Fentanyl use in APE

[fast65]

I realize we've had a decent amount of discussion around fentanyl recently, but here's something that's been bothering me for the past couple of days. I vaguely remember hearing at one point that fentanyl can be used in the treatment of acute pulmonary edema (APE). While researching on the forum, I stumbled across this thread where fentanyl use during APE to mitigate the sympathetic response, was once again referenced.

Unfortunately my Google-fu has failed me, and I can't seem to find anything on fentanyl use in APE. So, I'm curious as to if any of you are using fentanyl in the treatment of APE, and why you're using it. Thanks in advance.

 

[triemal04]

What are you using it for? To try and reduced preload? For sedation? As part of your RSI? To faciliate CPAP?

If it's to reduced preload and afterload by vasodilation there are better drugs out there. If it's for sedation and to reduce the levels of catacholamines and maybe decrease the BP then sure. Same goes for facilitating RSI/CPAP. Of course there are many drugs that will also have the same effect.

If you're trying to directly treat the pulmonary edema, no, move on to something different.

 

[Cup of Joe]

I have heard of it indicated for APE.

The sites that Fentanyl binds to (k-opoid receptors) causes negative regulation of anti-dieuritic hormone.

Not 100% sure, but I think the reduction of intracellular Ca++ caused by Fentanyl may also have something to do with it's diuretic effects.

 

[lightsandsirens5]

Yikes....I have been out of school too long. Good thing a job is in the works.....

Anyhow, I too have heard it referenced, and at one point it was explained to me. However I have completely drawn a blank. I replied mainly to subscribe to this thread.

All that being said, I am going to go through my notes from class and clinicals and see what I can come up with.

 

[MadMedic]

We don't have Fentanyl in our system yet, but a quick search gave me this information for the publication EMSWorld.

Reference the article here:
http://www.emsworld.com/article/10321758/prehospital-pharmacology-fentanyl?page=2

"Indications for the use of Fentanyl in the prehospital setting are identical to those of morphine. Specifically, there are three primary indications: non-cardiac pain management (which accounts for the vast majority of administrations across EMS systems), chest pain of presumed ischemic origin, and as a third-line agent in the management of a patient with acute pulmonary edema. "

"It causes less hypotension, respiratory sedation and mental status depression than morphine"

"Fentanyl does not affect hemodynamics, oxygen saturation or GCS when used appropriately. It is fast-acting, short-acting and causes less histamine release than other narcotics."

I know that my system is currently reviewing the studies and considering adding it to our boxes, but its not there yet. I'm very interested in it's uses and look forward to a full education on it. I think I will start asking my Docs about it.

 

[fast65]

What are you using it for? To try and reduced preload? For sedation? As part of your RSI? To faciliate CPAP?

If it's to reduced preload and afterload by vasodilation there are better drugs out there. If it's for sedation and to reduce the levels of catacholamines and maybe decrease the BP then sure. Same goes for facilitating RSI/CPAP. Of course there are many drugs that will also have the same effect.

If you're trying to directly treat the pulmonary edema, no, move on to something different.

Well, that's really kind of what I'm trying to figure out at this point. To the best of my knowledge, it's being used to facilitate the use of CPAP...something to do with the mitigation of the sympathetic response is what I'm understanding. I guess I'm just trying to understand how fentanyl is helpful with that.

 

[triemal04]

You'd probably be better off asking an anesthesiologist or picking up an anesthesia textbook, but this is what I can remember off the top of my head.

Because of where fentanyl works in the CNS it causes a decrease in the release of cAMP, dopamine, norepi and substance P (I think for that last one, and I'm sure there's more than that). Because it is an opiod it'll also still work as a sedative and help calm a panicking patient until your other treatements can take effect. If it's systolic failure then all of that is good. Better drugs out there for some of that and I don't know how much effect the average prehospital dose would really have, but if it's what you have...

Much more complicated than that, but that's what I've got.

 

[sleepless near seattle]

Our protocols don't mention Fentanyl for APE, though Fentanyl is an acceptable substitute for MS per our protocols. With MS being so difficult to come by, along with Valium, nearly all ACLS Jets, etc., is it possibly as simple as we're hearing more about it because it's what's available?

I think the reduction of pre load is reasonable, but the primary purpose would be to facilitate compliance for CPAP or induction.

Just thinking "out loud", also interested in joining the thread to see what others come up with.

 

[fast65]

You'd probably be better off asking an anesthesiologist or picking up an anesthesia textbook, but this is what I can remember off the top of my head.

Because of where fentanyl works in the CNS it causes a decrease in the release of cAMP, dopamine, norepi and substance P (I think for that last one, and I'm sure there's more than that). Because it is an opiod it'll also still work as a sedative and help calm a panicking patient until your other treatements can take effect. If it's systolic failure then all of that is good. Better drugs out there for some of that and I don't know how much effect the average prehospital dose would really have, but if it's what you have...

Much more complicated than that, but that's what I've got.

Well, that will at least get me off on the right foot for some more research. Thank you so much!

 

[blindsideflank]

"It causes less hypotension, respiratory sedation and mental status depression than morphine"

"Fentanyl does not affect hemodynamics, oxygen saturation or GCS when used appropriately. It is fast-acting, short-acting and causes less histamine release than other narcotics."

I would prefer morphine because of those characteristics (hypotension/ histamine release).

The fentanyl for decreased sympathetic response sounds like more of a reference to some sedation and thus reduced anxiety.