"What Is Fentanyl?" by Sherry Norman, RNC, BSN, CCRN, CLNC

FENTANYL SUBLIMAZE




CATEGORY:  Analgesic, Narcotic, General Anesthetic

BRAND NAMES: Actiq®; Duragesic®; Sublimaze®

USE:  
Fentanyl is used for sedation, relief of pain, preoperative medication, adjunct to general or regional anesthesia, management of chronic pain (transdermal product)
Actiq® is indicated only for management of breakthrough cancer pain in patients who are tolerant to and currently receiving opioid therapy for persistent cancer pain

Patients are considered opioid tolerant if they are receiving at least 60 mg/day of morphine, 50 mcg/hour of transdermal fentanyl, or an equivalent dose of another opioid for 1 week or longer.

 

MECHANISM OF ACTION
Fentanyl Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain pathways.   Fentanyl binds to brain receptors, relieving pain. It decreases the feeling of pain and a person's response to pain
Fentanyl is 50-100 times as potent as morphine; morphine 10 mg I.M. = fentanyl 0.1-0.2 mg I.M.; fentanyl has less hypotensive effects than morphine or meperidine due to minimal or no histamine release

PHARMACODYNAMICS – KINETICS:  
Respiratory depressant effect may last longer than analgesic effect
Onset of action: Analgesia:
  I.M.: 7-15 minutes
  I.V.: Almost immediate
  Transdermal: 6-8 hours
  Transmucosal: 5-15 minutes
Maximum effect:
  Transdermal: 24 hours
  Transmucosal: 20-30 minutes
Duration:
  I.M.: 1-2 hours
  I.V.: 30-60 minutes
  Transdermal: 72 hours
  Transmucosal: 1-2 hours
Absorption: Transmucosal: Rapid, approximately 25% from the buccal mucosa; 75% swallowed with saliva and slowly absorbed from GI tract
Distribution: Highly lipophilic, redistributes into muscle and fat
Metabolism: Hepatic
Excretion: Urine (primarily as metabolites, 10% as unchanged drug)
Half-life elimination:
  Children 5 months to 4.5 years: Mean: 2.4 hours
  Children 0.5-14 years (after long-term continuous infusion): approximately 21 hours (range: 11-36 hours)
  Adults: I.V.: 2-4 hours
    Transdermal: 17 hours (range: 13-22); apparent half-life increased with transdermal due to continued absorption
    Transmucosal: 6.6 hours (range: 5-15 hours)
Elimination: In urine primarily as metabolites and less than 10% as unchanged drug
  Clearance: Newborn infants: Clearance may be significantly correlated to gestational age and birth weight (Saarenmaa, 2000)

STABILITY
Commercially available fentanyl citrate injections should be protected from light and stored at room temperatures of 15–30°C; brief exposure to temperatures up to 40°C does not adversely affect the injection. Fentanyl citrate is hydrolyzed in acidic solutions.
Fentanyl citrate is reportedly physically incompatible with methohexital sodium, pentobarbital sodium, or thiopental sodium, but the compatibility depends on several factors (e.g., concentrations of the drugs, specific diluents used, resulting pH, temperature). Specialized references should be consulted for specific compatibility information.

ADMINISTRATION ROUTES:
 
PARENTERAL:
I.V.: Administer by slow I.V. push over 3-5 minutes or by continuous infusion; larger bolus doses (>5 mcg/kg) should be given slow I.V. push over 5-10 minutes
I.V.: Muscular rigidity may occur with rapid I.V. administration. During prolonged administration, dosage requirements may decrease.
Injection, solution, as citrate [preservative free]: 0.05 mg/mL available in 2 mL, 5 mL, 10 mL, 20 mL, 30 mL, 50 mL vials
 
 
TRANSDERMAL:
Apply to non-irritated and non-irradiated skin, such as chest, back, flank, or upper arm. Upper back is preferred location in children. Do not shave skin; hair at application site should be clipped. Prior to application, clean site with clear water and allow to dry completely. Do not cut patch. Apply patch immediately after removing from package. Firmly press in place and hold for 30 seconds. Change patch every 72 hours.
Keep transdermal product (both used and unused) out of the reach of children. Do not use soap, alcohol, or other solvents to remove transdermal gel if it accidentally touches skin, as they may increase transdermal absorption; use copious amounts of water. Avoid exposing application site to external heat sources (eg, heating pad, electric blanket, heat lamp, hot tub).
Transdermal system (Duragesic®) is available in the following dosages:  
25 mcg/hour [10 cm2] (5s); 50 mcg/hour [20 cm2] (5s); 75 mcg/hour [30 cm2]; 100 mcg/hour [40 cm2] (5s)

