Fentanyl for Sedation in the Pediatric Intensive Care Unit: Dealing with the Problems

Despite continued efforts to provide adequate analgesia and sedation for patients in the ICU, certain problems may arise that interfere with this goal. This paper presents four cases that outline some problems with fentanyl for ICU sedation, including its effects on intracranial pressure, the development of tolerance, and incompatibility with other pharmacologic agents that preclude intravenous administration. The first case describes an abrupt increase in intracranial pressure (ICP) following bolus doses of fentanyl. While the mechanisms responsible for increased ICP following fentanyl and sufentanil have not been fully delineated, animal and human studies suggest that these agents may increase ICP in patients with compromised intracranial compliance. The second case discusses the utility of switching from fentanyl to sufentanil to decrease the fluid volume required to deliver an equipotent dose. The final two cases discuss alternative routes of delivery, including subcutaneous and transdermal administration, which may become necessary when limited venous access and drug incompatibilities preclude the intravenous administration of opioids.