Transmucosal Fentanyl – A new hammer for the pain problem!

A few of us have been looking into what the correct dose of Fentanyl is for administering the drug via the transmucosal route.  I use a ton of Fentanyl in the ER via the IV route and am very comfortable with dosing the drug in this fashion and am starting to use it transnasally, but prior to just about 1 wk ago I had never even considered using the drug transmucosally.  

 

Apparently there are “Fentanyl Lollipops” available in the US (http://www.actiq.com/)  which are marketed for managing breakthrough pain in cancer patients, but some literature exists about using this route of administration in battlefield scenarios.  As such, when we were considering using this route of administration for my MD Ski Patrol/First Responder pack I was curious as to what was available in Canada.  As you may have guessed, the above lollipops are not available in Canada… However, I did find out from a pharmacist that you can get transmucosal Fentanyl tablets which would dissolve as like an sublingual Ativan would.

 

So… to find a dose I would be comfortable using….  My goal was to figure out what dose of a Fentanyl SL tablet would be useful to have in my pack for both adults and kids if I needed acute pain management and didn’t want to reach for the handy Ketamine.  Also, the fact that the drug would be in a tablet form means that I wouldn’t have to worry about it freezing quite as much as I would if carrying a liquid formulation.

This paper:

Evidence-Based Oral Transmucosal Fentanyl Citrate (OTFC) Dosing Guidelines

Lead author: Gerald M. Arnoff

Pain Medicine 2005 Vol 6, #4 pp 305-314 

Does a nice job of outlining the how to dose this medication.  There are reports of the Fentanyl Lollipops in the dosing rage of 1600 mgr being used, but that sounds like a bit of sledgehammer in my opinion.  I want a dose that I can administer to almost anyone I meet on the ski hill/backcountry with a seriously painful injury that I can re-dose as required and not be scared that I also need to carry Narcan with me as this medication only comes in a liquid formulation and again would probably freeze in my pack.

 

The literature states that when a transmucusal dose of Fentanyl is administered about 25% of the dose is rapid absorbed into the blood stream.  Not quite as fast as an IV push dose of course, but the maximum dose effect is probably around the 5 minute range.  This is fantastic as you would know if you need to re-dose the medication in a short period of time.  The remaining 75% is then absorbed though the gut mucosa and about 25% of the dose actually makes it past hepatic metabolism and into the bloodstream.  As such, if I commonly give a patient 1 mgr/kg of  IV Fentanyl for analgesia then a 100 kg patient would receive 100 mgr of Fentanyl.  As such, I would need to give 4x this dose (as only 25% is absorbed) if I was going to give it transmucosally.  Therefore, a 400 mgr dose would be perfect.

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This chart shows that a 400 mgr dose would probably lead to an equivalent dose of 4 – 8 mg of morphine, which seems to be about the perfect dose as a first bolus dose.  

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This table shows a loading dose of 400 mgr is what the authors recommend and repeating a bolus dose of 200 mgr as required.  As such, I am going to get some 200 mgr Fentanyl tabs to have in my pack so that I can give 2 tabs to an adult and 1 tab for a small adult/large child.

 

Let me know if you have any experience with any of the above or comments.

Sunshine Village Ski Patrol MD Medical Bag

I have been an active ski patroller at Sunshine Village ski resort in Banff Alberta for the past three years. As such, I have found myself in a few interesting medical scenarios which have led me to continue to think about exactly what equipment I want in my MD bag. I think of this bag as the kit that I would want with me on the ski hill and also in my car if I was to ever come upon a medical emergency on one of my adventures.  I think of this pack as a “MD First Responder” pack have intentionally not included and IV meds or IV access supplies as I feel these can be obtained by the real first responders (Fire/EMS).  Did I miss something?

