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King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
Address correspondence and reprint requests to Dr. William A. Tweed, Department of Anesthesiology, King Faisal Specialist Hospital & Research Centre, MBC-22, PO Box 3354, Riyadh 11211, Kingdom of Saudi Arabia. Address e-mail to anesthesiology@ kfshrc.edu.sa.
| Introduction |
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| Case Report |
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The child was separated from his parents and brought to the operating room unpremedicated but calm and cooperative. A #22 IV cannula had been placed in the dorsum of his left hand. After attachment of monitors and before preoxygenation, a 50-µg IV bolus of fentanyl (2 µg/kg) was injected and flushed through his IV cannula with normal saline. Within 30 s he began to cough explosively and struggled to a sitting position. Except for saliva, the cough was unproductive. Coughing persisted in spasmodic bursts for a further 23 min until anesthesia was induced with propofol 60 mg and atracurium 15 mg IV. With induction of anesthesia the coughing immediately ceased and ventilation of his lungs was easily achieved using a mask and oral airway. Intubation of the trachea with a 5F uncuffed nasal tracheal tube was accomplished easily without further coughing or "bucking." The remainder of the anesthetic was uneventful and there was no coughing during recovery or during the early postoperative period. After tracheal intubation and before surgery numerous conjunctival and periorbital petechiae were noted but none were noted elsewhere on his body. The rash was obvious enough to immediately alarm his parents postoperatively but had begun to fade by the end of the first postoperative day.
| Discussion |
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Böhrer et al. (1) reported that usually there were two to four coughs in sequence but in 4 of the 17 patients who coughed after fentanyl there was a staccato series of 815 cough efforts. Gin and Chui (5) observed a young patient with acute extradural hematoma who had continuous coughing for five seconds before suppression by thiopentone. The present case, however, is the first report of explosive spasmodic coughing with morbidity, that is, a petechial rash that was obvious enough to alarm his parents. Although a cause and effect relationship is impossible to prove, the temporal relationships and absence of other causative factors support the conclusion that this was an exaggerated reflex response to fentanyl. In situations where coughing should be avoided, such as anesthetic induction of patients an open eye injury or increased intracranial pressure, fentanyl (and probably also sufentanil and alfentanil) may not be suitable as the first drug of the anesthetic induction sequence.
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