Intranasal Fentanyl Use in Neonates

Abstract

Background: The recent addition of intranasal medication options for procedural sedation and analgesia has decreased the need for additional painful procedures such as intravenous lines for medication administration. Intranasal fentanyl (INF) has been used in the prehospital setting, as well as in the emergency department for several years, and is increasingly utilized in other locations such as the neonatal intensive care unit (NICU). A paucity of data exists in these smallest children, so we sought to explore trends in INF use in our NICU. Objective: The objective of the study was to describe INF use in the NICU from December 2014 to December 2017. Design/Methods: A retrospective cohort study was conducted of patients receiving INF in the NICU of a large free-standing quaternary inner-city children’s hospital from December 2014 to 2017. Demographic data were abstracted from the medical record including gestational age on administration, post-menstrual age, day of life on administration, sex, medication initial and total dose, reported indication, and documented adverse events. This study was approved by our local institutional review board. Results: A total of 54 patients received a total of 67 INF administrations: 32 women (59%), median day of life on administration = 57.1 (interquartile range [IQR] = 33.7-110.4), median weeks gestation = 26.0 (IQR = 24.1-36.1), post-menstrual age = 38.1 weeks (IQR = 33.1-45.4). Initial doses of medications were 1.49 µg/kg/dose INF (range = 0.5-2 µg/kg). Conclusions: Intranasal adjuncts are increasingly used in the NICU. Starting dose of INF is 1.5 µg/kg/dose, and typically, one dose is given.

Intranasal Fentanyl for Procedural Analgesia in Preterm Infants

“…Sucrose was administered to all patients in conjunction with IN fentanyl in the study by McNair et al (13) and IN midazolam was administered concurrently with IN fentanyl in almost half of the 67 events in the study by Kaushal et al (14). No major adverse events were attributed to IN fentanyl use in the published studies (12)(13)(14)(15).…”

“…Four retrospective studies on the use of IN fentanyl in newborns and infants have been published thus far (12)(13)(14)(15) (Table 1). Except for the study by Harlos et al that prescribed IN fentanyl in the palliative care setting (12), the remaining studies evaluated its use for procedural pain in the NICU (13)(14)(15). The sample size in these studies ranged from 2 to 54 patients with mean/median gestational age (GA) at birth ranging from 26 to 35 weeks (13)(14)(15).…”

“…Except for the study by Harlos et al that prescribed IN fentanyl in the palliative care setting (12), the remaining studies evaluated its use for procedural pain in the NICU (13)(14)(15). The sample size in these studies ranged from 2 to 54 patients with mean/median gestational age (GA) at birth ranging from 26 to 35 weeks (13)(14)(15). Infants < 28 weeks GA are considered extremely preterm while those between 28 and 32 weeks GA are considered very preterm.…”

“…Infants < 28 weeks GA are considered extremely preterm while those between 28 and 32 weeks GA are considered very preterm. The most common procedures for IN fentanyl use were intubation and insertion of epicutaneo-caval catheters (13)(14)(15). The dose of IN fentanyl ranged from 0.5 to 2 µg/kg (13)(14)(15) and was administered using a mucosal atomization device in the study by McNair et al (13) or directly instilled into the infants' nares in the studies by Kaushal et al and Ku et al (14,15).…”

Management of the Unexpected Difficult Airway in Neonatal Resuscitation

“…Nasal drugs for procedural sedation and analgesia in neonates are increasing (51)(52)(53)(54)(55) and may be used as pre-medication before intubation of newborns. Milési et al compared intranasal midazolam and ketamine for neonatal intubation in pre-term neonates and found that the initial respiratory and hemodynamic tolerance of the two drugs were comparable despite 2-4 mg/kg nasal ketamine being less efficient than nasal midazolam in rapidly achieving adequate sedation for intubation (54).…”