DL SUNSHINE MED KIT 

Airway:

– Adult face-mask

– Pocket BVM

– King tube sz. 4 and 2 with gel and syringe

– Pocket Bougie

– # 4 ETT for surgical airway

– Scalpel 15 blade

– OPA x 2 sizes

 

Trauma:

– Trauma shears

– Angiocath 14g x 3-1/4 x 2

– Kling roll x 2

– Triangular bandage x 2

– Roll white tape x 1

– Sam splint x 1

– 4x4s x 8

 

Meds:

– Fentanyl 400ug lollipop x 4

– Ondansetron 4 mg SL tab X 4

– Lorazepam 1 mg SL tab x 4

– Epinephrine 1:1000 vial x 2

– Benadryl 25 mg x 4

– Dexamethasone 10 mg vial x 2

– Tylenol 500 mg x 4

– Ibuprofen 400 mg x 4

– ASA 81 mg x 4

– Ventolin 1 inhailer

– NTG 1 bottle

 

Lacerations:

– Dermabond x 2

– Needle 18g x 2

– Needle 25g x 2

– Lidocaine 2% x 2 vials

– Band-aids x 10

– Syringe 10cc x 2, 3cc x 2

– Prolene 4.0 x 2

 

General:

– Gloves L x 2 pairs

– Finger Oxygen Sat monitor

Photo Version of FMC Ventilator set-up points

Don’t like YOUTUBE?  Here is a photo version

1) Approach the ventilator.  Don’t be scared!  It should be on and the standby screen should be what you see.  As you can see, the standby mode of ventilation for all the ventilators is VOLUME CONTROL with a FIO2 OF 60%, RR 16, PEEP 5 and a TV of 500 ml.  Quite reasonable for some patients, but really far from optimal for many.

If you are super keen you will notice that there is a button that has NIV (NON-INVASIVE) ventilation.  Although this is what you want to set up, this really confuses the machine when you want to swap over to an INVASIVE mode once you have paralyzed the patient.  As such, I think it is easiest to use an INVASIVE mode of ventilation (SIMV) with the rate dropped down really low instead of using a pure NON-INVASIVE mode.

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2) My plan is to use a SIMV mode of ventilation with the RR dropped really low as the patient is breathing spontaneously.  As such, you want to switch the mode of ventilation from PRVC to SIMV.  Just touch the screen and you find another menu.

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3) Voila.  Look at all those choices.  There is actually THREE different SIMV choices.  Choose the SIMV (Volume Control) with pressure support.

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4) Choosing this option brings up a bunch more options.  Touch the SIMV RATE and bring it down to it’s lowest setting.

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5) Hit the ACCEPT button
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6) Then push the POWER/GO button on the bottom of the vent to fire up the settings you just chose.

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7) Sweet.  Now your sick patient is getting some awesomely controlled and supported breaths.  They can breath as fast as they want and each breath is going to be delivered.  The could have a RR of 30 or 60 with these settings.  You may want to play with the inspiratory time if you think the patient is receiving the breaths too fast and a larger tidal volume if you feel there is a large mask leak and/or the pressures you are seeing on the graph are getting high.  However, this really isn’t going to be on the patient for too long so these settings are really a starting point and you can’t do your fine tuning once they are intubated.  If you have the end-tidal on the patient you can also see what this is reading to get an estimate of their really venous CO2.  If you see this number climbing you are not matching their demand and will need to increase the tidal volume.

8) Here is a simulated screen shot of a wicked sick patient with a RR of 42 who is breathing on their own. That little pink bar on the second graph shows you that all these breaths are trigged by the patient.
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9) So you push your induction agent +/- paralytic.  Some people would take the mask off the patient as they are concerned about ventilating the patient when their airway isn’t protected and distending the stomach.  The feeling is by some that this is such a controlled way of moving air as compared to a BVM that the risks of the patient becoming hypercarbic is much higher than the patient having some gastric distension.  This isn’t the case for all patients, but for critically ill acidotic patients I would most definitely keep this on.  To not over do it however, the feeling is you can move their SIMV Rate up to 12 or so.
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10)  Finally, your PGY 1 has passed the ETT and you have confirmed end-tidal CO2. Now dial the SIMV rate WAY up to match their pre-intubation rate.  This photo shows the rate at 30.
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10) High Fives all around!

