# Fentanyl nebs



## eggshen (Oct 28, 2007)

Who uses them and what are your thoughts?

Thanks
Egg


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## Ridryder911 (Oct 28, 2007)

Nope and why? 

Fentanyl is much stronger than Morphine, I have seen such for care of those in Hospice and long term therapy. I believe patients that are administered analgesics in an emergency setting should have an IV access. If this is the case, why administer the medication per nebulizer route? 

R/r 911


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## Asclepius (Oct 28, 2007)

I have to agree. Fentanyl has many of the same vasodilation properties of Morphine. I don't like to administer any drug that can cause side effects unless I have a way to counter act that medicine. ie NTG is great, but why risk bottoming out the BP without first having a way to maintain that BP? What if I overdose them on Morphine or Fentanyl? I would want a way to administer my Narcan. Fentanyl nebs have no place in prehospital or emergency medicine.


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## eggshen (Oct 28, 2007)

So far so good, thank you. Any further replies are quite welcome. As far as needing a line for narcan? We use intranasal narcan via a MAD. Works great. As far as giving narcs or whatever I am somewhat in the same boat, I feel better having a line before hand. I also never give NTG w/o a line, usually checking for RV involvement when applicable.


Egg


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## i5adam8 (Oct 28, 2007)

I myself have a morphine alergy,so what would you do for someone like me?


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## Ridryder911 (Oct 28, 2007)

i5adam8 said:


> I myself have a morphine alergy,so what would you do for someone like me?


First, I would ask you to define your "allergy". Was there redness and swelling up the arm, and itch or associated N/V? Which is not really an allergy, rather a common side effect. 

If you do have a true allergy, there are other options in some services. Demerol, NSAIDS, etc. May not be as effective in some instances, but better than nothing. 

R/r 911


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## Ridryder911 (Oct 28, 2007)

eggshen said:


> As far as needing a line for narcan? We use intranasal narcan via a MAD. Works great. Egg



Narcan per nasal atomizer is an oxymoron. The patient has to be having a enough tidal volume to allow to the medication to enter the lungs. In which the true indication of administering Narcan would be respiratory depression. 

My medical director, and including myself believe Narcan is administered way too much and too often. Most narcotic overdoses can managed well to allowed to wear off as long as there is no respiratory compromises. Coma cocktails (Narcan, D50w) should have been done away with years ago.


R/r 911


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## eggshen (Oct 28, 2007)

I agree that narcan is given way too much. Seems like most ED staff perpetuate this. Anytime I bring in someone that is altered they want to know if I gave narcan and why not. I only give it in the presence of ventilatory depression. As far as the intranasal narcan goes it is absorbed via the nasal mucosa, not the lungs.

Egg


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## Ridryder911 (Oct 28, 2007)

eggshen said:


> I agree that narcan is given way too much. Seems like most ED staff perpetuate this. Anytime I bring in someone that is altered they want to know if I gave narcan and why not. I only give it in the presence of ventilatory depression. As far as the intranasal narcan goes it is absorbed via the nasal mucosa, not the lungs.
> 
> Egg



Actually it is absorbed per the lungs, thus the reason for the atomizer. As well, it is one of the oldest per ETT med.'s If it was per nasal mucosa, the liquid could be adminstered or rubbed into the mucosa membrane. 

R/r 911


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## eggshen (Oct 28, 2007)

MAD, _mucosal _atomizing device. There is no way you can get it to the lungs. It is much too fine. Not sure how it might get to the lungs in apneic pts. If that was the case it would not work.

Egg


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## Ridryder911 (Oct 28, 2007)

You are correct, I stand corrected. 

R/r 911


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## eggshen (Oct 28, 2007)

No worries lad. If I remember right something like 83% of pts responded to IN nacrcan, good stuff. What about IN versed? What are your thoughts surrounding that.

Egg


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## VentMedic (Oct 28, 2007)

missed the post


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## VentMedic (Oct 28, 2007)

eggshen said:


> Who uses them and what are your thoughts?
> 
> Thanks
> Egg



Fentanyl nebs are considered "off label" or unlabeled use by the FDA. They are used in some cancer and hospice patients either in the hospital or more commonly at home. The total duration of effect and optimum dosage remain unknown. The medication should  be preservative-free and additive-free formulations which many IV formulations are not. There is still the chance of bronchospasm so patients are usually pre-medicated with a bronchodilator. 

