IV Fentanyl use on Med/Surg Unit

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I am wondering if anyone out there has concerns about the use of IV fentanyl on a general med/surg unit for pain. We have been debating this issue in our hospital for months. Physicians are pressuring administration to allow them to order it for any pain situations they want. Many of us Med/Surg nurses believe that the literature supports our reluctance to push IV fentanyl to patients that we may not be able to monitor closely in a 1:1 setting. The literature says IV fentanyl is used in anesthesia and sedation type settings...where patients are monitored very closely and people are trained in airway management. Our doctors are alway giving "ranges" of amount and frequency that leave a lot to nursing judgement. It is frightening to think of our junior nurses managing this medication. We are not afraid to IV push meds like MS or dilaudid as they do not "read" like fentanyl in the medication literature. Duragesic patches and Actiq are acceptable methods of delivering Fentanyl on a med/surg unit that we are happy to use.

We have been told we need to develop a "time line" to bring the IV method of delivering fentanyl to the med/surg unit. Therefore, we need to know how other institutions are handling this drug. Is it treated differently than IV morphine or dilaudid in your institution? Do nurses need ACLS or extra training? Do patients have monitors on them like oximetry?

Well there are a few sides of this. IV fentanyl in a CADD pump is used on our floors with q2 hr. pain, resp. and neuro assessment.

Iv fentanyl is used on the step downs, with a bedside heart and spo2 monitor, with suction set up, for proceedures like cardiversions, dropping lines. but for one solid hour, the patient is a 1:1, it is considered conscious sedation, and the nurse has to be "certified " in it.

In the ICU's where I work, we use it in a drip for intubated patients, pain controll and conscious sedation, but my ratio's are 1:3, during proceedures 1:1.

I mean absolutely NO disrespect to any floor nurse that administers this, but it is very strong, fast acting (had it myself), ad if you're giving it for pain, then you walk out the room and see your other 5 plus patients.... you're asking for trouble. There are a plethora of choices for pain management that are safer.. unless you're in oncology, I don't see the risks vrs. bennies weighing in the favor of using it...

If the pain is so severe you need higher dose morphine, dilaudid (which can be very dangerous, 10 x's potent as morphine) and the safest, although not fail safe treatment... the CADD pump.

Just because "oh I've given that before with no problems", does not ensure the next patient's safety.

I've received TOO MANY fentanyl OD's from the floors, which were of course inadvertant.... you never know which dose will be too much, too fast. You have the skills, but not the ratio for safe monitoring.

Bring your concerns to risk management. You never mentioned the hospitals P&P, it may need re-vamping .

excellent question, serious issue. hope this helps you

I don't work med-surg, but if I did I don't know how safe I'd feel using it. I've had many infants completely clamp down after IV push fentanyl, including one that needed CPR and intubation. It wasn't just respiratory depression - it was nearly impossible to bag the baby, and it wasn't until we got Narcan in him that his compliance improved. I would think the same kind of affects can happen with adults? We give 1-2 mcg/kg doses.

We don't use it in bolus form often, really only for procedures such as intubation, painful dressing changes, and PICC line insertion. With the continuous IV drips I haven't seen any respiratory problems though. But for regular IV bolus analgesia, we prefer morphine.

I do have a friend who was on a regular floor who recieved fentanyl and ended up having some respiratory depression. She ended up on monitors in the ICU after almost coding.

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Specializes in Med-Surg.

I've given it in med-surg before. As was stated it's half-life is so short, I don't think it's an effective med for pain control. Plus as was also stated, you have to monitor the patient for a while afterwards. Most of the docs here don't use it. It's quite often used in critical care situations for sedation in the form of a drip, however.

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Specializes in Registered Nurse.

It isn't done in the hospital where I have worked. It is given in PACU (Post Anesthesia.)

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my question is why wouldn't (on the floors) they be using PCA's - pt controlled, utilized less med in the long run, lock out limits....it is a win- win for nurse and pt...

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

we use fentanly PCA for our post-op's who cannot use morphine for one reason or another. generally, we don't PUSH fentanyl IVP .....it CAN be used in labor, but if so, we do attach them to SAO2 monitors and watched carefully. It's shortlived relief for labor pain, from my experience, and therefore, not very effective.

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Specializes in Critical Care,Recovery, ED.

If Fentanyl is used in PCA or in an epidural infusion on your med surg floor what is the concern if it is ordered IVP. Whats the difference between a PCA IV bolus and an IVP?

To me all the pump is doing is pushing the Fentanyl into a running IV instead of the RN pushing it. Same drug, same doses same potential for side effects?

