[Music] all right you guys welcome back to another video Lesson from ICU Advantage my name is Eddie Watson and my goal is to give you guys the confidence to succeed in the ICU by making these complex Critical Care subjects easy to understand I truly hope that I'm able to do just that and if I am I do invite you to subscribe to the Channel Down Below when you do make sure you hit that Bell icon and select all notifications so you never miss out when I release a new lesson alright in this lesson here we are going to be discussing fentanyl so let's start off with our history and background like usual so the pharmaceutical company Jansen first developed fentanyl in 1959 for primarily the use as an anesthetic and pain reliever fentanyl really started becoming widely available as an IV anesthetic during the 1960s fentanyl citrate is the commonly used version of IV retinol which is created by combining Fentanyl and citric acid at a one-to-one ratio and this is the version that's most commonly known by the trade name sublimaze and then outside of IV use we do have Fentanyl patches that were introduced as well as get this flavored lollipops gotta love this stuff so fentanyl itself is an opioid analgesic from the opioid family which includes other drugs such as morphine codeine and Oxycodone it is considered a scheduled to controlled substance by the DEA which means there is a high potential for abuse which may lead to severe psychological or physical dependence now the way that fentanyl works is it actually binds with the opioid receptors and the central nervous system so regions of the brain and spinal cord and thus Alters the perception and emotional response to pain Fentanyl and other opioid agonists appear to relieve pain by mimicking the actions of endogenous opioid peptides and primarily activation of the MU but also the Kappa receptors so the MU receptor activation response includes analgesia respiratory depression Euphoria and sedation while the Kappa receptors they're active Innovation response includes analgesia and sedation all right so for our indications for the use of fentanyl so we can primarily think of these in the categories of anesthesia sedation and analgesia so it is an adjunctive use in general as well as Regional anesthesia for general anesthesia we can use it in conjunction with various anesthesia gases accommodate paralytics as well as we're using it regionally it can be in conjunction with big pivot cane or republican which are anesthetics that then cause numbing to specific areas now we can use it to induce or maintain anesthesia and sedation and this can be helpful in Ventilator compliance it is very helpful with post-operative pain restlessness tachypnea and emergence delirium so it can be used to manage acute pain as well as it can also be used to manage the moderate to severe chronic pain and patients who are opioid tolerant but are requiring around-the-clock opioid analges visa for an extended period of time that can also be used for breakthrough cancer pain for patients who are already receiving or tolerating opioids and then just in general it's a potent analgesic sedative that has less hypotensive effect than the other opioids and this is primarily due to the lack of the histamine release as well as it has the shortest duration so this actually makes it an excellent choice for the use in critically ill patients now for our contraindications the only real contraindication would be if the patient has an allergy or hypersensitivity to the drug or known history of intolerance to the drug there are some cautions though we do want to use it in caution with patients with brain tumors COPD decreased respiratory Reserve potentially compromised respirations hepatic and renal disease or cardiac bradyarrhythmias and then opioids can cause sleep-related breathing disorders including Central sleep apnea and sleep-related hypoxemia all right so on to our adverse effects um there's quite a few so we're going to go through the system by System first we have the central nervous system and here we're looking at confusion Euphoria sedation somalence seizures anxiety depression dizziness hallucinations and headache for cardiovascular it can lead to arrhythmias chest pain hypertension hypotension bradycardia DVT and PE for ENT uh rhinitis is a possibility along with pharyngitis dry eyes and swelling for the GI it does slow down the motility so this can lead to constipation abdominal pain ileus nausea and vomiting can also within the gender urinary can lead to urine retention for a respiratory it can lead to apnea hypoventilation respiratory depression and dyspnea and the skin that can lead to diaphoresis puritis as well as erythema at the application site if we're doing transdermal applications and then finally as another category physical dependence to its use all right so let's talk about our dosing so for our common concentrations often when we're using this as an IV push we're going to find this in 100 micrograms and 2ml vials giving us a 50 microgram per ml concentration for our IV infusion this really can vary depending on on what brand or Preparation that your facility uses commonly we're going to see something like a thousand micrograms and 100 ml giving us a 10 microgram per ml concentration of a pre-filled bag we can also find these in pre-filled syringes as well either for continuous infusions or PCA dosing as well all right for the dosing itself for IV pushes we're typically going to give this anywhere from 25 to 100 micrograms in a dose for our continuous IV Administration protocols really are going to vary on this depending on the facility and the infusion reasons but in general so if we're using this for Sedation and pain management and patients who are mechanical ventilated then our dose can range anywhere from 25 to 250 micrograms per hour generally we're going to start this at 25 to 50 mics per hour the effect that we're going for is generally going to be monitored by our Ras score if we're using it for Sedation as well as our c pot if we're using it for analgesia we can also use this in a patient-controlled analgesia pump so a PCA pump and so here we're going to get orders from the provider that may or may not include any of the following an initial bolus dose potentially a continuous dose what the demand dose is going to be so each time the patient hits the button put the demand dose interval is going to be between the doses they can give if there's any PRN bolus doses for breakthrough pain that we can give as well as a total maximum dose allowed and lockout which is usually going to be measured every four hours now for the pharmacokinetics the medication can be given many different routes oral IM IV intranasal intradermal transmucosal as well as it can also be given as an adjunct to the anesthetic agent via either an epidural or an intrathecal catheter it is primarily metabolized by the liver and then excreted primarily in the urine although partially through feces as well it is highly lipophilic though so extended use as well as larger doses tend to accumulate in the adipose tissue and can lead to prolonged effects especially as we're weaning or turning this medication off as for onset Peak and duration obviously this is going to vary depending on how you give it but the main thing we're focused on here is our IV Administration so it has an onset of one to two minutes peaks in about three to five minutes and has a pretty short duration of just about 30 to 60 Minutes the antidote for this is going to be our naloxone or Narcan so our opioid and tag Agonist and here we're giving anywhere from point four to two milligrams IV every two to three minutes up to a Max of 10 milligrams but we can also do the continuous infusion as well all right so for our nursing considerations respiratory depression and or death can result when we're using this medication even as it's intended or recommended to be used so we do want to monitor patients closely especially in the first 24 to 72 hours during the initiation or drug changes so make sure that we do have a pulse ox in place and even more preferable especially if the patient is not intubated to have an entitled CO2 as this is going to give us an earlier recognition of respiratory depression now we don't want to stop treatment abruptly especially if they've been on this medication for prolonged periods of time we do want to withdraw it slowly and gradually taper the dose to prevent the signs and symptoms of withdrawal worsening pain psychological distress especially those patients who are dependent on it so some of the signs and symptoms of opioid withdrawal are going to include things like restlessness perspiration chills irritability anxiety insomnia joint pain weakness abdominal cramping nausea vomiting diarrhea increased blood pressure and or heart rate as well as an increased respiratory rate now we do want to monitor circulatory and respiratory status as well as urinary function pretty carefully make sure that we are frequently monitoring our Vital Signs as well as the bladder function high doses and prolonged doses may lead to constipation so we want to be assessing bowel function as well as the need for any potential bowel care regimen as well as make sure that we have naloxone and Narcan available as needed so if we do have any signs and symptoms of intentional or accidental overdose and then finally for some relevant laboratory studies may increase amylase and lipase levels so we do want to periodically check those all right and that was our review of fentanyl so I hope that you guys found this information useful if you did please leave me a like on the video down below uh really helps YouTube know to show this video to other people out there as well as leave me a comment down below I love reading the comments that you guys leave and I try to respond to as many people as I can make sure you subscribe to this channel if you 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