Comparative review of the clinical use of intranasal fentanyl versus morphine in a paediatric emergency department

Objectives: Comparison of intranasal fentanyl (INF) and parenteral morphine in children in an ED. Primary objective was to compare time to analgesia from presentation, with secondary objectives to assess patient profiles, specifics of opiate analgesics used plus rate of i.v. access for analgesia alone. Setting: Tertiary paediatric ED. Methods: Retrospective review of case notes identified through controlled drug register. Patients who received INF and/or parenteral morphine between 1 January and 31 March 2005 (before introduction of fentanyl) and in corresponding months in 2006 and 2007 were included. Results: A total of 617 patients were included. Geometric mean time to analgesia was statistically different for INF versus morphine in 2006 (31.2 min, SD 2.6 vs 55.6 min, SD 2.4) and in 2007 (23.7 min, SD 2.8 vs 53.1 min, SD 3.1) (both P < 0.000). Mean initial dose of INF in 2007 was 1.46 µg/kg (SD 0.11) compared with 1.32 µg/kg (SD 0.36) in 2006 [Correction made 22 May 2009 after publication: all 17 instances of fentanyl dosing and concentrations have been corrected from milligrams (mg) to micrograms (µg)]. Mean total dose in 2007 was 2.14 µg/kg (SD 0.93), increased from 1.60 µg/kg (SD 0.56) in 2006. INF was used most commonly for fractures and morphine for abdominal pain. The i.v. access for opiate analgesia decreased from 161/161 (100%) in 2005 to 99/237 (41.8%) in 2007. Conclusion: Use of INF in our paediatric ED setting was associated with a significantly reduced time to analgesia for patients requiring immediate analgesia compared with parenteral morphine. Since the introduction of an INF protocol to our department in mid‐2005, INF use has increased, with a corresponding decrease in the use of morphine and a reduction in i.v. access for analgesia.