We are seeing an increase in the number of ventilated patients due to COVID and options for maintaining continuous fentanyl infusions with existing pump supplies could become limited. There is some talk about using fentanyl 50 mcg/mL through the standard LVP pump with a lock box for security. From a safety perspective, this is concerning. The tubing volume, with extension sets, could easily reach 25 mL, representing 1.25 mg of fentanyl. While the LD 50 for fentanyl in humans is not known, it is estimated at 0.03 mg/kg (from monkeys). There is a risk that the pump may be programmed incorrectly, or the bag changed incorrectly, resulting in a flush of the tubing contents into the patient. For an 83 kg patient, the amount in the tubing could represent half of an LD 50 dose.

Are you aware of literature or guidance to protect against this risk? Could you share strategies in place to protect patients from an inadvertent, potentially lethal fentanyl bolus if LVP pumps have to be used?