Intranasal sedation

Intranasal delivery Materials:

1. Two syringes: 1 ml or 3 ml 2. Needle to draw up the medication 3. Atomizer 4. Vial of medication

Procedure:

1. Aspirate the proper volume/dose of medication per the weight based dosing protocol

2. Twist off/remove the syringe from the needle/needleless device

3. Attach the atomizer tip via Luer lock mechanism – it twists into place.

4. Using your free hand to hold the crown of the head stable, place the tip of the atomizer snugly against the nostril aiming slightly up and outward (towards the top of the ipsilateral ear).

5. Briskly compress the syringe plunger to deliver the medication into the nostril.

6. Place second device over to the opposite nostril and briskly administer the remaining half of the medication into that nostril.

7. Consider using a pulse oximeter for 45-60 minutes following medication delivery due to the rare but possible risk of respiratory depression from an opiate.

PROCEDURAL SEDATION: INTRANASAL OPIATES

PEDIATRIC MINOR PAINFUL INJURIES OR PROCEDURES: o Anytime pain control is needed but oral medication is too slow OR IV access not obtainable o Burn dressing changes o Re-packing wounds such as abscesses o Any time you consider an IM shot for pain control (IN works as well or better with faster onset and no pain on delivery) 2. Titration of opiates is often needed and very easy and effective – repeat does every 15 minutes until desired effect is obtained. 3. Research data now demonstrates IN opiates are as effective as IV, just faster due to no delays in obtaining an IV:

APPROPREATE DELIVERY METHOD: 1. 1/3 to ½ ml per nostril is ideal but you can push up to 1 ml per nostril though some will run off. If you need more than 2 ml total, consider titration with second dose in 5 minutes. 2. Consider administering an oral pain medication at the same time as the nasal medication or after about 15 minutes. This way as the effect of the nasal drug wanes, the effect of the oral medication begins to have an effect. 3. The single biggest reason for failure of intranasal opiates is the clinician gives an in-appropriate dose (i.e. they underdose with an IV dose which tends to be too low). Be aware of the “dead space” in your delivery atomizer and add that extra volume to your dose You should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.1 ml represents a typical dead space in a 1 ml syringe connected to a syringe driven atomizer.

• • If the volume exceeds 1 ml you might want to consider delivering as two separate doses 5 minutes apart**

Volumes in this range should definitely be divided in half and administered 5 minutes apart to reduce runoff

Fentanyl, for IN delivery a. Reasonable IN starting dose for painful procedures: 1. Fentanyl: 2 ug/kg (comes in 50 ug/ml) (best for children) b. Be Wary of respiratory depression – monitor patients with pulse oximetry and close observation whenever using this powerful opiate. c. Titration to pain is often necessary – repeat dosing (1/2 to full dose) every 15 minutes until desired effect is achieved. d. Be aware of dead space in delivery device: – failure to account for the device dead space may lead to under-dosing of these highly concentrated drugs.