That said if your argument for not using FentanylIVP is because of its short duration and should be utilized via PCA to assure better pain control that can be a valid arguement. Or if the usual patient load would preclude close monitoring that is another arguement. However, if you are arguing that the patient load is too great to allow for adequate assessment of IVP Fentanyl then I would say it is also to0 high to care for patients with PCA or continuous epidural infusions.

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I've seen Fentanyl used in small doses IV, and in larger doses IM, in all areas of the hospital. Like all narcotics, the effect is dose and patient dependent. I wouldn't refuse to give it on Medsurg unless the dose was too high, the patient too compromised, etc. I also feel giving a partial narcotic test dose is a good nursing judgment in many cases, to asess response. In my facility a nurse recently gave 50 of Fentanyl IV on the floor and caused a patient to arrest. This was a case of a nurse not familiar enough with the drug, did not seek advice, did not use good judgment and thus harmed the patient with her actions, IMO. Not because 'giving the drug on the floor is dangerous" all on its own.

Final investigation showed she misread a '50 IM' order. :o

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Specializes in Med-Surg, Long Term Care.

I have never seen it ordered on our med-surg unit. We only see Fentanyl in continuous epidurals (with continuous pulse ox and frequent VS) or in a patch.

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If Fentanyl is used in PCA or in an epidural infusion on your med surg floor what is the concern if it is ordered IVP. Whats the difference between a PCA IV bolus and an IVP?

To me all the pump is doing is pushing the Fentanyl into a running IV instead of the RN pushing it. Same drug, same doses same potential for side effects?

That said if your argument for not using FentanylIVP is because of its short duration and should be utilized via PCA to assure better pain control that can be a valid arguement. Or if the usual patient load would preclude close monitoring that is another arguement. However, if you are arguing that the patient load is too great to allow for adequate assessment of IVP Fentanyl then I would say it is also to0 high to care for patients with PCA or continuous epidural infusions.

My thoughts exactly (tho mine are not as well composed).

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Specializes in Everything except surgery.

I totally agree!

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I have been doing some more research and ran across an article from the American Hospital Formulary Service. This information is "manufacturer's recommendations" and says that residual effects of one dose of fentanyl may potentiate the effects of subsequent doses. It talks about "redistribution" as the main cause of the brief analgesic effect of fentanyl. "Following IV administration, fentanyl distributes rapidly from blood into the lungs and skeletal muscle and more slowly into deeper fat compartments. The drug then redistributes slowly from these tissues into systemic circulation. Large single doses or repeated doses can result in substantial accumulation of the drug, potentially resulting in an extended duration of effect." This may explain why small continuous PCA fentanyl seems to be safer than giving IV bolus doses.

The article goes on to state,"Because of the potential respiratory depressant effects of the drug, the manufacturers recommend that fentanyl injections and buccal lozenges only be used in a monitored setting by individuals specifically trained in the use of anesthetic agents and the management of opiate-induced respiratory effects in the age group being treated, including establishment and maintenance of an adequate airway and assisted ventilation... and only used as a premedicant prior to anesthesia or for inducing conscious sedation prior to diagnostic or therapeutic procedures in a monitored anesthesia setting." "Skeletal and thoracic muscle rigidity occur frequently...Muscular rigidity may be associated with reduced pulmonary compliance and/apnea, laryngospasm, and bronchoconstiction." (Explains the baby problems!)

Now, I must wonder, if the manufacturer has such strong directives and warnings for the use of this medication and it really isn't all that great a drug for short or long term pain control....why are we taking the risk to use it on a general med/surg unit that is not that controlled a setting? In fact, Massachusetts General Hospital Departments of Pharmacy and Nursing developed administration guidelines for use in Critical Care but under "special considerations" it states, "consideration of an alternative agent should be explored as other medications provide superior analgesia."

I appreciate the information, stories and comments...much food for thought!

We do try to provide our patients with the best and latest in treatment. The push for this drug from our physicians really puzzles me though, I don't see the advantages! We use epidurals and PCA's regularly so we are keeping up with technologies. We do have P&P's in place for these types of things, it is just that this push for IV fentanyl is new for us!

Please keep sharing your information and thoughts and I will continue to monitor and let you know how this turns out!

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Specializes in ER.

If you push it too fast it can cause respiratory paralysis, and of course large amounts are dangerous. But, if you have a patient in so much pain that you are pushing Fentanyl I assume you are not going to be leaving them alone anyway, until the med has taken effect and the pain is under control. Plus all nurses need to be aware of precautions before giving any med. I think that metoproplol IVP can be just as dangerous if you just push it and walk away, but that is a common med on our MS unit.

We rarely use Fentanyl IVP, usually it is in a PCA in small frequent doses, or a continuous drip. Works very well for us that way.

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