Hospital Pharmacy - April 2020 - 128

128

Hospital Pharmacy 55(2)

Table 2. Indication for Intranasal Fentanyl Administration
(N = 61 Procedures).
Indication
Intubation
Peripherally inserted central catheter placement
Chest tube
Umbilical line
Nasogastric tube placement
Pain management
Lumbar puncture
Tracheostomy
Agitation
Continuous positive airway pressure initiation

n (%)
40 (65.7)
12 (19.8)
2 (3.3)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)

should be considered when intubating or performing a painful procedure on a neonate. Only 4 out 67 procedures had an
IV documented in place at the time of INF administration.
The reason for IN route could not be identified through our
retrospective study; however, we postulate that it was likely
due to the emergent nature of the procedure in those patients.
The IN route is especially advantageous when the patient
does not have line access to safely and efficiently provide
analgesia.
One important consideration with the use of IN medications is delivering the appropriate dose of the drug. The IN
medications rely on rapid absorption of the drug from the
highly vascularized nasal mucosa and olfactory tissue
directly to both the central nervous system and the bloodstream. This allows for rapid onset of action similar to IV
medications.9,14 In addition, drugs administered in this route
bypass first pass metabolism in the liver, allowing for high
bioavailability of medications. To optimize this process, the
goal is to maximize both the drug concentration and
the absorptive mucosal surface that is being exposed to the
drug.14 Typically, this involves the use of an atomizer to
break up the particles and enhance drug absorption. However,
in the case of neonates, the amount of medication being
delivered is too small to allow for accurate use of an atomizer
and the physical use of an atomizer is limited by the size of
the neonatal nostril. Therefore, INF was used without an
atomizer for the patients in this study. The dose was not
recorded to be diluted; thus, at the small doses administered
in this study, it is possible that less drug was actually delivered. Further pharmacokinetic and pharmacodynamic studies are required to accurately study this possibility.
One limitation of our retrospective study was the determination of whether INF was administered to some of the
patients. The INF used at our institution is the same concentration and dosing for that of IV fentanyl, and is coded in the
system as IV fentanyl for IN use. Therefore, it is plausible that
some of our patients may have received fentanyl intravenously, while the order stated IV fentanyl for IN use. To mitigate this, we had multiple investigators (SK, JP, and SM)

manually review concerning charts and orders to resolve any
inconsistencies and accurately report the data. We included
only those patients who were confirmed to receive an IN
dose. When considering our findings in conjunction with previous studies in infants, we feel that INF is an appropriate
choice for analgesia in neonates and young infants. This study
will serve as a foundation for prospective studies further
examining the safety and efficacy of INF in this population.

Conclusion
Intranasal fentanyl is increasingly being used for a variety of
painful procedures and provides a minimally invasive means
of providing analgesia to patients in the NICU.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Corrie E. Chumpitazi

https://orcid.org/0000-0001-5323-2743

References
1. Maxwell LG, Malavolta CP, Fraga MV. Assessment of pain in
the neonate. Clin Perinatol. 2013;40:457-469.
2. Johnston CC, Stevens BJ. Experience in a neonatal intensive
care unit affects pain response. Pediatrics. 1996;98:925-930.
3. Brummelte S, Grunau RE, Chau V, et al. Procedural pain
and brain development in premature newborns. Ann Neurol.
2012;71:385-396.
4. Anand KJ, Scalzo FM. Can adverse neonatal experiences alter
brain development and subsequent behavior? Biol Neonate.
2000;77:69-82.
5. Sarkar S, Schumacher RE, Baumgart S, Donn SM. Are newborns receiving premedication before elective intubation? J
Perinatol. 2006;26:286-289.
6. Kumar P, Denson SE, Mancuso TJ, Committee on Fetus and
Newborn, Section on Anesthesiology and Pain Medicine.
Premedication for nonemergency endotracheal intubation in
the neonate. Pediatrics. 2010;125:608-615.
7. Prestes AC, Balda Rde C, dos Santos GM, et al. Painful procedures and analgesia in the NICU: what has changed in the
medical perception and practice in a ten-year period? J Pediatr
(Rio J). 2016;92:88-95.
8. Borland M, Jacobs I, King B, O'Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency
department. Ann Emerg Med. 2007;49:335-340.
9. Borland ML, Clark L-J, Esson A. Comparative review of
the clinical use of intranasal fentanyl versus morphine in a
paediatric emergency department. Emerg Med Australas.
2008;20:515-520.

https://www.orcid.org/0000-0001-5323-2743

Hospital Pharmacy - April 2020

Table of Contents for the Digital Edition of Hospital Pharmacy - April 2020