- Email: [email protected]
Priming dose of intravenous rocuronium suppresses fentanyl-induced coughing
Acta Anaesthesiologica Taiwanica 50 (2012) 147e149
Contents lists available at SciVerse ScienceDirect
Acta Anaesthesiologica Taiwanica journal homepage: www.e-aat.com
Original Article
Priming dose of intravenous rocuronium suppresses fentanyl-induced coughing Huei-Chi Horng 1, Bo-Feng Lin 2, Ting-Chuan Wang 3, Shinn-Long Lin 2, Wen-Jinn Liaw 2, Hung-Jui Wang 1, Chih-Shung Wong 4 * 1
Department Department Department 4 Department 2 3
of of of of
Anesthesiology, Taichung Armed Forces General Hospital, Taichung, Taiwan Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan Medical Research, Cathay General Hospital, Taipei, Taiwan Anesthesiology, Cathay General Hospital, Taipei, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 July 2012 Received in revised form 12 September 2012 Accepted 17 September 2012
Objectives: An intravenous bolus of fentanyl often induces a cough reflex. This study investigates whether priming with rocuronium can effectively attenuate fentanyl-induced coughing. Methods: The study involved 260 participants, aged between 18 and 80 years of age, who were undergoing various elective surgeries. They were randomly assigned to two groups. Patients in the study group (the rocuronium group) were treated with intravenous (IV) 0.06 mg/kg rocuronium, whereas those in the control group were treated with the same volume of normal saline. Fentanyl (1.5 mg/kg IV, given over 2 seconds) was administered 30 seconds after the injection of rocuronium or normal saline. We recorded the number of coughs for 1 minute after the fentanyl injection. Results: Patients in the rocuronium group showed a significantly lower incidence of coughing (8.5% vs. 23.1%, in the control group; p < 0.05) and a milder severity of cough in comparison with the patients in the control group. Conclusion: Pretreatment with IV rocuronium (0.06 mg/kg) suppressed the cough reflex induced by fentanyl. Therefore, priming with rocuronium may be a clinically useful method for preventing fentanylinduced cough. Copyright Ó 2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
Key words: cough; fentanyl; neuromuscular nondepolarizing agents: rocuronium bromide
1. Introduction Fentanyl is widely used for analgesia and anesthesia because of its rapid onset of action, intense analgesic effect, lower cardiovascular depressive effect, and low histamine release.1,2 However, fentanyl-induced coughing (FIC) often occurs. According to previous reports, the incidence of FIC can be as high as 65% depending on the given dose, infusion route, and speed of infusion.35 Although the cough reflex is usually transient and self-limiting, it should be avoided in situations of elevated intracranial, intraocular, or intra-abdominal pressure, and with unstable hemodynamics.6,7 The cause of FIC is unclear. One hypothesis is that vocal cord spasms might induce coughing because of fentanyl-induced muscle rigidity and histamine release.8 Muscle relaxants are commonly
* Corresponding author. Department of Anesthesiology, Cathay General Hospital, 280 Renai Road, Section 4, Taipei, Taiwan. E-mail address: [email protected] (C.-S. Wong).
used to treat this disorder.9 We hypothesized that priming with muscle relaxants could prevent or suppress FIC and ventured to investigate whether the muscle relaxant rocuronium could effectively attenuate FIC. 2. Materials and methods After the study (no. TC100-05) had been approved by the ethical committee of Tri-Service General Hospital, written informed consent was obtained from each patient. This randomized, prospective, placebo-controlled study involved 260 American Society of Anesthesiologists (ASA) physical status Grade IeIII patients, aged between 18 and 80 years, who were undergoing general anesthesia for various elective surgeries at Taichung Armed Forces General Hospital. Exclusion criteria included a history of asthma, chronic cough, smoking, an upper respiratory tract infection in the previous 2 weeks, medication containing angiotensinconverting enzyme inhibitors, and anesthetic premedication.
1875-4597/$ e see front matter Copyright Ó 2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.aat.2012.12.003
148
H.-C. Horng et al.
