fentanyl

(fen' ta nil)
Actiq; Duragesic 25, 50, 75, 100; Sublimaze Pregnancy Category C Controlled Substance C-II
Drug class

Opioid agonist analgesic

Therapeutic actions

Acts at specific opioid receptors, causing analgesia, respiratory depression, physical depression, euphoria.
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 opioid analgesia Actiq: Treatment of breakthrough pain in cancer patients being treated with and tolerant to opioids Contraindicated with hypersensitivity to opioids, diarrhea caused by poisoning, acute bronchial asthma, upper airway obstruction, pregnancy. Use cautiously with bradycardia, history of seizures, lactation, renal dysfunction.

Contraindications and cautions

Available forms

Lozenge on a stick (Actiq)200, 400, 600, 800, 1,200, 1,600 mcg; transdermal25, 50, 75, 100 mcg/hr; injection0.05 mg/mL
Dosages

Individualize dosage; monitor vital signs.

ADULTS

Premedication: 0.050.1 mg IM 3060 min prior to surgery. Adjunct to general anesthesia: Total dosage is 0.0020.02 mg/kg. Maintenance dose, 0.0250.1 mg IV or IM when changes in vital signs indicate surgical stress or lightening of analgesia. With oxygen for anesthesia: Total high dose is 0.050.1 mg/kg IV; up to 0.15 mg/kg may be necessary. Adjunct to regional anesthesia: 0.050.1 mg IM or slowly IV over 12 min.

Postoperatively: 0.050.1 mg IM for the control of pain, tachypnea, or emergence delirium; repeat in 12 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.
Lozenges

Place Actiq 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.
PEDIATRIC PATIENTS 212 YR Parenteral

23 mcg/kg IV as vital signs indicate.

Transdermal

Do not exceed 15 mcg/kg.

Lozenges

515 mcg/kg transmucosal Oralets.

Pharmacokinetics
Route IV IM Transdermal Transmucosa l Onset 12 min 78 min Gradual 15 min Duration 0.51 hr 12 hr 72 hr 1 hr

Metabolism: Plasma; T1/2: 1.56 hr Distribution: Crosses placenta; may enter breast milk
IV facts

Preparation: May be used undiluted or diluted with 250 mL of D5W. Protect vials from light. Infusion: Administer slowly by direct injection, each mL over at least 1 min, or into running IV tubing. Incompatibilities: Do not mix with methohexital, pentobarbital, thiopental.
Adverse effects

CNS: Sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness, lethargy, confusion, light-headedness, nervousness, unusual dreams, agitation, euphoria, hallucinations, delirium, insomnia, anxiety, fear, disorientation, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures

CV: Palpitation, increase or decrease in BP, circulatory depression, cardiac arrest, shock, tachycardia, bradycardia, arrhythmia, palpitations Dermatologic: Rash, hives, pruritus, flushing, warmth, sensitivity to cold EENT: Diplopia, blurred vision GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency Local: Phlebitis following IV injection, pain at injection site; tissue irritation and induration (SC injection) Respiratory: Slow, shallow respiration, apnea, suppression of cough reflex, laryngospasm, bronchospasm Other: Physical tolerance and dependence, psychological dependence; local skin irritation with transdermal system

Interactions

Drug-drug Potentiation of effects when given with other CNS acting drugs or barbiturate anesthetics; decrease dose of fentanyl when coadministering Potentiation of effects may occur when given with macrolide antibiotics, ketoconazole, itraconazole, and protease inhibitors Do not administer an MAOI within 14 days of fentanyl (increased CNS effects) Drug-food Decreased metabolism and risk of toxic effects if taken with grapefruit juice; avoid this combination Drug-lab test Elevated biliary tract pressure may cause increases in plasma amylase, lipase; determinations of these levels may be unreliable for 24 hr after administration of opioids
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 dysfunction Physical: Orientation, reflexes, bilateral grip strength, affect; pupil size, vision; P, auscultation, BP; R, adventitious sounds; bowel sounds, normal output; liver and kidney function tests

Interventions

Administer to women who are nursing a baby 46 hr before the next scheduled feeding to minimize the amount in milk. 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 1020 sec, making sure the contact is complete. Must be worn continually for 72 hr. 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. Do not drink grapefruit juice while using this drug. These side effects may occur: 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.

Teaching points

Adverse effects in Italic are most common; those in Bold are life-threatening.