IN pain control protocol

Seizing child recieving IN treatmentTherapeutic Intranasal Drug Delivery

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Intranasal fentanyl, sufentanil, diamorphine protocol for pain control

Pain control with Intranasal opiates

Indications:

  1. Adult and pediatric minor painful injuries or procedures:
    • Orthopedic trauma not requiring an IV (or prior to starting an IV)
    • Anytime pain control is needed but oral medication is too slow
    • Burn dressing changes
    • Re-packing wounds such as abscesses
    • Any time you consider an IM shot for pain control (IN works as well or better with faster onset and no pain on delivery)
    • Titration of opiates is often needed - repeat another half to full dose every 15 minutes to until desired effect is obtained
    • The single biggest reason for failure of intranasal opiates is the clinician gives an in-appropriate dose (too low) similar to an IV dose which will simply fail in most situations.

Dosing and method:

  1. Fentanyl, sufentanil or diamorphine are most appropriate for IN delivery to treat pain
    1. Reasonable IN starting dose for painful procedures:
      1. Fentanyl: 2 ug/kg (comes in 50 ug/ml, you can ask your pharmacy to concentrate the solution or use sufentanil in larger patients).
      2. Sufentanil: 0.5 to 0.7 ug/kg (0.5 for elderly, 0.7 for young)
      3. Diamorphine 0.1 mg/kg (not available in USA)
    2. Administer half the dose into each nostril
    3. 1/3 to ½ ml per nostril is ideal but can push up to 1 ml per nostril though some will run off. If you need more than 2 ml total, consider titration with second dose in 5 minutes or use sufentanil. If you have diamorphine you can simply solubilize it within the appropriate volume of liquid so you deliver 1/3 ml per nostril.
    4. Be Wary of respiratory depression with sufentanil – monitor patients with pulse oximetry and close observation whenever using this powerful opiate.
    5. Titration to pain is often necessary – repeat dosing (1/2 to full dose) every 15 minutes until desired effect is achieved.

Strongly consider administering an oral pain medication at the same time as the nasal medication. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect.

Naloxone is effective intranasally if you need a reversal agent

Be aware that there is often a "dead space" within the delivery device you use - this leads to some of the drug remaining within the device and not being delivered to the patient.  Be certain to draw up that extra volume into the syringe to account for the dead space that will remain.

Dosing tables (to assist with volume calculations)

Generic Intranasal Fentanyl dosing table

Fentanyl (generic) is most appropriate for children since it becomes too dilute as the child's weight (and therefore the volume delivered) increases.

Dosing Plan: Fentanyl concentration -  0.1ml = 5 mcg (50 mcg/ml)

Simple calculation: Dose in ml = Wt in Kg x 0.04 plus 0.1 ml dead space

Patient weight

Fentanyl dose in micrograms (at 2 mcg/kg)

Fentanyl volume (including extra 0.1 ml for dead space)*

3-5 kg

10 mcg

0.2 + 0.1 ml

6-10 kg

20 mcg

0.4 + 0.1 ml

11-15 kg 

30 mcg

0.6 + 0.1 ml

16-20 kg 

40 mcg

0.8 + 0.1 ml

21-25 kg 

50 mcg

1.0 + 0.1 ml

26-30 kg 

60 mcg

1.2 + 0.1 ml**

31-35 kg 

70 mcg

1.4 + 0.1 ml**

36-40 kg 

80 mcg

1.6 + 0.1 ml**

41-45 kg

90 mcg

1.8 + 0.1 ml**

46-50 kg

100 mcg

2.0 ml**

51-55 kg

110 mcg

2.2 + 0.1 ml#

56-60 kg

120 mcg

2.4 + 0.1 ml#

61-70 kg

140 mcg

2.8 + 0.1 ml#

71-80 kg

160 mcg

3.2 + 0.1 ml#

81-90 kg

180 mcg

3.6 + 0.1 ml#

91-100 kg

200 mcg

4.0 ml#

   

  You should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.1 ml represents a typical dead space in a 1 ml syringe connected to a syringe driven atomizer.

**If the volume exceeds 1 ml you might want to consider using sufentanil instead.

# Volumes in this range should be divided in half and administered 10 minutes apart to reduce runoff. It would likely be more appropriate to use sufentanil if that is available.

Generic Intranasal Sufentanil dosing table

Sufentanil is more appropriate for adult patients because it is so concentrated that it is difficult to measure for small children.  It comes in 50 mcg/1 ml vials. Occasionally you will need two vials for adequate dosing.

Dosing Plan: Sufentanil concentration -  0.1ml = 5 mcg (50 mcg/ml)

Patient weight

Sufentanil dose in micrograms (at 0.70 mcg/kg)

Sufentanil volume (including extra 0.1 ml for dead space)*

3-5 kg

--use fentanyl--

--use fentanyl--

6-10 kg

--use fentanyl--

--use fentanyl--

11-15 kg 

--use fentanyl--

--use fentanyl--

16-20 kg 

14 mcg

0.3 +0.1 ml

21-25 kg 

18 mcg

0.35 + 0.1 ml

26-30 kg 

21 mcg

0.40 + 0.1 ml

31-35 kg 

25 mcg

0.5 + 0.1 ml

36-40 kg 

28 mcg

0.55 + 0.1 ml

41-45 kg

32 mcg

0.65 + 0.1 ml

46-50 kg

35 mcg

0.70 + 0.1 ml

51-55 kg

39 mcg

0.8 + 0.1 ml

56-60 kg

42 mcg

0.85 + 0.1 ml

61-70 kg

49 mcg

1.0 + 0.1 ml

71-80 kg

56 mcg

1.1 + 0.1 ml **

81-90 kg

63 mcg

1.3 + 0.1 ml **

91-100 kg

70 mcg

1.4 + 0.1 ml **

   

*The volumes are rounded up to the nearest 0.05 ml and you should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.1 ml represents a typical dead space in a 1 ml syringe connected to a syringe driven atomizer.

It is best to use a 1 ml syringe to draw up this drug so you get accurate measurements.

** If the volume exceeds 1 ml, you will need to simply administer a lower mcg/kg dose (just give the entire 50 mcg vial) and re-assess in 10 -12 minutes at which point you can administer additional medication from a second vial. You may also simply obtain a second vial and a second syringe (or draw it up in a 3 ml syringe) at the outset and administer the entire volume at once– you can switch a nasal atomizer from one syringe to the second syringe.

Small Children should probably have fentanyl used rather than sufentanil to simplify the dosing volumes.

Intranasal Diamorphine dosing table

Diamorphine is supplied as a powder and needs to be re-concentrated in a diluent prior to administration.  The following link will connect you to a web site that provides directions for reconstitution. Be aware that this link assumes you will be administering the drug to one nostril and that you will use a dropper to administer the medication. If you use an atomizer you must add the additional dead space of the device or you risk under dosing the patient

Leeds Hospital Intranasal Diamorphine reconstitution and dosing protocol (click here).

The Leeds protocol assumes you will drip the drug into the patients nose. If you use an atomizer, be sure to ADD the system dead space to the total volume you draw into the syringe or you will may under dose the patient.

Download IN fentanyl photo guide as PDF file (click here)

Download IN sufentanil photo guide as PDF file (click here)