fentanyl

Drug Name

Generic Name : fentanyl

Brand Name: Actiq; Duragesic 12, 25, 50, 75, 100; Fentora, Ionsys, Sublimaze

Classification: Opioid agonist analgesic

Pregnancy Category C
Controlled Substance C-II

Dosage & Route

Available forms :Lozenge on a stick (Actiq)—200, 400, 600, 800, 1,200, 1,600 mcg; transdermal—12.5, 25, 50, 75, 100 mcg/hr; injection—50 mcg/mL; buccal tablets—100, 200, 400, 600, 800 mcg; ionic delivery system—40 mcg/10 min

ADULTS

Parenteral

  • Premedication: 50–100 mcg IM 30–60 min before surgery.
  • Adjunct to general anesthesia: Initial dosage is 2 mcg/kg. Maintenance dose, 2–20 mcg IV or IM when changes in vital signs indicate surgical stress or lightening of analgesia.
  • With oxygen for anesthesia: Total high dose is 20–50 mcg/kg IV.
  • Adjunct to regional anesthesia: 500–100 mcg IM or slowly IV over 1–2 min.
  • Postoperatively: 50–100 mcg IM for the control of pain, tachypnea, or emergence delirium; repeat in 1–2 hr if needed.

Transdermal

  • Initiate therapy with 25 mcg/hr system; adjust dose as needed and tolerated. Apply to nonirritated and nonirradiated skin on a flat surface of the upper torso; may require replacement in 72 hr if pain has not subsided; do not use torn or damaged systems, serious overdose can occur.

Lozenges

  • Actiq: Place unit in mouth between cheek and lower gum. Start with initial dose of 200 mcg. Until appropriate dose is reached, an additional dose can be used to treat an episode of breakthrough pain. Redosing may start 15 min after the previous lozenge has been completed. No more than two lozenges should be used for each breakthrough pain episode. Can consider increasing dose if requiring more than one lozenge for treatment of several consecutive breakthrough pain episodes. If more than four lozenges are needed daily, increase the dosage of long-acting opioid. Actiq should be sucked slowly over 15 min.
  • Buccal tablets: Initially, 100-mcg tablet placed between cheek and gum for 14–25 min; may be repeated in 30 min if needed. Adjust slowly to control pain.

Ionic delivery system

  • Apply to chest or upper, outer arm. With each activation, 40 mcg delivered over 10 min. Each system contains 80 doses. May use up to 3 units sequentially, if needed.
PEDIATRIC PATIENTS 2–12 YR

Parenteral

  • 2–3 mcg/kg IV as vital signs indicate.

Transdermal

  • Do not exceed 15 mcg/kg.

Lozenges

  • 5–15 mcg/kg transmucosal.
Therapeutic actions
  • Fentanyl is a potent opioid analgesic that increases pain threshold, alters pain reception and inhibits ascending pain pathways by binding to stereospecific receptors within the CNS.
Indications
  • Analgesic action of short duration during anesthesia and immediate postoperative period
  • Analgesic supplement in general or regional anesthesia
  • Administration with a neuroleptic as an anesthetic premedication, for induction of anesthesia, and as an adjunct in maintenance of general and regional anesthesia
  • For use as an anesthetic agent with oxygen in selected high-risk patients
  • Transdermal system: Management of chronic pain in patients requiring continuous opioid analgesia over an extended period of time who cannot be managed by other means and who are already receiving opioid therapy
  • Actiq: Treatment of breakthrough pain in cancer patients being treated with and tolerant to opioids
  • Fentora: Management of breakthrough pain in cancer patients being treated with and tolerant to opioid therapy for underlyng cancer pain
Adverse effects
  • Nausea, vomiting; bradycardia, oedema, CNS depression, confusion, dizziness,drowsiness, headache, sedation, transient hypotension, peripheral vasodilation; increased intracranial pressure. High IV dose may cause chest wall rigidity. Transdermal: Rash, erythema and itching.
  • Potentially Fatal: Respiratory depression, trunk rigidity, laryngospasm, bronchoconstriction.
Contraindications
  • Hypersensitivity.
Nursing considerations

CLINICAL ALERT! Name confusion has occurred between fentanyl and sufentanil; use extreme caution.

Assessment
  • History: Hypersensitivity to fentanyl or opioids, physical dependence on an opioid analgesic, pregnancy, labor, lactation, COPD, respiratory depression, anoxia, increased intracranial pressure, acute MI, ventricular failure, coronary insufficiency, hypertension, biliary tract surgery, renal or hepatic impairment
  • Physical: Orientation, reflexes, bilateral grip strength, affect; pupil size, vision; P, auscultation, BP; R, adventitious sounds; bowel sounds, normal output; LFTs, renal function tests
Interventions
  • Administer to women who are nursing a baby 4–6 hr before the next scheduled feeding to minimize the amount in milk.
  • BLACK BOX WARNING: Keep opioid antagonist and facilities for assisted or controlled respiration readily available during parenteral administration.
  • Prepare site for transdermal form by clipping (not shaving) hair at site; do not use soap, oils, lotions, alcohol; allow skin to dry completely before application. Apply immediately after removal from the sealed package; firmly press the transdermal system in place with the palm of the hand for 10–20 sec, making sure the contact is complete. Must be worn continually for 72 hr. Do not use any system that has been torn or damaged. Remove old patch before applying a new one.
  • Note that the patch does not work quickly. It may take up to 12 hr to get the full therapeutic effect. Breakthrough medications need to be used.
  • Do not use Actiq in patients who never received narcotics before; should be used only in opioid tolerant patients.
  • Use caution with Actiq form to keep this drug out of the reach of children (it looks like a lollipop) and follow the distribution restrictions in place with this drug very carefully.
  • Use Ionsys only for hospitalized adults. Apply to intact, nonirritated skin on chest or upper arm. Patient presses button twice, firmly. System will deliver dose over 10 min. Up to 3 units may be used sequentially, if needed.
Teaching points
  • Do not drink grapefruit juice while using this drug. If using the patch, do not use any patch that has been torn or damaged. Remove old patch before applying a new one.
  • You may experience these side effects: Dizziness, sedation, drowsiness, impaired visual acuity (ask for assistance if you need to move); nausea, loss of appetite (lie quietly, eat frequent small meals); constipation (a laxative may help).
  • Report severe nausea, vomiting, palpitations, shortness of breath, or difficulty breathing.