TRANSMUCOSAL:
Foil overwrap should be removed just prior to administration. Once removed, patient should place the unit in mouth and allow it to dissolve. Do not chew.
Actiq® units may be occasionally moved from one side of the mouth to the other. The unit should be consumed over a period of 15 minutes. Unit should be removed after it is consumed or if patient has achieved an adequate response and/or shows signs of respiratory depression.
For patients who have received transmucosal product within 6-12 hours, it is recommended that if other narcotics are required, they should be used at starting doses 1/4 to 1/3 those usually recommended.
Lozenge, oral transmucosal, as citrate [mounted on a plastic radiopaque handle] (Actiq®) is available in the following dosages:  200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg [raspberry flavor]


DOSING FOR ADULTS:  — Note: These are guidelines and do not represent the maximum doses that may be required in all patients. Doses should be titrated to pain relief/prevention. Monitor vital signs routinely. Single I.M. doses have a duration of 1-2 hours, single I.V. doses last 0.5-1 hour.

Pre-medication: I.M., slow I.V.: 50-100 mcg/dose 30-60 minutes prior to surgery
Adjunct to regional anesthesia: I.M., slow I.V.: 50-100 mcg /dose; if I.V. used give over 1-2 minutes
Severe pain: I.M.: 50-100 mcg/dose every 1-2 hours as needed; patients with prior opiate exposure may tolerate higher initial doses
Adjunct to general anesthesia: Slow I.V.:
  Low dose: Initial: 2 mcg/kg/dose; Maintenance: Additional doses infrequently needed
  Moderate dose: Initial: 2-20 mcg/kg/dose; Maintenance: 25-100 mcg/dose may be given slow I.V. or I.M. as needed
  High dose: Initial: 20-50 mcg/kg/dose; Maintenance: 25 mcg to one-half the initial loading dose may be given as needed
General anesthesia without additional anesthetic agents: Slow I.V.: 50-100 mcg/kg with oxygen and skeletal muscle relaxant
Mechanically-ventilated patients (based on 70 kg patient): Slow I.V.: 0.35-1.5 mcg/kg every 30-60 minutes as needed; infusion: 0.7-10 mcg/kg/hour
Patient-controlled analgesia (PCA): I.V.: Usual concentration: 50 mcg/mL
  Demand dose: Usual: 10 mcg; range: 10-50 mcg
  Lockout interval: 5-8 minutes
Breakthrough cancer pain: Transmucosal: Actiq® dosing should be individually titrated to provide adequate analgesia with minimal side effects. It is indicated only for management of breakthrough cancer pain in patients who are tolerant to and currently receiving opioid therapy for persistent cancer pain. An initial starting dose of 200 mcg should be used for the treatment of breakthrough cancer pain. Patients should be monitored closely in order to determine the proper dose. If re-dosing for the same episode is necessary, the second dose may be started 15 minutes after completion of the first dose. Dosing should be titrated so that the patient's pain can be treated with one single dose. Generally, 1-2 days is required to determine the proper dose of analgesia with limited side effects. Once the dose has been determined, consumption should be limited to 4 units/day or less. Patients needing more than 4 units/day should have the dose of their long-term opioid re-evaluated. If signs of excessive opioid effects occur before a dose is complete, the unit should be removed from the patient's mouth immediately, and subsequent doses decreased.
Pain control: Transdermal: Initial: 25 mcg/hour system; if currently receiving opiates, convert to fentanyl equivalent and administer equianalgesic dosage titrated to minimize the adverse effects and provide analgesia. Change patch every 72 hours.
The dosage should not be titrated more frequently than every 3 days after the initial dose or every 6 days thereafter. The majority of patients are controlled on every 72-hour administration, however, a small number of patients require every 48-hour administration.

