hpm journal club: intranasal fentanyl in symptom management for newborns and infants at end of life

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?