Anesthesia Drug Handbook
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Preparation, Pharmacology, Pharmacokinetics
Principal Adverse Reactions
treatment of acute, chronic pain and cancer pain
Pain/Premedication: Transmucosal Oralets: 200-400 mcg (Adult 5 mcg/kg, Children 5-15 mcg/kg Elderly 2.5-5 mcg/kg) every 4-6 hours as needed. Oralets should be sucked and not chewed. For premedication, administer oralets 20-40 minutes prior to procedure. Oralets are contraindicated in doses > 5 mcg/kg in adults and > 15 mcg/kg in children. Do not exceed a maximum dose of 400 mcg for adults or children. Do not use in children <15 kg.
Cancer Pain: Initial : Actiq Transmucosal 200 mcg. Dose may be repeated in 30 minutes. Patients should be prescribed an initial titration supply not exceeding six 200 mcg Actiq units. Titrate dose upwards every 1-2 days until the patient reaches a dose that provides adequate analgesia using a single Actiq dosage unit per breakthrough cancer pain episode. Once a successful dose has been found, patients should limit consumption to four or fewer units per day. If consumption increases above four units per day, the dose of the long acting opioid used for persistent cancer pain should be re-evaluated. Actiq oralets are intended for use only in the treatment of breakthrough cancer pain in patients who are already receiving and who are tolerant to opioid therapy for their underlying cancer pain. Do not use Actiq for acute or postoperative pain.
Pain: Transdermal System: Initial: 25-50 mcg/hr
Maintenance: 25-100 mcg/hr.
Base dose on prior 24 hour analgesic requirements.
60 mg IM morphine dose = 360 mg PO morphine dose =100-200 mcg/hr transdermal fentanyl dose. Doses > 50 mcg/hr should only be used in patients who are already receiving and have developed some tolerance to opioids.
Each transdermal application provides 72 hours of reliable analgesic delivery. Therapeutic concentrations are not achieved until 12 to 24 hours after initial application. Initial dosage may be increased after three days. Further titration should be evaluated after two applications (6 days) on the new dose. To maintain adequate pain control, add short acting opioids p.r.n. for breakthrough pain.
IV/IM 25-100 mcg (0.7-2 mcg/kg)
Epidural: bolus 50-100 mcg (1-2 mcg/kg) infusion 10- 60 mcg/hr (0.2-0.7 mcg/kg/hr)
Spinal: bolus 5-20 mcg (0.1-0.4 mcg/kg)
IV Regional Block: Add 50 mcg (1 mcg/kg) fentanyl to Local Anesthetic. (see lidocaine, prilocaine or bupivacaine for dosing and volume).
Brachial Plexus Block: Add 50-100 mcg (1-2 mcg/kg ) fentanyl to 40 mls (0.5-0.75 mls/kg) Local Anesthetic.
Patient Controlled Analgesia IV: bolus 15-75 mcg (0.3-1.5 mcg/kg)
infusion 15- 100 mcg/hr (0.3-2 mcg/kg/hr)
Lockout Interval 3-10 mins
Patient Controlled Analgesia Epidural: bolus 4-8 mcg (0.08-0.16 mcg/kg)
infusion 5-10 mcg/hr (0.1 -0.2 mcg/kg/hr)
Lockout Interval 10 minutes
Administer analgesic regularly (not prn). Due to impaired elimination, accumulation and excess sedation may occur in patients with hepatic dysfunction. Analgesia may be enhanced by addition of adjuvant drugs e.g. NSAIDs, antidepressant agents (see front matter for drug combinations) and use of non-drug therapies e.g. TENS.
Fentanyl Citrate (Duragesic)
Transdermal: 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr.
Fentanyl Citrate (Fentanyl Oralet)
Transmucosal Oralets: 100 mcg, 200 mcg, 300 mcg, 400 mcg
Fentanyl Citrate (Actiq)
Transmucosal Oralets: 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg
Fentanyl Citrate (Sublimaze)
Injection: 50 mcg/ml
DILUTION FOR INFUSION: IV: 500 mcg in 100 mls NS (5 mcg/ml)
Epidural bolus: 50-100 mcg in 15-20 mls local anesthetic or (preservative free) NS.
infusion: 100-500 mcg in 100 mls local anesthetic or (preservative free) NS. (1-5 mcg/ml)
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Every effort has been made to ensure that the drug dosage schedules
herein are accurate and in accord with the standards accepted
at the time of publication. As new research and experience broaden
our knowledge, changes in treatment and drug therapy occur. The
medications described do not necessarily have specific approval
by the Food and Drug Administration for use in the situations
and the dosages for which they are recommended. This information
is advisory only. The package insert should be consulted for use
and dosage as approved by the FDA, for any changes in indications
and dosages and for added warnings and precautions. The ultimate
responsibility lies with the prescribing physician.
No part of this information may be reproduced or transmitted electronically
in any information storage or retrieval system, or within any
monitoring system without prior permission in writing from S.O.T.A.
Technologies (Electronic Publishers).
The Universal Drug Infusion Slide Ruler (patent pending) is now
available. It incorporates an infusion data guide and enables
infusion calculations for any drug at any dose and at any concentration.
It may be obtained by calling S.O.T.A Technologies (800 9-MEDIC-9)
TOPICAL MEDICATIONS MAY BE ORDERED (BY PRESCRIPTION ONLY) FROM L.A.
PAIN CLINIC. CALL 310 675-9121 or 1 800 9-MEDIC-9.
Copyright 2000. Sota Omoigui, M.D. All rights reserved.