DOSING THE ELDERLY PATIENT:
Elderly have been found to be twice as sensitive as younger patients to the effects of fentanyl. A wide range of doses may be used. When choosing a dose, take into consideration the following patient factors: age, weight, physical status, underlying disease states, other drugs used, type of anesthesia used, and the surgical procedure to be performed.
Transmucosal: Dose should be reduced to 2.5-5 mcg/kg. Suck on lozenge vigorously approximately 20-40 minutes before the start of procedure.

DOSING THE HEPATIC IMPAIRMENT:
Actiq®: Although fentanyl kinetics may be altered in hepatic disease, Actiq® can be used successfully in the management of breakthrough cancer pain. Doses should be titrated to reach clinical effect with careful monitoring of patients with severe hepatic disease.

DOSING FOR PEDIATRICS:  — Note: These are guidelines and do not represent the maximum doses that may be required in all patients. Doses should be titrated to pain relief/prevention. Monitor vital signs routinely. Single I.M. doses have a duration of 1-2 hours, single I.V. doses last 0.5-1 hour.

CHILDREN 1-12 YEARS:
  Sedation for minor procedures/analgesia: I.M., I.V.: 1-2 mcg/kg/dose; may repeat at 30- to 60-minute intervals. Note: Children 18-36 months of age may require 2-3 mcg/kg/dose

  Continuous sedation/analgesia: Initial I.V. bolus: 1-2 mcg/kg then 1 mcg/kg/hour; titrate upward; usual: 1-3 mcg/kg/hour

  Pain control: Transdermal:
 
Children >2 years who are opioid tolerant: Initial dose: 25 mcg/hour system (higher doses have been used based on equianalgesic conversion); change patch every 72 hours
 CHILDREN >12 YEARS AND ADULTS:
 Sedation for minor procedures/analgesia: I.V.: 0.5-1 mcg/kg/dose; may repeat after 30-60 minutes; or 25-50 mcg, repeat full dose in 5 minutes if needed, may repeat 4-5 times with 25 mcg at 5-minute intervals if needed. Note: Higher doses are used for major procedures.

  Preoperative sedation, adjunct to regional anesthesia, postoperative pain: I.M., I.V.: 50-100 mcg/dose

 Adjunct to general anesthesia: I.M., I.V.: 2-50 mcg/kg

 NEONATES AND YOUNGER INFANTS:
 Sedation/analgesia: Slow I.V. push: 1-4 mcg/kg/dose; may repeat every 2-4 hours

Continuous sedation/analgesia: Initial I.V. bolus: 1-2 mcg/kg, then 0.5-1 mcg/kg/hour; titrate upward

 Mean required dose: Neonates with gestational age <34 weeks: 0.64 mcg/kg/hour; neonates with gestational age  34 weeks: 0.75 mcg/kg/hour

Continuous sedation/analgesia during ECMO: Initial I.V. bolus: 5-10 mcg/kg slow I.V. push over 10 minutes, then 1-5 mcg/kg/hour; titrate upward; tolerance may develop; higher doses (up to 20 mcg/kg/hour) may be needed by day 6 of ECMO
Neonates: Analgesia: International Evidence-Based Group for Neonatal Pain recommendations (Anand, 2001):  
 Intermittent doses: Slow I.V. push: 0.5-3 mcg/kg/dose.  
 Continuous infusion: 0.5-2 mcg/kg/hour


SIGNIFICANT ADVERSE REACTIONS:  
LESS THAN 10% OF PATIENTS MAY EXPERIENCE:
  Cardiovascular: Bradycardia, hypotension, peripheral vasodilation
  Central nervous system: Drowsiness, sedation, increased intracranial pressure
  Gastrointestinal: Nausea, vomiting
  Endocrine & metabolic: Antidiuretic hormone release
  Neuromuscular & skeletal: Chest wall rigidity (high dose I.V.) – ESPECIALLY FOLLOWING RAPID IF ADMINISTRATION
  Ocular: Miosis
1% to 10% OF PATIENTS MAY EXPERIENCE:
  Cardiovascular: Cardiac arrhythmias, orthostatic hypotension
  Central nervous system: Confusion, CNS depression
  Gastrointestinal: Constipation
  Ocular: Blurred vision
  Respiratory: Apnea, postoperative respiratory depression
LESS THAN 1% (LIMITED TO IMPORTANT OR LIFE-THREATENING): Bronchospasm, convulsions, hypercarbia, laryngospasm, respiratory depression
OTHER:
Cardiovascular:  flushing
Cns - euphoria
Dermatologic: erythema, pruritus, facial pruritus with oral transmucosal product
Gastrointestinal:  biliary tract spasm
Genitourinary:  urinary tract spasm

