Intranasal Fentanyl in the Palliative Care of Newborns

and InfantsMichael Harlos et al. Journal of pain and Symptom Management.

Vol. 46 No 2. August 2013: 265-274.

Journal Club February 20, 2014Andi Chatburn, DO

Case #1

• Baby M• 6 month old born with hypoplastic left heart• Respiratory failure, trach with vent• Frequent episodes of desat and bradycardia

over past 72 hours• Dyspneic• No IV. • Sublingual Morphine not alleviating dyspnea

Clinical Question

Is intranasal Fentanyl a safe, quick, and effective way to relieve pain and dyspnea in

infants at the end of life?

PICO• Patients: 11 neonates at end of life

• Intervention: Intranasal Fentanyl

• Comparison: sublingual morphine**not used due to poor absorption and long time to maximal concentration

• Outcome: Intranasal Fentanyl alleviated distress in dying neonates

Background

• Researchers:Palliative Care, Anesthesiology

• Why:• IN Fentanyl safe and effective in adults• No good minimally invasive method for

palliating symptoms in dying neonates• IO/UAC/UVC routes too invasive/traumatic• Peripheral IV often unobtainable.

Methods• Single Hospital• St. Boniface General Hospital, Winnipeg

• When? • Nov 2006-July 2010

• Where? • Winnipeg Regional Health Authority

• Who? • Patients admitted to Peds Palliative Care Service• 58 patient charts reviewed• 11 cases used IN Fentanyl

Inclusion Criteria

• Infants perceived to be in respiratory distress• Increased work of breathing:• Tachypnea• Nasal flaring• Grunting• Use of accessory muscles• Chest wall retractions

• Evidence of Distress:• Restlessness, irritability, crying

Exclusion Criteria

• Fentanyl not used:• Increased work of breathing in the absence of

distress• Newborns with progressive apneic episodes

Cases

Outcomes

• Primary Endpoints: control of pain • Secondary Endpoints: • Maximizes family time with infant• Minimizes medical team interruptions• Minimizes “medicalization” of death

Findings

• IN Fentanyl allowed all 11 infants to be comfortable

• 7 of the infants were able to receive care in settings that would not conventionally support the care of a dying

• No adverse events reported

Discussion• Simple administration• Clinically effective• Allows for sharing minimal time with family• Transmucosal route may buffer risk of glottic

or chest wall rigidity• Challenge: no validated tool for assessing

respiratory distress in newborns

Did it Change My Practice?

• Yes!• But how much does it cost? • Is it practical?