Safe Travels,

DL

Delayed Sequence Intubation and/or Bipap before Induction and Paralysis

Delayed Sequence Intubation and/or Bipap before Induction and Paralysis

So, you have probably heard about or even done both of the the above.

Where you might have heard it from
a) Intubating a patient with severe acidosis
http://emcrit.org/podcasts/tube-severe-acidosis/

b) Delayed Sequence Intubation
http://emcrit.org/podcasts/dsi/

We recently had a FMC Sim session where it was quite clear that getting this actually done was something I should review. So I thought I could put together a quick email with some photos and a video you can check out and comment on if you are interested as well.

1) To “BIPAP” a patient we are basically talking about providing a patient with an amount of pressure support when they inspire and an amount of PEEP when they exhale.  We almost always ask the RT’s to bring a “BIPAP” machine to the bedside as we don’t seem to use the actual ventilator to do this.  Why is this???  Mainly because these machines do BIPAP really well, the are simple to use and they are also portable, meaning they can be hooked up to an bottle of oxygen and the patient can be transported while being BIPAP’ed where as this can’t be done with the large ventilators.  The downside is that they are really large and take up a lot of real-estate in the trauma bays and such.
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FMC BIPAP MACHINE

2) You may not know that you need to use a special mask with the BIPAP machine!  I don’t mean that it is special in the fact that it is nice and soft and needs to be on the patient really tightly, but there are actually two different masks for non-invasive ventilation.

BIPAP MACHINE: As you can see there is only one tube going to the patient providing air, but no return circuit.  As such, where does the patient exhale?  You MUST use a make with exhalation holes in it with this mask or the patient really can’t exhale at all other than leaking around the mask.  The photo below shows the mask the RT’s will put on the patient which has these holes or vents.

3) You most definitely can do non-invasive ventilation with the regular ventilators we have in the department.  However, you need to use a special NON-VENTED mask as the ventilator DOES have a exhalation tube that returns to the machine.  As you can see, the NON-VENTED mask has the blue nose looking thing and no holes in it.

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4) I have decided that bringing in a BIPAP machine into a code room when I have every intention to intubate them in the very near future makes not sense.  The RT’s agree with me.  As such, I have done some playing with the vent and figured out ONE of the ways of doing this.  I am sure some of you will have lots of comments on other ways of doing this as well.

5) Find a ventilator and let the RT know what you are thinking.  “I want to non-invasively ventilate this patient until I am ready to pass the ETT”.  Perhaps you are doing this for a patient with an ASA overdose or a severe DKA patient and you are really worried that if the patient becomes any more hypercarbic they really aren’t going to do well.  Or, maybe they are wild and crazy and have a severe pneumonia and you feel that they need some sedation and pre oxygenation prior to intubation.

6) Here is what the ventilators look like in standby mode.

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6) You can attache the ventilator hosing to the the NON-VENTED BIPAP mask if you wish.  Notice I have also hooked up the end-tidal CO2 to this set up which would be helpful as well.  Using the wrong mask in this setting.  Meaning if you can’t find the non-vented mask you could use the vented one, but there is just going to be a big “leak” out the holes.  It wouldn’t be dangerous, whereas doing the opposite (using a non-vented mask on the BIPAP machine would be).

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7) I also like this set up as it totally removes any concern of using a special mask and would solve the same problem, but just require someone to maintain a good seal with the patient.  I suspect to do this well you would have to have a obtunded or very cooperative patient.  This is where some Ketamine/Haldol might go a long way.

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8) I suggest you listen to the podcast on incubating the acidotic patient and see the video I made below.

Agree/disagree?  I look forward to your comments.

Safe Travels,

DL