LETTER TO THE EDITOR

Intranasal fentanyl paediatricclinical practice guidelinesemm_1207 335

Dear Editor,It was with great interest that we read the paper fromDrs Dalton and Babl.1 They suggested that collabora-tion would likely decrease duplication of effort andincrease the number of available, current and evidence-based clinical practice guidelines.

Dr Babl was involved in the development of aresearch collaborative – the Paediatric Research inEmergency Departments International Collaborative(PREDICT) research network of ED – which includes allthe paediatric ED and several large mixed ED in Aus-tralia and New Zealand.2 Site representatives from thePREDICT network meet biannually and teleconferencesoccur between these face-to-face meetings. Knowledgetranslation occurs in the form of informal discussionand sharing of clinical practice guidelines.

Intranasal fentanyl is an effective needle-free paintreatment acceptable to children.3 Intranasal fentanyluse has increased based on clinical experience of effec-tiveness and following several publications, includingrandomized controlled trials in Australia.4

Recently, a survey of the PREDICT network site rep-resentatives was done to determine the use of clinicalpractice guidelines for the provision of intranasal fenta-nyl. The survey goal was to determine if practice varia-tion existed between ED to determine where furtherresearch might be warranted.

All 13 PREDICT ED responded, and all had a proto-col which they provided. Remarkable uniformity wasfound. The lowest age limit for intranasal fentanyl usewas 1 year in nine ED, and 3 years in one ED. Two EDused 10 kg as their lowest use weight limit. One ED hadno specific limit, but care was advised under 10 kg. Theroutine recommended dose was 1.5 mg/kg in 12 of 13ED; the other ED reported a range of 1–2 mg/kg. ElevenED used the standard i.v. formulation of 50 mg/mL solu-tion, and two ED used a specially produced 300 mg/mLformulation.

All ED used the Tory Wolfe Medical mucosal atom-iser device (Salt Lake City, UT, USA); one also had aGo Medical Nasal Inhaler (Go Medical, Subiaco, WA,

Australia) atomiser delivery device. Indication descrip-tions varied but were of consistent intent, namely, mod-erate to severe pain in a child without i.v. access.

Intranasal fentanyl has also been used before hospitalmainly in adults.5 Four ED in three Australian states(WA, NSW, SA) reported that their ambulance serviceused intranasal fentanyl.

Although not a causal relationship, this survey sup-ports Drs Dalton and Babl’s assertions that collabora-tion aids dissemination of practice guidelines. Areas ofpractice variation that might be of interest for futureresearch include: determining which concentration ofintranasal fentanyl is more effective; effectiveness andsafety in infancy and early childhood; and effectivenessand safety for prehospital intranasal fentanyl use inchildren.

References

1. Dalton S, Babl FE. Paediatric emergency guidelines: could onesize fit all? Emerg. Med. Australas. 2009; 21: 67–70.

2. Babl F, Borland M, Ngo P et al. Paediatric Research in Emer-gency Departments International Collaborative (PREDICT): firststeps towards the development of an Australian and NewZealand research network. Emerg. Med. Australas. 2006; 18:143–7.

3. Borland ML, Clark LJ, Esson A. Comparative review of the clini-cal use of intranasal fentanyl versus morphine in a paediatricemergency department. Emerg. Med. Australas. 2008; 20: 515–20.

4. Borland M, Jacobs I, King B, O’Brien D. A randomized controlledtrial comparing intranasal fentanyl to intravenous morphine formanaging acute pain in children in the emergency department.Ann. Emerg. Med. 2007; 49: 335–40.

5. Rickard C, O’Meara P, McGrail M, Garner D, McLean A, LeLievre P. A randomized controlled trial of intranasal fentanyl vsintravenous morphine for analgesia in the prehospital setting.Am. J. Emerg. Med. 2007; 25: 911–17.

David Herd1 and Meredith Borland2

1Mater Children’s Hospital, Raymond Terrace, South Brisbane,

Queensland, and 2Princess Margaret Hospital for Children,

Emergency Department, Perth, Western Australia, Australia

doi: 10.1111/j.1742-6723.2009.01207.x Emergency Medicine Australasia (2009) 21, 335

© 2009 The AuthorsJournal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine