1. Michel J. Sabbagh, M.D., Maunak V. Rana, M.D. Intraoperative Intrasal Opioid Delivery Michel J. Sabbagh, M.D., Maunak V. Rana, M.D. Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA Conclusions Abstract References Case Description Discussion Intranasal medication delivery has good absorption from the nasal mucosa, is needleless, and bypasses first-pass metabolism. We present a case of intraoperative intranasal opioid delivery in a 17 year old non- verbal autistic female presenting for dental rehabilitation. The patient was premedicated with 4mg/kg of ketamine and 0.2mg of glycopyrrolate intramuscularly. Intraoperative pain control was achieved using intranasal fentanyl boluses of 1mcg/kg. The patient was extubated smoothly, and transferred to the recovery room with stable vital signs, where she remained calm and collected until her discharge. Intranasal fentanyl specifically has been shown to have similar onset and duration as intravenous formulations. We present a case of intraoperative intranasal opioid delivery in a 17 year old non- verbal autistic female presenting for extensive dental rehabilitation. The patient was assessed preoperatively with her parents at her bedside. She was premedicated with 4mg/kg of ketamine and 0.2mg of glycopyrrolate intramuscularly. The patient was then transported to the operating room where intravenous access was established and general anesthesia was induced after application of standard monitors. Nasal intubation was performed atraumatically and was well tolerated. The procedure was then started and intraoperative pain control was achieved using intranasal fentanyl boluses of 1mcg/kg as needed. At the procedure’s end, extubation occurred smoothly, and the patient was transferred to the recovery room with stable vital signs, where she remained calm and collected until her discharge. There are several advantages to intranasal medication delivery. It is noninvasive, well absorbed from the highly vascularized nasal mucosa, is needleless, venous drainage bypasses first-pass metabolism, rapid absorption and plasma concentration, reduces the risk of needlestick to the staff, and has some patient controlled analgesia applications. Side effects of the intranasal route include a bitter or burning taste, stinging in the nose, coughing, and nasal pruritus. Commonly used intranasal medications include midazolam, ketamine, fentanyl, sufentanil, morphine, naloxone, ketorolac, butorphenol, and dexmedetomidine. Fentanyl especially lends itself to the intranasal route due to its high lipid solubility, low molecular weight, and high potency. Intranasal fentanyl specifically has been shown to have similar onset and duration as intravenous formulations, and it has gained popularity in settings where intravenous access is difficult or would be otherwise unnecessary. These include the prehospital setting, the emergency room – especially in the pediatric population, postoperatively in a patient controlled formulation, and for breakthrough pain in the chronic pain patient population. Intranasal medication delivery can be accomplished in a dry powder or in solution form, as a nasal spray, as a nasal dropper, or as a nebulized inhaler. Intranasal medication administration is a viable option for rapid and effective medication delivery. The vascularity of the nasal mucosa and its ease of access make this route of administration an important alternative to traditional methods, especially in settings where intravenous access is not necessary. Patient controlled intranasal analgesia may become more prevalent as devices which emphasize safety and efficacy become widely available. 1.Striebel HW, Koenigs D, Krämer J. Anesthesiology. 1992 Aug;77(2):281-5. 2.Viscusi ER. Reg Anesth Pain Med. 2008 Mar-Apr;33(2):146-58. 3.Christrup LL, Foster D, Popper LD, et al. Clin Ther. 2008 Mar;30(3):469- 81. Taken from Christrup LL, et al. Clin Ther 2008;30:469-81. Figure 1. (A) Mean (SD) plasma concentration-time profiles after IN and IV dosing 100  g of fentanyl (n=7). (B) Expanded plot of the first 25 minutes.