Transcript Style E 24 by 48 - Advocate Health Care

Intraoperative Intrasal Opioid Delivery
Michel J. Sabbagh, M.D., Maunak V. Rana, M.D.
Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA
Abstract
Case Description
Intranasal medication delivery has
good absorption from the nasal
mucosa, is needleless, and
bypasses first-pass metabolism.
We
present
a
case
of
intraoperative intranasal opioid
delivery in a 17 year old nonverbal autistic female presenting
for dental rehabilitation. The
patient was premedicated with
4mg/kg of ketamine and 0.2mg of
glycopyrrolate
intramuscularly.
Intraoperative pain control was
achieved using intranasal fentanyl
boluses of 1mcg/kg. The patient
was extubated smoothly, and
transferred to the recovery room
with stable vital signs, where she
remained calm and collected until
her discharge.
Intranasal fentanyl specifically has
been shown to have similar onset
and duration as intravenous
formulations.
We
present
a
case
of
intraoperative intranasal opioid
delivery in a 17 year old nonverbal autistic female presenting
for extensive dental rehabilitation.
The
patient
was
assessed
preoperatively with her parents at
her
bedside.
She
was
premedicated with 4mg/kg of
ketamine
and
0.2mg
of
glycopyrrolate
intramuscularly.
The patient was then transported
to the operating room where
intravenous
access
was
established
and
general
anesthesia was induced after
application of standard monitors.
Nasal intubation was performed
atraumatically and was well
tolerated.
The procedure was then started
and intraoperative pain control
was achieved using intranasal
fentanyl boluses of 1mcg/kg as
needed. At the procedure’s end,
extubation occurred smoothly, and
the patient was transferred to the
recovery room with stable vital
signs, where she remained calm
and collected until her discharge.
Discussion
There are several advantages to intranasal medication delivery. It is noninvasive,
well absorbed from the highly vascularized nasal mucosa, is needleless, venous
drainage bypasses first-pass metabolism, rapid absorption and plasma
concentration, reduces the risk of needlestick to the staff, and has some patient
controlled analgesia applications. Side effects of the intranasal route include a
bitter or burning taste, stinging in the nose, coughing, and nasal pruritus.
Commonly used intranasal medications include midazolam, ketamine, fentanyl,
sufentanil, morphine, naloxone, ketorolac, butorphenol, and dexmedetomidine.
Fentanyl especially lends itself to the intranasal route due to its high lipid solubility,
low molecular weight, and high potency. Intranasal fentanyl specifically has been
shown to have similar onset and duration as intravenous formulations, and it has
gained popularity in settings where intravenous access is difficult or would be
otherwise unnecessary. These include the prehospital setting, the emergency room
– especially in the pediatric population, postoperatively in a patient controlled
formulation, and for breakthrough pain in the chronic pain patient population.
Intranasal medication delivery can be accomplished in a dry powder or in solution
form, as a nasal spray, as a nasal dropper, or as a nebulized inhaler.
Conclusions
• Intranasal
medication
administration is a viable option
for rapid and effective medication
delivery.
• The vascularity of the nasal
mucosa and its ease of access
make this route of administration
an important alternative to
traditional methods, especially in
settings
where
intravenous
access is not necessary.
• Patient controlled intranasal
analgesia may become more
prevalent as devices which
emphasize safety and efficacy
become widely available.
References
Figure 1. (A) Mean (SD) plasma
concentration-time profiles after IN and IV
dosing 100 g of fentanyl (n=7).
(B) Expanded plot of the first 25 minutes.
Taken from Christrup LL, et al. Clin Ther 2008;30:469-81.
1. Striebel HW, Koenigs D, Krämer J.
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1992
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2. Viscusi ER. Reg Anesth Pain Med.
2008 Mar-Apr;33(2):146-58.
3. Christrup LL, Foster D, Popper LD,
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