fentanyl dosing on a vent

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    As of late we have recieved a number of patients from our ED already intubated and they have the fentanyl gtt running at 9 or 10 mcg/kg and our guidelines say 3 is the max, so my question is with the overdosing of fentanyl what clinical effects will happen, everything ive read is that it can cause muscle ridgidity, or resp depression, their respirations are controled by the vent and its a short acting drug, so what other effects should i be aware of? anything i can do to help/ counter when overdosed for a period of time?
    ativan has been overdosed as well, but not as much, clinical effects on this too?
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  3. 11 Comments so far...

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    I've given high doses of fentanyl to intubated kiddos, but usually those that have worked up a tolerance. A just intubated patient (who should have received decent sedation prior to intubation) should not have those as starting doses. I think the better question is why is the ER sending them up on such high doses?
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    That's an insane amount of Fentanyl to start off with. I'd either verify that you're using the correct terms (maybe they're on 10 mcg/hr not 10 mcg/kg/hr) or let someone else know if they are in fact coming up with that much running.

    Fentanyl doesn't have the associated vasodilation due to histamine like Morphine will, so the effects are not as drastic in an overdose situation. Usually they'll just be really stoned, and you may see a drop in blood pressure and heart rate, but if you shut the drip off entirely the effects are quickly reversed in about an hour for someone somewhat healthy.
    Mully likes this.
  6. 0
    Quote from detroitdano
    That's an insane amount of Fentanyl to start off with. I'd either verify that you're using the correct terms (maybe they're on 10 mcg/hr not 10 mcg/kg/hr) or let someone else know if they are in fact coming up with that much running.
    This.

    We use mcg/hr, not mcg/kg (I assume you mean mcg/kg/hr?), and the typical dose is 50 mcg/hr, but I've seen low as 12.5 and high as 250 (that was on a heroin user).
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    Usually our ED brings them up on propofol and we transition as ordered. We run at mcg/hr. I've used as high as 300/hr before (the dude was still awake and writing notes...no lie). We'll use the fentanyl for a few days and then switch to another agent if it is proving ineffective or we have any problems with ventilation. Generally the policy is that we start with PRN pushes, usually 50 or 100 mcg q1 hour and if we're giving pushes hourly x2+ hours, we'll start the drip. I usually start at whatever the dose of push I've been giving is.

    We also do a wake up every shift. Turn it off, let them wake up, do the whole PRN thing all over again and then if needed restart the gtt at half the original dose.

    Seems from clinical experience that the rigidity can take a few days but it doesn't always happen.
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    If they're rocking out on 300 mcg/hr of Fentanyl, that's when it's time to bring in a little Propofol. I've had drug addicts on 300 of Fentanyl and 30 of Versed who were climbing over the rails. Even a wussy little 5-25 mcg/kg/min dose is enough to see a drastic change. Take down the Versed and swap it for Prop, they fall asleep like little babies, and you can usually half the dose of your Fentanyl at the least. LOVE Propofol.
    JenRN30 likes this.
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    If we really need to sedate a pt (like with ICP monitors with cerebral edema, or even ARDS pt on pronator beds) we can go up to 600 mcg/hr. I've seen fent 600 mcg/hr, versed 10 mg/hr, propofol 70 mcg/kg/min. That's what it took to keep em down. Crazy stuff.
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    Where I work its pretty standard for intubated patients to be on both a fentanyl drip ( use mcg/hr) and propofol. We generally start fentanyl at 50-100 mcg/hr and adjust from there. That being said some of our really sick patients that we need paralyzed and sedated for different reasons like high ICPs or ARDS we will go as high as 700mcg/hr, but that is with a physician specifically ordering that amount and not us titrating.
    JenRN30 likes this.
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    Just out of general interest. When you are talking about Fentanyl. Do you mean Sufentanil?

    We usually combine propofol and sufentanil.
    Propofol 6-12 mg/kg/hr, Sufentanil 10 mcg/hr. (0,15–0,7 microg/kg)

    Depending on what reason we can make everybody go to sleep . Not limited to: Dexdor (Dexmedetomidine), Ultiva (Remifentanil), Dormicum (Midazolam), Sodiumthiopental (last resort, TBI)
  12. 0
    Quote from Roben
    Just out of general interest. When you are talking about Fentanyl. Do you mean Sufentanil? We usually combine propofol and sufentanil. Propofol 6-12 mg/kg/hr, Sufentanil 10 mcg/hr. (0,15–0,7 microg/kg) Depending on what reason we can make everybody go to sleep . Not limited to: Dexdor (Dexmedetomidine), Ultiva (Remifentanil), Dormicum (Midazolam), Sodiumthiopental (last resort, TBI)
    Fentanyl and sufenta are two different drugs.


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