10 minute intervals.

8 No maximum dose.< 1 year QAS Clinical Consultation and Advice Line approval required in all dosages (cont.)ACP2 ACP2 CCPACP1 1 year microg/kgSingle maximum dose 50 microg. Repeated once at 1 microg/kg at 10 minutes. Total maximum dose 100 microg (or MME).< 1 year QAS Clinical Consultation and Advice Line approval required in all situations. Significant painSignificant painSignificant painNASW eightDoseVolume10 < 15 kg20 mL15 < 20 kg25 mL20 < 25 kg30 mL25 30 kg40 mL>30 kg45 mLWeightDoseVolume10 < 15 kg10 mL15 < 20 kg15 mL20 < 25 kg20 mL25 30 kg25 mL>30 kg30 mLPaediatric dosages [2,4,5]FentanylACP1 Initial dose of Fentanyl must be administered using the following once at 1 microg/kg at 10 less than 1 year of age (10 kg) QAS Clinical Consultation and Advice Line approval required UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED1008 QUEENSLAND AMBULANCE SERVICEF entanylPaediatric dosages (cont.)

9 Significant pain (cont.)Significant pain (cont.)Significant pain (cont.)IV 1 year 1 microg/kgSingle maximum dose 25 at microg/kg (maximum 25 microg) at 5 minute intervals. Total maximum dose 2 microg/kg (or MME).< 1 year QAS Clinical Consultation and Advice Line approval required in all 1 year 1 microg/kgSingle maximum dose 25 at microg/kg (maximum 25 microg) at 5 minute intervals. No maximum dose.< 1 year QAS Clinical Consultation and Advice Line approval required in all situations. Sedation Sedation Sedation IV 1 year 1 microg/kgSingle maximum dose 25 administration with midazolam. Repeated PRN. No maximum dose.< 1 year QAS Clinical Consultation and Advice Line approval required in all 1 year 1 microg/kgSingle maximum dose 25 administration with midazolam. Repeated PRN. No maximum dose.< 1 year QAS Clinical Consultation and Advice Line approval required in all situations.

10 Induction for RSI Induction for RSI Induction for RSI IVQAS Clinical Consultation and Advice Line approval required in all Clinical Consultation and Advice Line approval required in all : QAS officers are NOT authorised to administer Fentanyl to paediatric patients presenting with cardiogenic chest dosages (cont.)CCPECCPEUNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED