[ALCCRN]

I need some info to write the policy for Fentanyl IV push. Our state board of nursing doesn't allow anesthetic agents to be given by registered nurses for "anesthetic purposes". However, we can give it for pain. We recently had an MD order it for a vent patient. He claims it won't drop the BP like morphine will. We need a policy written on it before our nurses can do this....Any suggestions??

[Gompers]

Originally Posted by ALCCRN

I need some info to write the policy for Fentanyl IV push. Our state board of nursing doesn't allow anesthetic agents to be given by registered nurses for "anesthetic purposes". However, we can give it for pain. We recently had an MD order it for a vent patient. He claims it won't drop the BP like morphine will. We need a policy written on it before our nurses can do this....Any suggestions??

I don't work in CCU, I'm in the NICU, but we routinely give Fentanyl IV push for pain. (We don't have a whole lot of options for approved meds for the babies - fentanyl and morphine are the only IV analgesics we can use.) We prefer to have it running as a continuous IV drip for pain control, but we often give bolus doses IV for breakthrough pain or procedures. It doesn't seem to cause a drop in the BP, I agree with that - unless of course the BP is elevated due to pain, then it does drop but only to a normal range as pain is controlled. BUT you have to give it slowly, like over 5 minutes, or it can cause the lungs to clamp down pretty badly.

[ALCCRN]

Is the patient required to be on a vent for bolus Fentanyl at your facility? Or is it similar to conscious sedation, where you have to have emergency airway equipment nearby?

To change the subject....Congratulations on motherhood!!!

[Gompers]

Originally Posted by ALCCRN

Is the patient required to be on a vent for bolus Fentanyl at your facility? Or is it similar to conscious sedation, where you have to have emergency airway equipment nearby?

To change the subject....Congratulations on motherhood!!!

Our patients don't need to be vented to be given Fentanyl, no. We do have all our patients on monitors and we have a bag, mask, and O2 ready at every bedside all the time. I wouldn't do Fentanyl in ANY patient without those things available. We typically give 1-2 mcg/kg to our babies, just to give you an idea of how much I'm talking about. They don't seem to go apneic if we give it slowly enough. It's just when someone slams it in, like REALLY gives it IV push, that we see major clampdowns. They're scary ones too - the type where even the respiratory therapists can't seem to bag those lungs open and even if the patient is already intubated and we have a secure airway, we can't get them to open up for several minutes. In those cases, we try a few puffs of Albuteral. If that doesn't work and if the patient is intubated, then we resort to a dose of Rocuronium or Pavulon (approved paralytics in neonates) because that's the only way we are going to get those lungs to stop!

OVERALL though...if given over 5 minutes, we very rarely see any complications. Timing is everything with Fentanyl!

Thanks for the congrats!

[Altra]

We very frequently give adults 50-100mcg IV push.

I keep a continuous pulse ox monitor on. O2 is immediately available in all our rooms.

We also use it in combo w/Versed or Etomidate for moderate sedations.

[augigi]

I also used to give fentanly 50-100mcg via IV push in adults post-cardiac surgery. This was ICU, so we had O2/bag and mask at every bed. Never seen a bad reaction though.

[shadowflightnurse]

I don't have a specific policy I could forward, but I do use Fentanyl VERY frequently. I do pre-hospital/transport nursing on a helicopter and we give a ton of Fentanyl. Our guidelines are 1mcg/kg for peds and generally 50-100mcg for adults and can be repeated. I have known people who have given 200-300mcgs on a long flight. Fentanyl is both a narcotic analgesic and an anesthesia adjunct/induction agent. It's effect is dose dependent. The refernce I have states the dose for induction is 50-100mcg PER KG. Medications used for pain control and/or sedation are frequently the topic of hot debates between anesthesia providers and non-anesthesia providers. Meds such as Propofol and Etomidate are at the top of many lists regarding who should and should not be administering them. I would get written clarification from your state BON regarding the use, specific limitations, etc. Then I would get some written information from your hospital pharmacy (package insert, PDR etc) regarding usual dosage, contraindications, rate of adminstration and dilution. Pulling all of this together you should be able to draft a pretty good policy.

good luck

[caroladybelle]

We give IV fentanyl all the time for cancer pain. No particular policy in place, and they do not need to be on the vent or on a monitor. We treat it just like IV morphine, dilaudid, unless we are giving in direct combo w/ativan or versed purposefully for conscious sedation. Then they are monitored.

[ZASHAGALKA]

We have a sedation protocol that encourage diprivan first in MOST instances and then:

Morphine in hemodynamically stable pts

or

Fentanyl in hemodynamically compromised pts.

So, the fact that fentanyl is better for pts with lower bp is on point. AS far as RNs and anesthetic agents, in TEXAS at least, the BON specifically states that it is not referring to critical care pts on vents.

http://www.bne.state.tx.us/position.htm#15.8

"Therefore, it is the position of the Board that the administration of anesthetic agents (e.g. propofol, brevitol, ketamine, and etomidate) is outside the scope of practice for RNs and non-CRNA advanced practice nurses except in the following situations:

- when assisting in the physical presence of a CRNA or anesthesiologist

- when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist)

- when administering these medications to patients who are intubated and mechanically ventilated in critical care settings

- when assisting an individual qualified in advanced airway management, including emergency intubation procedures"

But, I can only speak for Texas because it's the only BNE NPA and rules that I study.

But a KEY question is also this: what is the PURPOSE of giving fentanyl? If it is specifically for pain management, then I believe it falls along the same lines as using morphine for pain control.

If it is for sedation, then it falls in the 'anesthetic' concerns and should not be used on unintubated pts by a non CRNA/ANP RN, except as outlined above.

~faith,
Timothy.

[cardiacRN2006]

I give Fentanyl IVP when doing procedures. The dose is usually 25-50mcgs +1mg of Versed. Pts are on O2, monitor, and of course, there is always a MD there. Once, I had a pt who was on 100 of Propofol and we still couldn't keep her down, so we gave 100mcgs of Fentanyl IVP then as well.
The majority of our vented pts are also on Fentanyl gtts along with Propofol.