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PEDIATRIC ANESTHESIA

Explosive Coughing After Bolus Fentanyl Injection

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

Top Introduction Case Report Discussion References

 
Reflex coughing after a preinduction IV bolus of fentanyl was observed in controlled studies reported by Böhrer et al. (1) in 1990 and by Phua et al. (2) in 1991, though neither reported morbidity. Bailey et al. in Miller’s Fifth Edition of Anesthesia (3) state that "Curiously, fentanyl, sufentanil and alfentanil elicit a brief cough in up to 50% of patients when injected by IV bolus." However, fentanyl-induced coughing may not always be brief and benign. We report a case of explosive, spasmodic coughing after peripheral IV injection of fentanyl that was severe enough to produce periorbital petechiae and was only relieved after induction of general anesthesia.

	Case Report

Top Introduction Case Report Discussion References

 
The patient was a 7-yr old Saudi boy with Trisomy-21 syndrome who was admitted to hospital for dental surgery under general anesthesia. This was to be his first general anesthetic and his past medical history mentioned only the usual childhood illnesses and suspected allergies to penicillin and sulfa drugs. There was no history of environmental allergies, respiratory tract disease, or congenital heart malformations nor any recent fever, cough, or sore throat. His height and weight were 116 cm and 27.5 kg, oral temperature 35.9°C, arterial blood pressure 90/58 to 100/60 mm Hg, heart rate 90–100 bpm, and respiratory rate 18–20/min. There was no macroglossia and airway examination was normal (Mallampati score III). Auscultation of his chest revealed neither adventitious sounds in his lungs nor cardiac murmurs. Preoperative laboratory results were as follows: white blood count 8.15 x 10⁹/L with a normal differential count, hemoglobin 114 g/L, and platelet count of 456 x 10⁹/L. The prothrombin time was 12.3 s (lab normal 11.9–14.3), partial thromboplastin time 32.3 s (lab normal 34.7–42.2), and international normalized ratio was 1.0. Other routine lab results were normal.

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 2–3 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

Top Introduction Case Report Discussion References

 
Fentanyl-elicited coughing, though common, has not been viewed as a serious anesthetic complication. A MEDLINE search using the terms "fentanyl and cough*" and "fentanyl and tussive" identified only five references. In the first reported controlled study, Böhrer et al (1) found that 46% of patients coughed after receiving 7 µg/kg through a central venous catheter. Phua et al. (2) observed that 28% of patients coughed after 1.5 µg/kg IV of fentanyl injected through a peripheral cannula and that coughing was prevented by morphine but not by atropine or midazolam. The rapid response of the reflex and morphine’s efficacy in preventing cough suggest that a pulmonary chemoreflex is the likely mechanism, mediated by either irritant receptors (rapidly adapting receptors) or by vagal C-fiber receptors that are close to pulmonary vessels (J or juxtacapillary receptors) (3). However, fentanyl-induced vocal cord spasm and vagally mediated bronchoconstriction may also be important. In support of bronchoconstriction, Lui et al. (4) demonstrated that inhalation of a selective ß 2-adrenergic bronchodilator, terbutaline, suppressed the reflex.

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 8–15 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.

	References

Top Introduction Case Report Discussion References

 

1. Bohrer H, Fleischer F, Werning P. Tussive effect of a fentanyl bolus administered through a central venous catheter. Anaesthesia 1990; 45: 18–21.[ISI][Medline]
2. Phua WT, Teh BT, Jong W, et al. Tussive effect of a fentanyl bolus. Can J Anaesth 1991; 38: 330–4.[Abstract/Free Full Text]
3. Bailey PL, Egan TD, Stanley TH. Intravenous opioid anesthetics. In: Miller RD, ed. Anesthesia. 5th ed. New York: Churchill Livingstone, 2000: 294.
4. Lui PW, Hsing CH, Chu YC. Terbutaline inhalation suppresses fentanyl-induced coughing. Can J Anaesth 1996; 43: 1216–9.[Abstract/Free Full Text]
5. Gin T, Chui PT. Coughing after fentanyl [letter]. Can J Anaesth 1992; 39: 406.[Medline]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (10) Citing Articles via Google Scholar Google Scholar Articles by Tweed, W. A. Articles by Dakin, D. Search for Related Content PubMed PubMed Citation Articles by Tweed, W. A. Articles by Dakin, D. Related Collections Pediatrics Pharmacology

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999