The recommended nebulizers (breath-actuated nebulizer and RespiraGuard) are much more expensive and not usually carried by EMS. These nebs are recommended to protect the caregivers and to assure better medication delivery.  Note: The average Albuterol dosage actually received by a patient using the standard acorn neb is 10%-15%. 20% is considered as good lung deposition for these nebs.


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## Ridryder911 (Oct 29, 2007)

eggshen said:


> . What about IN versed? What are your thoughts surrounding that.
> 
> Egg



I probably have given more IN Versed than IV in the past two years. I routinely use this as the first med if there is active seizures (status) then start a line after the sz activity stops. Personally, I have seen much more response to IN than IV lately. 

Personally, I do not attempt to stop seizure activity unless it is status, prolonged, or a post multiple type. Remembering that all we are doing is stopping the muscle action, not the seizure itself. These patients need Cerebyx, Dilantin, etc. not just muscle relaxers. I did work at a very rural service in which we would draw Dilantin level (of those that were on Dilantin), then give the standard dosage of Dilantin or Phenobarb. Stopping the seizure activity or the cause, not just the side effect. 

R/r 911


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## eggshen (Oct 29, 2007)

As far as the fentanyl nebs, I have not had even a moment to research this. Is it manufactured for use in a SVN? I mean in regards to additives and preservatives?

Rid, I am with you on SZ tx, only status. It seems one can usually pick out the vet based on their reation to sz activity. Unfortunatly all we carry is valium or versed, infact we just got versed. I'll also admit (sheepishly) that after 15yrs I never tire of seeing watching it.

Egg


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## Rattletrap (Oct 29, 2007)

Ridryder911 said:


> First, I would ask you to define your "allergy". Was there redness and swelling up the arm, and itch or associated N/V? Which is not really an allergy, rather a common side effect.
> 
> If you do have a true allergy, there are other options in some services. Demerol, NSAIDS, etc. May not be as effective in some instances, but better than nothing.
> 
> R/r 911



With me, anaphylaxis. Have your benadryl and epi handy. 

My reaction is so bad that my partner is required to have an epi pen handy and I lay out the benadryl out when I administer MS to a patient. However I do not have any reactions to any MS derivatives. Interesting, even to my allergist.


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## eggshen (Oct 29, 2007)

Please observe my last post. That last bit is a good example why one should not post when very tired.

Egg


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## VentMedic (Oct 29, 2007)

eggshen said:


> As far as the fentanyl nebs, I have not had even a moment to research this. Is it manufactured for use in a SVN? I mean in regards to additives and preservatives?
> 
> Egg



No, that is why fentanyl it is still considered as off-label use. 

Fentanyl has been effective for alleviating dyspnea in cancer patients and a few select respiratory patients.  At this time, there is not a preservative free formulation. 

There are many other meds used off label in the SVN from steroids to antibiotics. 

Morphine is still consider off label also for the SVN but it has been used for almost 30 years in hospice and is available in a preservative free formulation.  Morphine is still our standard on the RT formulary at my hospital. Fentanyl has been shown to have some better results for dyspnea than morphine. 

Tobramycin has also been used for over 30 years and now has a formulation specifically made for inhalation, TOBI. 

Again, I would not recommend using the standard nebulizer to administer any of the above medications.   For patients that rely on TOBI, they treat it like liquid gold due to its cost. 

Of course you also have nebulizers designed for treating sinus infections which have become in more demand in the past few years among healthcare workers who have contracted an active MRSA or some other super bug infection in their sinuses. 

Sorry, I got a little off track.

The advantages of nebulized medications; less systemic side effects.  

A pt can still get IV morphine as well as the nebulized form and not be too concerned about a synergistic systemic response.  Nebulized morphine and fentanyl are aimed at the dypnea centers in the lungs to reduce the air hunger feeling.


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## Ridryder911 (Oct 30, 2007)

Rattletrap said:


> With me, anaphylaxis. Have your benadryl and epi handy.
> 
> My reaction is so bad that my partner is required to have an epi pen handy and I lay out the benadryl out when I administer MS to a patient. However I do not have any reactions to any MS derivatives. Interesting, even to my allergist.



Hope you wear a "Medic Alert" tag. I wonder if it is the suspension or preservative that is used? My "ex" was sensitive to some med.'s dependent upon the manufacture. Interesting though..


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