MISCELLANEOUS:
Physical and psychological dependence with prolonged use. Note: Neonates who receive a total fentanyl dose >1.6 mg/kg or continuous infusion duration >5 days are more likely to develop narcotic withdrawal symptoms; children 1 week to 22 months: those who receive a total dose of 1.5 mg/kg or duration >5 days have a 50% chance of developing narcotic withdrawal and those receiving a total dose >2.5 mg/kg or duration of infusion >9 days have a 100% chance of developing withdrawal. Doses should be tapered to prevent withdrawal symptoms.

Below is a chart of the occurance of adverse reactions from “First Databank”
 
Adverse Effects List from First Databank         

More Frequent

BRADYCARDIA
severe

DROWSINESS

HYPOTENSION
severe

NAUSEA

RESPIRATORY DEPRESSION
severe

VOMITING

Less Frequent

CARDIAC ARRHYTHMIAS
severe

Rare or Very Rare

ALLERGIC DERMATITIS
severe

BILIARY SPASM

BLURRED VISION

BRONCHOSPASM, ALLERGIC
severe

CHILLS

CIRCULATORY DEPRESSION
severe

CNS DEPRESSION

CNS EXCITATION
severe

CONFUSION, POSTOPERATIVE
severe

CONSTIPATION

CONVULSIONS
severe

DELIRIUM
severe

DOUBLE VISION

HIVES
severe

ITCHING
severe

LARYNGOSPASM
severe

MENTAL DEPRESSION
severe

ORTHOSTATIC HYPOTENSION

PARESTHESIA
severe

SKIN RASH
severe

URETERAL SPASM

VISION CHANGES


     (MEDSCAPE 2004)

CONTRAINDICATIONS:  
Hypersensitivity to fentanyl or any component of the formulation; increased intracranial pressure; severe respiratory depression; severe liver or renal insufficiency; pregnancy (prolonged use or high doses near term)
Actiq® must not be used in patients who are intolerant to opioids. Patients are considered opioid-tolerant if they are taking at least 60 mg morphine/day, 50 mcg transdermal fentanyl/hour, or an equivalent dose of another opioid for greater than or equal to 1 week.

NURSING IMPLICATIONS
An opioid antagonist, resuscitative and intubation equipment, and oxygen should be available; rapid I.V. injection may result in apnea.
Patients with elevated temperature may have increased fentanyl absorption transdermally, observe for adverse effects, dosage adjustment may be needed; pharmacologic and adverse effects can be seen after discontinuation of transdermal system, observe patients for at least 12 hours after transdermal product removed; destroy unused portion of Actiq® according to hospital policy on controlled substances; partial unused doses of Actiq® can be dissolved under hot running tap water; dispose of handle properly

PATIENT TEACHING INFORMATION:
Patients should be instructed to Avoid alcohol and the herbal medicine St John's Wort; may cause drowsiness and impair ability to perform activities requiring mental alertness or physical coordination;
Fentanyl may be habit-forming; avoid abrupt discontinuation after prolonged use;
an Actiq® Welcome Kit, containing educational materials and safe storage containers (to keep medication away from children), as well as a patient safety video, is available from the manufacturer; these can be obtained by healthcare professionals who call 1-800-896-5855;
dispose of transmucosal and transdermal products properly; keep all products (even if used) out of the reach of children;  keep transmucosal and transdermal products (both used and unused) out of the reach of children; special child-resistant containers are available to temporarily store partially-consumed units that cannot be disposed of immediately  see Actiq® Patient Leaflet for details on proper storage, administration, and disposal of Actiq®, as well as, instructions about overdose management. Frequent use of Actiq® may increase risk of dental caries; consult dentist for appropriate oral hygiene. Diabetic patients should note that Actiq® contains 2 grams of sugar/unit (about 1/2 teaspoon of sugar).


