(482) Daily application of transdermal fentanyl in patients receiving hyperbaric oxygen therapy

Abstract

Therapy with hyperbaric oxygen (HBOT) can pose challenges in pain management when a patient’s drug regimen involves topical drug delivery. Safety protocols require that topically applied medications be removed from patients prior to entrance in the hyperbaric chamber, and many institutional policies state that removed patches are not to be re-applied. Ideally, a patient’s analgesic regimen would be changed to oral or parenteral analgesics while HBOT is underway. However, in certain instances this is not feasible, therefore, clinicians must seek safe methods of providing adequate analgesia to support patient adherence to HBOT. Transdermal fentanyl has a specialized drug delivery mechanism and provides an advantage in terms of selecting favorable routes of administration while considering patient ease of use. Coupled with the favorable route of administration is the risk of patient harm due to various factors: use of a narcotic analgesic with potent activity, equianalgesic dosing ranges, clinician unfamiliarity with pharmacokinetics specific to this formulation, or patient uncertainty about dosing schedule or factors which may alter drug absorption. While the recommended dosing interval is 72 hours, many references discuss the use of 48 hour intervals in select patients, and no published reference recommends dosing intervals shorter than 48 hours. This case series discusses the use of transdermal fentanyl, applied every 24 hours, in patients undergoing hyperbaric oxygen therapy for wound care. Patient 1 was a 47 year old female with diabetes mellitus, sepsis, and left foot wound with toe necrosis. Complicating her management was the presence of chronic pain syndrome secondary to fibromyalgia. Patient 2 was a 70 year old female with paralysis secondary to spinal fracture who presented with a stage IV sacral pressure ulcer, who was later diagnosed with osteomyelitis. Both patients were successfully managed with daily application of fentanyl transdermal patch. Therapy with hyperbaric oxygen (HBOT) can pose challenges in pain management when a patient’s drug regimen involves topical drug delivery. Safety protocols require that topically applied medications be removed from patients prior to entrance in the hyperbaric chamber, and many institutional policies state that removed patches are not to be re-applied. Ideally, a patient’s analgesic regimen would be changed to oral or parenteral analgesics while HBOT is underway. However, in certain instances this is not feasible, therefore, clinicians must seek safe methods of providing adequate analgesia to support patient adherence to HBOT. Transdermal fentanyl has a specialized drug delivery mechanism and provides an advantage in terms of selecting favorable routes of administration while considering patient ease of use. Coupled with the favorable route of administration is the risk of patient harm due to various factors: use of a narcotic analgesic with potent activity, equianalgesic dosing ranges, clinician unfamiliarity with pharmacokinetics specific to this formulation, or patient uncertainty about dosing schedule or factors which may alter drug absorption. While the recommended dosing interval is 72 hours, many references discuss the use of 48 hour intervals in select patients, and no published reference recommends dosing intervals shorter than 48 hours. This case series discusses the use of transdermal fentanyl, applied every 24 hours, in patients undergoing hyperbaric oxygen therapy for wound care. Patient 1 was a 47 year old female with diabetes mellitus, sepsis, and left foot wound with toe necrosis. Complicating her management was the presence of chronic pain syndrome secondary to fibromyalgia. Patient 2 was a 70 year old female with paralysis secondary to spinal fracture who presented with a stage IV sacral pressure ulcer, who was later diagnosed with osteomyelitis. Both patients were successfully managed with daily application of fentanyl transdermal patch.