Presented as a part of University of Kansas Palliative Medicine Fellowship requirement, 2/20/14

1. Intranasal Fentanyl in the
Palliative Care of Newborns
and Infants
Michael Harlos et al. Journal of pain and Symptom
Management. Vol. 46 No 2. August 2013: 265-274.
Journal Club February 20, 2014
Andi Chatburn, DO

2. 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

3. Clinical Question
Is intranasal Fentanyl a safe, quick, and effective
way to relieve pain and dyspnea in infants at the
end of life?

4. 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

5. 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.

6. 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

7. 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

8. Exclusion Criteria
• Fentanyl not used:
• Increased work of breathing in the absence of
distress
• Newborns with progressive apneic episodes

9. Cases

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

11. 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

12. 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

13. Did it Change My
Practice?
• Yes!
• But how much does it cost?
• Is it practical?