WARNINGS & PRECAUTIONS:
Fentanyl is An opioid-containing analgesic.  The dosing regimen should be tailored to each patient's needs and based upon the type of pain being treated (acute versus chronic), the route of administration, degree of tolerance for opioids (naive versus chronic user), age, weight, and medical condition.
The optimal analgesic dose varies widely among patients. Doses should be titrated to pain relief/prevention. Fentanyl shares the toxic potentials of opiate agonists, and precautions of opiate agonist therapy should be observed;
Fentanyl should be used with caution in patients with bradycardia; rapid I.V. infusion may result in skeletal muscle and chest wall rigidity leading to respiratory distress and/or apnea, bronchoconstriction, laryngospasm;
Inject slowly over 3-5 minutes; non-depolarizing skeletal muscle relaxant may be required.
Tolerance of drug dependence may result from extended use. The elderly may be particularly susceptible to the CNS depressant and constipating effects of narcotics.
Actiq® should be used only for the care of cancer patients and is intended for use by specialists who are knowledgeable in treating cancer pain. For patients who have received transmucosal product within 6-12 hours, it is recommended that if other narcotics are required, they should be used at starting doses 1/4 to 1/3 those usually recommended. Actiq® preparations contain an amount of medication that can be fatal to children. Keep all units out of the reach of children and discard any open units properly. Patients and caregivers should be counseled on the dangers to children including the risk of exposure to partially consumed units. Safety and efficacy have not been established in children <16 years of age.
Topical patches: Serum fentanyl concentrations may increase approximately one-third for patients with a body temperature of 40ºC secondary to a temperature-dependent increase in fentanyl release from the system and increased skin permeability.
Patients who experience adverse reactions should be monitored for at least 12 hours after removal of the patch. Safety and efficacy of transdermal system have been limited to children >2 years of age who are opioid tolerant.

PRECAUTIONS:
Use with caution in patients with bradycardia, hepatic, renal, or respiratory disease or those with increased ICP, head injuries, or impaired consciousness; patients must be monitored until fully recovered;
Decrease dose in patients with hepatic and/or renal disease; not recommended if patient received MAO inhibitors within 14 days;
Use of transdermal system is not recommended in children less than 12 years or those less than 18 years who weigh less than 50 kg;
Frequent use of Actiq® may increase risk of dental caries; Actiq® contains 2 g of sugar/unit; inform diabetic patients of sugar content
WARNINGS:
Physical and psychological dependence may occur with prolonged use; abrupt discontinuation may result in withdrawal or seizures. Symptoms of opioid withdrawal may occur in patients after conversion of one dosage form to another or after dosage adjustment.


DRUG/FOOD INTERACTIONS:
CNS depressants: Increased sedation when used with CNS depressants, phenothiazines
CYP3A4 inhibitors: May increase the levels/effects of fentanyl. Example inhibitors include azole antifungals, ciprofloxacin, clarithromycin, diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone, nicardipine, propofol, protease inhibitors, quinidine, and verapamil.
MAO inhibitors: Not recommended to use Actiq® within 14 days. Severe and unpredictable potentiation by MAO inhibitors has been reported with opioid analgesics.
ETHANOL / NUTRITION / HERB INTERACTIONS:

Ethanol: Avoid ethanol (may increase CNS depression).
Food: Glucose may cause hyperglycemia.
Herb/Nutraceutical: St John's Wort may decrease fentanyl levels. Avoid valerian, St John's Wort, Kava Kava, Gotu Kola (may increase CNS depression).
PREGNANCY IMPLICATIONS:
Fentanyl crosses the placenta and has been used safely during labor. Chronic use during pregnancy has shown detectable serum levels in the newborn with mild opioid withdrawal (case report).
LACTATION — Enters breast milk/not recommended (AAP rates "compatible")
BREAST-FEEDING CONSIDERATIONS — Fentanyl is excreted in low concentrations into breast milk. Breast-feeding is considered acceptable following single doses to the mother; however, no information is available when used long-term.
DIETARY CONSIDERATIONS:
Glucose may cause hyperglycemia; monitor blood glucose concentrations. Actiq® contains 2 g sugar per unit.
MONITORING PARAMETERS:
Respiratory and cardiovascular status, blood pressure, heart rate. oxygen saturation, bowel sounds and abdominal distention.  
TOXICOLOGY / OVERDOSE COMPREHENSIVE:
Symptoms include CNS depression, respiratory depression, and miosis. Overdose treatment includes airway support, establishment of an I.V. line, and administration of naloxone 2 mg I.V. (0.01 mg/kg for children), with repeat administration as necessary, up to a total of 10 mg.


