Overview

Definition: Intranasal (IN) administration of fentanyl and ketamine provides a rapid, effective, and relatively non-invasive route for analgesia and sedation in pediatric patients within the emergency department, particularly for painful procedures or acute pain management.
Epidemiology:
-Acute pain is common in pediatric emergency departments, stemming from trauma, fractures, lacerations, and various medical conditions
-Effective pain management improves patient comfort, reduces anxiety, and facilitates procedures
-IN medications offer a valuable alternative when IV access is difficult or undesirable.
Clinical Significance:
-Timely and effective pain control is a critical component of pediatric emergency care
-Intranasal fentanyl and ketamine offer rapid onset of action, bypass the need for challenging IV or IM routes, and are associated with good safety profiles when used appropriately, making them essential tools for pediatric residents preparing for DNB and NEET SS exams.

Age Considerations

Infants:
-Careful dose titration is crucial
-Risk of respiratory depression and apnea is higher
-Monitor airway and breathing closely
-Use with caution in neonates due to immature metabolic pathways.
Toddlers:
-Often fearful of medical procedures
-IN route can significantly reduce anxiety
-Dosing requires careful calculation based on weight
-Behavioural management is key alongside pharmacotherapy.
Older Children:
-May tolerate verbal reassurance better but still experience significant pain
-IN route is often preferred over IM injections
-Potential for psychological distress should be addressed.
Adolescents:
-May express pain more verbally
-Choice of agent and dose should be tailored to pain severity and procedure
-Concerns regarding diversion or misuse of potent analgesics should be considered in context.

Pharmacology

Intranasal Fentanyl:
-A potent synthetic opioid agonist
-Rapid absorption through nasal mucosa leads to quick systemic availability
-Onset of analgesia within 5-10 minutes
-Duration of action 30-60 minutes
-Metabolized by CYP3A4.
Intranasal Ketamine:
-An NMDA receptor antagonist and dissociative anesthetic
-Provides analgesia, anxiolysis, and amnesia
-Rapid absorption via nasal mucosa
-Onset of analgesia and sedation within 5-10 minutes
-Duration of effects 30-60 minutes
-Primarily excreted unchanged in urine.
Mechanism Of Action:
-Fentanyl acts on mu-opioid receptors in the central nervous system to inhibit pain signal transmission
-Ketamine blocks NMDA receptors, preventing central sensitization and reducing the perception of pain, while also inducing a dissociative state.
Synergistic Effects:
-Combined use of fentanyl and ketamine can provide superior analgesia and sedation compared to either agent alone, allowing for lower individual doses and potentially reducing side effects
-Careful titration is essential.

Indications

Painful Procedures: Fracture reduction, laceration repair, burn debridement, lumbar puncture, foreign body removal, venous access attempts, circumcision.
Acute Pain Management: Significant pain from trauma (e.g., significant contusions, sprains), sickle cell crisis, severe headache, or other acute painful medical conditions.
Patient Preference: When patients or guardians express a strong preference for non-invasive routes or have a history of difficult venous access.
Procedural Sedation: Facilitation of procedures requiring patient immobility and reduced anxiety, especially when IV access is challenging or contraindicated.

Management

Fentanyl Dosing:
-Typically 1.5-2 mcg/kg per nostril (total 3-4 mcg/kg), administered via mucosal atomization device (MAD Nasal device)
-Maximum dose generally 50-100 mcg
-Repeat doses may be considered based on response and patient status, not to exceed 100 mcg total for IN administration.
Ketamine Dosing:
-Typically 0.5 mg/kg per nostril (total 1 mg/kg), administered via MAD Nasal device
-Can be increased to 1 mg/kg per nostril (total 2 mg/kg) for deeper sedation or more severe pain
-Onset 5-10 minutes, duration 30-60 minutes.
Combined Dosing:
-A common regimen is IN fentanyl 1.5 mcg/kg followed by IN ketamine 0.5-1 mg/kg, administered concurrently or sequentially
-Dosing should be guided by patient age, weight, pain severity, and desired level of sedation.
Monitoring:
-Continuous pulse oximetry, cardiac monitoring, and frequent assessment of respiratory rate, depth, and patency of airway are essential
-Monitor vital signs, level of consciousness, and pain scores
-Be prepared to manage airway and provide ventilatory support if needed
-Have reversal agents (naloxone for fentanyl) and airway adjuncts readily available.
Post Procedure Care:
-Patients should be observed in a quiet environment until vital signs are stable and they have returned to their baseline mental status
-Adequate hydration and pain management should be continued as needed
-Discharge criteria should be met prior to leaving the ED.

Contraindications And Precautions

Absolute Contraindications:
-Known hypersensitivity to fentanyl or ketamine
-Acute asthma or severe bronchospasm (relative contraindication for ketamine)
-Significant hemodynamic instability.
Relative Contraindications:
-Severe respiratory compromise
-Increased intracranial pressure (for ketamine)
-Porphyria (for ketamine)
-History of severe psychiatric disorders (ketamine).
Precautions:
-Use with caution in patients with known or suspected difficult airway
-Avoid in settings with inadequate cardiorespiratory monitoring and resuscitation capabilities
-Consider potential for emergence reactions with ketamine, especially in older children and adults.
Drug Interactions:
-Potentiation of CNS depressant effects with other sedatives, hypnotics, or opioids
-Monitor for additive respiratory depression.

Complications

Respiratory Depression:
-The most significant risk with both agents, particularly fentanyl
-May manifest as decreased respiratory rate or tidal volume, leading to hypoxia or hypercapnia.
Hypotension And Hypertension:
-Ketamine can cause transient hypertension and increased myocardial oxygen demand
-Fentanyl can cause bradycardia and hypotension.
Emergence Reactions:
-With ketamine, can include vivid dreams, hallucinations, delirium, or dysphoria
-Usually transient and can be managed with reassurance or benzodiazepines.
Nausea And Vomiting:
-Can occur with both agents, though more common with opioids
-Management may include antiemetics.
Laryngospasm Bronchospasm:
-Rare but possible, especially with ketamine
-Requires prompt recognition and management.

Key Points

Exam Focus: Understanding the pharmacokinetic profiles, appropriate dosing strategies (mcg/kg for fentanyl, mg/kg for ketamine), administration routes (MAD device), and essential monitoring parameters for IN fentanyl and ketamine in pediatric emergencies is critical for DNB and NEET SS exams.
Clinical Pearls:
-Always use a mucosal atomization device (MAD) for optimal IN delivery
-Start with lower doses and titrate to effect
-Ensure continuous monitoring of ABCs
-Have naloxone and airway support readily available when administering fentanyl
-Reassurance and a calm environment are crucial adjuncts to pharmacotherapy.
Common Mistakes:
-Underestimating respiratory depression risk
-Inadequate monitoring
-Incorrect calculation of doses (e.g., confusing mcg and mg)
-Failure to have reversal agents and airway equipment readily accessible
-Over-sedation leading to prolonged recovery.