Intranasal drug delivery in anesthesia

Intranasal Medications in Anesthesia : 

Intranasal Medications in Anesthesia

Scenario 1: Frightened child : 

Scenario 1: Frightened child Your prior case turned over quickly and you are ready to take the next patient, a 5-year old boy, back to the operating room. However: He will not relax and clings to his parent, screaming and afraid. He does not have an IV in place and is terrified of needles. You administer 0.5 mg/kg of IN midazolam and 10 minutes later he is dozing off and is easily separated from his parent and taken into the operating suite.

Scenario 2: Myringotomy : 

Scenario 2: Myringotomy Following mask induction and placement of ear tubes, your child is awakening and is becoming agitated. He does not have an IV in place since it is not required for this short case You administer 2.0 mcg/kg of IN fentanyl and by the time the child awakens his pain is well controlled and he is not agitated.

Why IN medications? : 

Why IN medications? This delivery route has several advantages: Its easy and convenient Almost everyone has a nose The nose is a very easy access point for medication delivery - even easier to access than IM or IV sites No special training is required to deliver the medication No shots are needed It is painless It eliminates any risk of a needle stick to the medical provider

Understanding IN delivery: Definitions : 

Understanding IN delivery: Definitions First pass metabolism Nose brain pathway Lipophilicity Bioavailability These have already been reviewed in Part 1 – please refer to that broad cast for overview details

Pre-operative pediatric sedation : 

Pre-operative pediatric sedation Nasal sedative Medications to enhance separation from parents • Midazolam • Sufentanil • Dexmedetomidine

Pre-operative pediatric sedation : 

Pre-operative pediatric sedation Zedie: Comparison of intranasal midazolam and sufentanil premedication in pediatric outpatients. Clin Pharmacol Ther 1996 Pre-operative sedation 30 minutes prior to anesthesia induction with Midazolam or Sufentanil “Both intranasal midazolam and sufentanil provide rapid, safe, and effective sedation in small children before anesthesia for ambulatory surgery.”

Pre-operative pediatric sedation : 

Pre-operative pediatric sedation Saint-Maurice: The use of midazolam in diagnostic and short surgical procedures in children. Acta Anaesthesiol Scand Suppl 1990 “a relatively safe, adaptable, non-invasive method of inducing sedation in children”

Pre-operative pediatric sedation : 

Pre-operative pediatric sedation Henderson: Pre-induction of anesthesia in pediatric patients with nasally administered sufentanil. Anesthesiology 1988 Prospective placebo controlled RCT 80 patients given IN sufentanil versus IN saline Results Easier separation, calmer within 10 minutes Moved less, coughed less, required less halothane during intubation Cried less, fewer analgesics during awakening – but no increase in time Few side effects at dose of 1.5 to 3.0 mcg/kg Higher dose of 4.5 mcg/kg is too much (nausea, vomiting, stiffer chest)

Pre-operative pediatric sedation : 

Pre-operative pediatric sedation Yuen: A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial. Anesth Analg 2008 Prospective placebo controlled RCT 96 patients given IN dexmedetomidine versus oral midazolam Results Similar rates of separation acceptance, behavior at induction and wake up scores for all groups More sedation in the IN dexmedetomidine groups

Pre-operative pediatric sedation : 

Pre-operative pediatric sedation Conclusions: Many additional articles exist confirming the efficacy of intranasal medications for pre-operative sedation and reduction of separation anxiety. The onset of action is faster than oral pre-operative sedation and requires less patient participation, though it may cause transient nasal burning (midazolam). Intranasal pre-operative sedation is another “TOOL” expanding your options for sedation.

Post-operative pain control : 

Post-operative pain control Nasal Pain Medication • Fentanyl • Sufentanil Potential indications: • Myringotomy • Other procedures where opiates are appropriate

Post-operative pain control : 

Post-operative pain control Finkel: The effect of intranasal fentanyl on the emergence characteristics after sevoflurane anesthesia in children undergoing surgery for bilateral myringotomy tube placement. Anesth Analg 2001 “nasally administered fentanyl … was found to reduce the incidence of agitation in these patients”

Post-operative pain control : 

Post-operative pain control Galinkin: Use of intranasal fentanyl in children undergoing myringotomy and tube placement. Anesthesiology 2000 Prospective, placebo controlled, RCT 265 patients, mask induction, randomized to IN fentanyl (2 mcg/kg) or IN saline Results for IN fentanyl vs. IN saline Diminished post-operative agitation No increase in nausea, vomiting, hypoxemia

Post-operative pain control : 

Post-operative pain control Heshmati, Ir J Pharm, 2006. Intranasal sufentanil for treatment of postoperative pain following abdominal surgery Dose – 0.7 mcg/kg Onset of good pain control within 10 minutes

Post-operative pain control : 

Post-operative pain control Manjushree: Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients. Can J Anaesth 2002 “The intranasal route provides a good alternative for administration of fentanyl in pediatric surgical patients”

Post-operative pain control : 

Post-operative pain control Conclusions: Many additional articles exist confirming the efficacy of intranasal opiates for post operative pain control in both adults and children. The indications may be limited since most patients will have intravenous access – BUT if they do not this is an effective route of opiate delivery with efficacy comparable to IV opiates. Once again - Intranasal opiate administration is another “TOOL” expanding your options for pain control.

Photo guide for IN drug delivery : 

Photo guide for IN drug delivery Collect supplies: Proper drug in correct concentration Syringe Method to aspirate drug from vial Atomization delivery device

Photo guide for IN drug delivery : 

Photo guide for IN drug delivery Aspirate drug Connect atomizer

Photo guide for IN drug delivery : 

Photo guide for IN drug delivery Deliver drug: Place atomizer against nostril and briskly compress to deliver half the drug to one nostril Move atomizer to other nostril and repeat – delivering the remaining drug into that nostril