SAMPLE PATIENT EDUCATION SHEET
 

PATIENT EDUCATION — Actiq® preparations contain an amount of medication that can be fatal to children. Keep all units out of the reach of children and discard any open units properly. Actiq® Welcome Kits are available which contain educational materials, safe storage and disposal instructions

PATIENT WARNING:  This warning is for Actiq® only. It is for cancer pain that is poorly treated by other pain medicines. It is not to be used for pain caused by surgery. Keep away from children.
REASONS PATIENTS SHOULD NOT TAKE THIS MEDICINE
    If you have an allergy to fentanyl or any other part of this medicine.

    Tell healthcare provider if you are allergic to any medicine. Make sure to tell about the allergy and how it affected you. This includes telling about rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other symptoms involved.

    If you have any of the following conditions: Increased pressure in your brain, kidney disease, liver disease, or severe lung disease.
PURPOSE OF THIS MEDICINE:
    This medicine is used to relieve pain.
HOW TO TAKE THIS MEDICINE:
All forms:
    Drink plenty of non-caffeine containing liquid unless told to drink less liquid by healthcare provider.
Skin patch:
    Apply patch to clean, dry, healthy skin on the chest, back, upper leg, or upper arm.

    Clip hair at site before putting patch on. Do not shave.

    Move patch site with each patch.
Lollipop:
    Place lollipop in your mouth between the cheek and lower gum.

    Suck lollipop. Do not chew, break, or crush.
IF YOU MISS A DOSE:  
    Use a missed dose as soon as possible.

    If it is almost time for the next dose, skip the missed dose and return to your regular schedule.

    Many times this medicine is taken on an as needed basis.
PRECAUTIONS WHEN TAKING THIS MEDICINE:
    This medicine may be habit-forming with long-term use.

    If you are 65 or older, use this medicine with caution. You could have more side effects.

    Check medicines with healthcare provider. This medicine may not mix well with other medicines.

    You may not be alert. Avoid driving, doing other tasks or activities until you see how this medicine affects you.

    Avoid alcohol (includes wine, beer, and liquor) or other medicines and natural products that slow your actions and reactions. These include sedatives, tranquilizers, mood stabilizers, antihistamines, and other pain medicine.

    Tell healthcare provider if you are pregnant or plan on getting pregnant.

    Tell healthcare provider if you are breast-feeding.
THE COMMON SIDE EFFECTS OF THIS MEDICINE INCLUDE:  
    Feeling lightheaded, sleepy, having blurred vision, or a change in thinking clearly. Avoid driving, doing other tasks or activities that require you to be alert or have clear vision until you see how this medicine affects you.

    Nausea or vomiting. Small frequent meals, frequent mouth care, sucking hard candy, or chewing gum may help.

    Constipation. More liquids, regular exercise, or a fiber-containing diet may help. Talk with healthcare provider about a stool softener or laxative.
THE FOLLOWING ARE THINGS YOU SHOULD MONITOR AND REPORT TO YOUR HEALTHCARE PROVIDER
    Change in condition being treated. Is it better, worse, or about the same?

    Keep a diary of pain control.

    Bowel movements.
REASONS TO CALL HEALTHCARE PROVIDER IMMEDIATELY
       If you suspect an overdose, call your local poison control center immediately or dial 911.

    Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat.

    Severe dizziness or passing out.

    Difficulty breathing.

    Significant change in thinking clearly and logically.

    Poor pain control.

    Severe nausea or vomiting.

    Severe constipation.

    Feeling extremely tired or weak.

    Any rash.

    No improvement in condition or feeling worse.
HOW TO STORE THIS MEDICINE:
    Store at room temperature. Do not freeze.

    Throw away any unused lollipops in a sealed container away from children and pets.
GENERAL STATEMENTS
       If you have a life-threatening allergy, wear an allergy identification bracelet at all times.

    Do not share your medicine with others and do not take anyone else's medicine.

    Keep all medicine out of the reach of children and pets.

    Keep a list of all your medicines (prescription, natural products, supplements, vitamins, over-the-counter) with you. Give this list to healthcare provider (doctor, nurse, nurse practitioner, pharmacist, physician assistant).

    Talk with healthcare provider before starting any new medicine, including over-the-counter, natural products, or vitamins.







