CC Pharm | Fentanyl

Fentanyl (Sublimaze): Elite Nursing 80/20 Summary 1. ID & Action: Phenylpiperidine synthetic opioid agonist. Binds mu/kappa receptors. Inhibits adenylyl cyclase, decreasing cAMP to block release of neurotransmitters (substance P, GABA, dopamine, acetylcholine, norepinephrine). Highly lipophilic (580:1 vs. morphine); rapid onset. 2. Therapeutic Use: General/spinal anesthesia adjunct; chronic and breakthrough pain (transmucosal/nasal only). 3. 80/20 Formulations (NOT Interchangeable mcg-to-mcg): IV/IM: Peak IV analgesia in minutes. Inject slowly over 1–3 min; rapid injection can cause apnea or chest wall rigidity. Transdermal Patch: Onset 12–24h; changed every 72h. Epidermal depot slowly absorbs. Critical: Avoid external heat (pads, saunas, fevers >104°F); heat increases absorption by 120%, risking fatal overdose. Clip, do not shave, hair. Fold adhesive inward and flush. Transmucosal (Actiq, Fentora, Onsolis, Abstral, Subsys, Lazanda): For breakthrough pain in opioid-tolerant patients ONLY. Follow specific directions (e.g., suck Actiq lozenge, do not chew; do not suck/chew/swallow Abstral). Dry hands. Flush unneeded forms or use specific pouches. Ionsys: Iontophoretic system (hospital only). Delivers dose via 10-min current. Wear gloves; never touch hydrogels. 4. High-Yield Contraindications & Precautions: Respiratory: Contraindicated in severe respiratory depression or acute/severe asthma in unmonitored settings. Renal/Hepatic: Reduce transdermal dose by 50% in mild-to-moderate impairment; avoid in severe. Pregnancy: Prolonged maternal use causes Neonatal Opioid Withdrawal Syndrome (NOWS); monitor newborn for tremors, high-pitched cry, irritability, vomiting, and diarrhea. 5. Black Box Warnings & Toxicity: Addiction, abuse, misuse, and fatal respiratory depression. Accidental Exposure: Ingestion of patches is fatal, especially in children. Wash hands after handling. Reversal: Keep Naloxone (Narcan) and resuscitative equipment readily available. 6. Key Drug Interactions: CYP3A4 Inhibitors: Prevent fentanyl metabolism, increasing levels and risk of fatal respiratory depression. CNS Depressants: Cause profound sedation, respiratory depression, coma, and death. 7. Nursing Interventions: Assess: Prioritize respiratory rate, depth, and pupil size (miosis). Monitor pain and sedation. Monitor: Use continuous pulse oximetry for infusions. Monitor patch adhesion, especially in pediatric or cognitively impaired patients. Hold & Notify: If RR < 12/min, shallow breathing, or excessive sedation.