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HPM Journal Club: Intranasal Fentanyl in Symptom Management for Newborns and Infants at End of Life
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
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?