REFERENCES:



1.  AHFS – American Society of Health Systems Pharmacists Drug Information, 2004; p 2036 – 2041.

2.  Medscape:  First Databank – Adverse effects list Fentanyl, 2004

3.  Skidmore – Roth, Mosby’s Nursing Drug Reference, 2004, p 438 – 442.

4.  UpToDate:  Fentanyl  Drug Information @ http://www.utdol.com/fentanyl




OBJECTIVES:



THE LEARNER WILL BE ABLE TO:

Identify the use, mechanism of action and common doses of Fentanyl with adult, pediatric, neonatal and elderly considerations.

Identify adverse reactions to Fentanyl including food and drug interactions.

Identify monitoring parameters for patients receiving Fentanyl.  


FENTANYL POST TEST
One Contact Hour awarded upon passing the post test with at least a 70% score


1. Sublimaze / Fentanyl is a drug classified as a/an:
A. Narcotic / analgesic
B. Subliminal message for pain control
C. Anti-inflammatory
D. Opoid antagonist


2. Fentanyl is:
A. Deposited in the muscle and eliminated with fat.
B. Metabolized in the buccal mucosa with hepatic elimination
C. Metabolized in the liver and excreted in the urine
D. Metabolized in the saliva and excreted in the urine


3. Administration routes for Fentanyl include all except:
A. transmucosal
B. rapid IV push
C. IM
D. Transdermal


4. Pediatric / neonatal initial IV bolus of Fentanyl with continuous IV sedation analgesia is:
A. 1 - 2 mg/kg
B. 0.5 - 1 mg/kg
C. 1 – 2 meq/kg
D. 0.5 – 1 meq/kg


5. Significant adverse reactions to Fentanyl include all except:
A. Increased intracranial pressure
B. Chest wall rigidity – especially with rapid IV high dose administration
C. Bradycardia
D. Thyroid stimulating hormone release


6. The transmucosal form of Fentanyl is known as:
A. The all day sucker
B. The welcome kit
C. Actiq
D. St. John’s wort


7. Abrupt withdrawal from prolonged use of Fentanyl may result in:
A. Further dependency
B. Seizures
C. CNS depression
D. Skeletal muscle / chest wall rigidity


8. The following herbs when used with Fentanyl may increase CNS depression except:
A. St. John’s wort
B. Kava kava
C. Gotu kola
D. all of the above


9. Monitoring parameters for patients on Fentanyl include:
A. Respiratory / neurological / cardiovascular status
B. Blood pressure, heart rate and urine ketones
C. Oxygen saturation and cardiac enzymes
D. Basal metabolic rate and eating patterns.


10. Rapid IV infusion of Fentanyl may result in skeletal muscle and chest wall rigidity – leading to respiratory distress, apnea, broncho-constriction and / or laryngospasm:
A. True
B. False

RealNurseEd.com

(Cynthia F. Cramer, BA, RN, OCN)

Participant Self-Learning Program Evaluation

The information below is required before contact hours can be given.

Program Title:
 

"What Is Fentanyl?"

Date: (month / day / year)

Nursing License Number:

State

Name:

Complete E-mail address ( example: nurse@aol.com ) :

Your feedback is valued and will assist in improving this program. Please explain ratings of 2 or 1.

Ratings: 5 = Excellent 4 = Very Good 3 = Good 2 = Fair 1 = Poor

1.   Objectives of program were clear.54321

2.   Objectives were met. 1

3.   Time allotted was adequate 5431

4.   Author’s Knowledge of  subject matter5431

5.   Efficient Method of Instruction54321

6.   Provided for material review 531

7.   Program expectations satisfied 51

8.   Organization/readability of program 531

9.   Test correlated with objectives41

10.  Would you recommend this Self-Learning Program to another student?yesno

11. One contact hour should take approximately 50-60 minutes to complete.
If you read all the material, did the practice problems, and took both tests - Do you
feel this program was in the one hour range? yesno

11a. If not - please explain.

12. What could have improved the program?

13. Any suggestions for future Self-Learning Programs?

14. Would you utilize another Self-Learning experience by this instructor?yesno

      14a. Why or why not?

15. Was the cost reasonable? (if applicable) yesno

       15a. If not--what would you suggest?

16. Any other comments?