Legal Notices

Palliative Care Incident Pain and Incident Dyspnea Protocol
Last Edited Dec. 31, 2014
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(Please also read Legal Notices for a more comprehensive disclaimer)

The information provided on the Web site is for Health Care Practitioners and is for informational purposes only. It is not professional medical advice, diagnosis, treatment or care, nor is it intended to be a substitute therefor.

If you are a Health Care Professional this information is shared with you
on the express condition that you will use your own expertise and
professional judgment in applying any information to a specific
case. This is general information only the validity of which may be
affected by individual patient factors that are unknown to the

It is the responsibility of those using this information to ensure
appropriate interpretation and application is undertaken with
regards to any specific clinical situation.
Please feel free to use this protocol, and to modify it as needed in order to meet specific needs of your practice/program. It is not necessary to seek my permission to do so, or to acknowledge its source. It is offered to the public domain without restrictions.
My Contact Info
Mike Harlos MD, CCFP, FCFP
Professor and Section Head, Palliative Medicine, University of Manitoba
Medical Director, Adult and Pediatric Palliative Care Program, Winnipeg Regional Health Authority
Rm. A8024, 409 Taché Ave.    Winnipeg, Manitoba, Canada   R2H 2A6
Ph:1-204-235-3929  Fax:1-204-237-9162

Clinical Cautions
This protocol is intended for use on adults. For pediatric dosing refer to the references linked at the bottom of this page, or consult with an appropriate expert.
See also: for pediatric doses.

The fentanyl and sufentanil preparations used in this protocol are extremely potent opioids (approximately 100x and 1000x the potency of morphine, respectively... approximate equivalences are: Morphine 10 mg = Fentanyl 100 micrograms = Sufentanil 10 micrograms). Consequently, they must be used with appropriate clinical assessment and monitoring, particularly when first initiating use on a patient.

In opioid naïve patients, or frail patients with small body mass, consider starting at 12.5 or 25 micrograms of fentanyl sublingually or intranasally

Definition of Incident Pain and Incident Dyspnea , and Statement of Purpose of the Protocol
Incident Pain/Incident Dyspnea are defined as pain/dyspnea which comes on as a result of an action or activity.
Examples of situations in which the Incident Pain and Incident Dyspnea Protocol is initiated: The purpose of this protocol is to facilitate effective management of Incident Pain and/or Incident Dyspnea in palliative care patients through the use of very short acting opioids, minimizing the lingering adverse effects of breakthrough opioids when the patient is at rest.

Implementation of the Incident Pain and Incident Dyspnea Protocol assumes that the Protocol will be initiated at Step 1 (see table below).

Steps of the Incident Pain and Incident Dyspnea Protocol

Step Medication # micrograms SL/Intranasal* (50 microgm/ml)
1 Fentanyl 50
2 Sufentanil 25
3 Sufentanil 50
4 Sufentanil 100 **

* For intranasal administration in adults, volumes above 0.5 ml will not be well absorbed, tending to drip down the back of the throat and be swallowed. The oral bioavailability (i.e. after swallowing) is only approx. 30% compared to up to 89% intranasally. Volumes greater than 0.5 ml should be divided between nostrils when possible.
** A dose of 100 micrograms requires 2 ml of the 50 micrograms/ml preparation, which is a rather large volume to be absorbed transmucosally at once. It is recommended that it be given in two portions of 1 ml (50 micrograms) each, 10 - 15 minutes apart (if used intranasally, dividing into 0.5 ml aliquots per nostril). The planned activity (dressing change, moving the patient, etc) should wait until 10 - 15 minutes after the second portion.

Application of the Incident Pain and Incident Dyspnea Protocol
  1. The short acting opioid (fentanyl or sufentanil) is administered sublingually or intranasally 10-15 minutes prior to anticipated activity (see Incident Pain and Incident Dyspnea Protocol Table for dose). For sublingual administration, the patient is asked to try to hold the liquid under the tongue for about 10 minutes if possible without swallowing it. The may be challenging for some patients; my preference is for intranasal administration.
  2. If the initial dose appears to be insufficient, that same dose may be repeated up to two further doses, at 10-15 minute intervals.
    If a given dose is sufficient, the patient will typically appear drowsy 10 - 15 minutes following the dose. If this is not the case, or if the patient experiences discomfort during the planned activity, then repeat doses may be given up to a total of three as stated above.
  3. Progression to the next step on the Incident Pain and Incident Dyspnea Protocol is undertaken at the discretion of the Registered Nurse who has the approval to use the Protocol, or the physician. All increases or decreases of doses MUST be written on the Physician's Order Sheet by the Registered Nurse or physician.
    Increasing to the next step of the Incident Pain and Incident Dyspnea Protocol is undertaken if the maximum number of doses (three) is required to achieve comfort, or is insufficient to achieve comfort with activity. Increasing to the next step of the Incident Pain and Incident Dyspnea Protocol cannot be done within one hour of the last dose of fentanyl or sufentanil on the most recent implementation, except after contacting the physician. If the maximum number of doses (three) has been given, and the patient remains in discomfort with activity that must be undertaken presently, the physician should be contacted for consideration of immediately proceeding to the next step of the Incident Pain and Incident Dyspnea Protocol.
  4. The Incident Pain and Incident Dyspnea Protocol may be used up to q 1h prn.

As an alternative approach (this isn't part of the protocol)...
Consider nasal sufentanil (50 micrograms/ml undiluted injectable preparation) using a metered-dose nasal sprayer which delivers 0.1 ml per spray. This will deliver 5 micrograms sufentanil per spray, which is roughly equivalent to 5 mg morphine. This can be very useful for in-home care, where the preparation of multiple pre-drawn syringes can be tedious. 
The patient simply takes one or more sprays approximately 10 - 15 minutes prior to activity, such as mobilizing to the toilet, or having a dressing changed.

See also:

Click herefor references

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Created on ... March 17, 2001