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