April 5, 2024

Welcome to UH EMS-I’s Pharmacy Phriday 2024 series. In this week’s installment, we focus on the medication Fentanyl, one of the most widely used pain medications allowed within the UH “Pain Management” algorithm. In fact, Fentanyl was given nearly five times more often than the next most frequent pain medication, Hydromorphone. Not surprisingly, Fentanyl remained one of the top 10 medications administered during 2023.  

Fentanyl, a synthetic opioid, is one of the most often used pain medications for many reasons. The medication is 50-100 times more potent than morphine and other opiates. Of all the pain medications carried in our drug boxes, it is the quickest acting, has the shortest duration, and has the least side effects. It can also be administered via the IN route, making dosing quicker for most patients and, in the pediatric patient, much easier than starting a difficult IV. Additionally, the medication’s side effects can be reversed easily with the use of Naloxone.

One of the most widely discussed side effects of Fentanyl is related to respiratory depression. When administering the medication, the medic must monitor the patient for any untoward effects. Monitoring should include continuous ECG monitoring, pulse oximetry, and frequent vital signs as a minimum. Capnography is strongly recommended in most circumstances and required in many circumstances.

Per UH protocol, the dosing of Fentanyl is 25-100mcg, IV/IO/IM/IN, repeated every 10 minutes as needed, up to a max dose of 200mcg for the adult patient. In the case of a pediatric patient, the dosing is 1mcg/kg IV/IO/IM/IN, repeated every 10 minutes, up to a max of 50mcg, unless given IN, which then increases the max to 100mcg. (IN administration in the pediatric patient is still highly recommended). Fentanyl can also be found as a pharmacological intervention in cases of CPR Induced Consciousness (dosing is 100 mcg IV/IO/IM/IN, repeated as needed) and as an analgesic to be administered by the paramedic provider for drug-assisted airway or RSI procedures (a 25 mcg bolus given as needed up to a maximum of 200 mcg).   

Caution is advised when administering Fentanyl in the elderly patient or patient with known renal failure or disease. In these cases, a lower starting dose is recommended. Reduced dosing should also be considered for patients with known recent use of another CNS depressant. When administering a dose via the IV route, it should be administered slowly over 1-3 minutes as the likelihood of side effects increases with rapid administration.

One last consideration to bring attention to is the use of Fentanyl for the ACS patient. Fentanyl is known to interfere with Brilinta, and therefore, the ACS protocol suggests Aspirin and Brilinta prior to the administration of Fentanyl.

Abuse and overdose of Fentanyl continue to be of concern in our society. Still, the role of pain management for our patients should remain a priority, and protocols should be followed appropriately.

As always, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

January 27, 2023

Dear Colleagues,

Welcome to week 4 of UH’s Pharmacy Phriday 2023 series.  As we continue to review recent changes to the UH Protocols, we focus this week on one of the two medications with new, increased dosing.  One of those medications was TXA, discussed in a Monday Morning Medical Directors message earlier this month.  The new dose for TXA is now two grams. The other medication with increased dosing is Fentanyl. The increase for this medication is reflected in the maximum dose for the adult patient now being 200mcg.  Planning is still in progress as to how the increased medications will be provided in the drug boxes.  Watch for information from the pharmacy supplying your drug boxes as to how these changes will occur.

As you may recall, Fentanyl is one of the most widely used pain medications.  From statistics compiled in 2022 UH prehospital reports, Fentanyl was the choice nearly 70% of the time a pain medication was given and was within the top 10 of all medications given. 



Fentanyl, a synthetic opioid, is one of the most used pain medications for many reasons.  The medication is 50-100 times more potent than morphine and other opiates.  Of all the pain medications carried in our drug boxes, it is the quickest acting, has the shortest duration, and has the least side effects. It can also be administered via the IN route, making dosing quicker for most patients, and in the pediatric patient, much easier than starting a difficult IV.  Additionally, the medication’s side effects can be reversed easily with the use of Narcan.

One of the most widely discussed side effects of Fentanyl is related to respiratory depression. When administering the medication, the medic must be sure to monitor the patient for any untoward effects.  Monitoring should include continuous ECG monitoring, pulse oximetry, and frequent vital signs as a minimum.  Capnography is also strongly recommended.

Per UH protocol, the dosing of Fentanyl is 25-100mcg, IV/IO/IM/IN, repeated every 10 minutes as needed, now up to a max dose of 200mcg for the adult patient.  In the case of a pediatric patient, the dosing is 1mcg/kg IV/IO/IM/IN, repeated every 10 minutes, up to a max of 50mcg, unless given IN, which then increases the max to 100mcg. (IN administration in the pediatric patient is still highly recommended).  Although Fentanyl is not the preferred medication for CPR Induced Consciousness, as discussed in last week’s article, it is an option, and dosing is 100 mcg IV/IO/IM/IN and repeated as needed.   

Caution is advised when administering Fentanyl in the elderly patient or patients with known renal failure or disease, and lower starting doses are recommended.  Reduced dosing should also be considered for patients with known recent use of another CNS depressant. When administering a dose via the IV route, it should be administered slowly over 1-3 minutes as the likelihood of side effects increases with rapid administration.

Remember to consider the order of medications for the ACS patient.  Fentanyl is known to interfere with Brilinta, and therefore, the ACS protocol suggests Aspirin and Brilinta prior to the administration of Fentanyl.

Abuse and overdose of Fentanyl continue to be of concern in our society.  Research continues to attempt to find measures to address these problems, including vaccines and Narcan pumps! Still, the role of pain management for our patients should remain a priority, and protocols should be followed appropriately.

As always, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals