Intranasal fentanyl paediatric clinical practice guidelines

Dear Editor, It was with great interest that we read the paper from Drs Dalton and Babl. They suggested that collaboration would likely decrease duplication of effort and increase the number of available, current and evidencebased clinical practice guidelines. Dr Babl was involved in the development of a research collaborative – the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network of ED – which includes all the paediatric ED and several large mixed ED in Australia and New Zealand. Site representatives from the PREDICT network meet biannually and teleconferences occur between these face-to-face meetings. Knowledge translation occurs in the form of informal discussion and sharing of clinical practice guidelines. Intranasal fentanyl is an effective needle-free pain treatment acceptable to children. Intranasal fentanyl use has increased based on clinical experience of effectiveness and following several publications, including randomized controlled trials in Australia. Recently, a survey of the PREDICT network site representatives was done to determine the use of clinical practice guidelines for the provision of intranasal fentanyl. The survey goal was to determine if practice variation existed between ED to determine where further research might be warranted. All 13 PREDICT ED responded, and all had a protocol which they provided. Remarkable uniformity was found. The lowest age limit for intranasal fentanyl use was 1 year in nine ED, and 3 years in one ED. Two ED used 10 kg as their lowest use weight limit. One ED had no specific limit, but care was advised under 10 kg. The routine recommended dose was 1.5 mg/kg in 12 of 13 ED; the other ED reported a range of 1–2 mg/kg. Eleven ED used the standard i.v. formulation of 50 mg/mL solution, and two ED used a specially produced 300 mg/mL formulation. All ED used the Tory Wolfe Medical mucosal atomiser device (Salt Lake City, UT, USA); one also had a Go Medical Nasal Inhaler (Go Medical, Subiaco, WA, Australia) atomiser delivery device. Indication descriptions varied but were of consistent intent, namely, moderate to severe pain in a child without i.v. access. Intranasal fentanyl has also been used before hospital mainly in adults. Four ED in three Australian states (WA, NSW, SA) reported that their ambulance service used intranasal fentanyl. Although not a causal relationship, this survey supports Drs Dalton and Babl’s assertions that collaboration aids dissemination of practice guidelines. Areas of practice variation that might be of interest for future research include: determining which concentration of intranasal fentanyl is more effective; effectiveness and safety in infancy and early childhood; and effectiveness and safety for prehospital intranasal fentanyl use in children.