Fig. 1. Flow diagram for the trial.
Using a computer-generated table of random numbers, patients were randomly assigned to two groups to receive either rocuronium or normal saline. Intraoperative monitory included pulse oximetry, noninvasive blood pressure, and electrocardiography. A freely running intravenous line was established on the dorsum of either hand. All patients were given oxygen via a face mask, and premedication was omitted. The patients were then given the designated medications intravenously in accordance with the protocol; that is, patients in the rocuronium group were given rocuronium at 0.06 mg/kg, and those in the control group were given the same volume of normal saline 30 seconds before intravenous injection of the fentanyl bolus (1.5 mg/kg, given over 2 seconds). Following the fentanyl injection, an anesthetist who was blind to the treatment recorded the number of coughs for 1 minute. The severity of coughing was graded as mild (1e2 times), moderate (3e5 times), or severe (>5 times) based on the number of coughs within the 1 minute following the fentanyl injection. Assisted mask ventilation with oxygen was applied if oxygen desaturation occurred (SpO2 < 90%). For estimation of the sample size, the pilot study we performed showed that the treatment of rocuronium could cause a 15% reduction in the incidence of FIC (in each group of 20 patients). With a ¼ 0.05 and b ¼ 0.1, we required an enrollment of 100 patients for each group; we therefore aimed to recruit 130 patients for each group to compensate for any dropouts. All data were presented as means standard deviations or as percentages. The demographic characteristics of the patients in both groups were evaluated with the Student t test for continuous variables and Chi-square test for categorical variables. The incidence of FIC was analyzed using the Chi-square test, and severity
was analyzed with the ManneWhitney U test. A value of p < 0.05 was considered statistically significant.zxz 3. Results From March 2011 to October 2011, we evaluated 298 consecutive patients. Thirty-eight patients were excluded from the study due to violation of the exclusion criteria or refusal to participate. Therefore, 130 patients in each group were subjected to further statistical analysis (Fig. 1). No significant differences were found between the two groups for the demographic data, including age, ASA status, body height, and gender, although body weight was found to differ (Table 1). Following the fentanyl bolus, patients in the rocuronium group showed a significantly lower incidence of coughing than those in the control group (8.5% vs. 23.1%; p < 0.05) (Table 2). The Table 1 Patient characteristics. Parameters
Age (y), mean SD Sex (M/F), n ASA status (I/II/III), n Weight (kg), mean SD Height (cm), mean SD
Groups Control group (n ¼ 130)
Rocuronium group (n ¼ 130)
43.92 20.13 80/50 59/51/20 63.21 12.18 163.12 8.76
48.42 17.90 67/63 43/52/35 66.85 13.09 162.22 8.02
p
0.058 0.104 0.087 0.021 0.390
There were no significant differences between the groups by Student t test for continuous variables, and by Chi-square test for categorical variables (p > 0.05), except for weight. ASA ¼ American Society of Anesthesiologists physical status; SD ¼ standard deviation.
Rocuronium attenuates fentanyl-induced coughing
149
Table 2 Incidence and severity of cough. Variables
Incidence of cough, n (%) Severity of cough, n (%)a Mild Moderate Severe
Groups
p
Control group (n ¼ 130)
Rocuronium group (n ¼ 130)
30 (23.1%)
11 (8.5%)
0.037
21 (16.2%) 4 (3.0%) 5 (3.9%)
7 (5.5%) 4 (3.0%) 0 (0%)
0.001
A significant difference between the groups was observed for incidence of cough using the Chi-square test, and severity of cough using the ManneWhitney U test. a Severity of cough ¼ number of coughs observed at 1 minute of fentanyl injection: mild (1e2), moderate (3e5), and severe (>5).
rocuronium group also had a lower severity of cough (Table 2). No patient in either group suffered from hypoxemia, apnea, truncal rigidity, nausea, vomiting, or other adverse effects.
Many patients have reported pain on injection of rocuronium.19 Although none of the patients in this study complained of severe pain, mild or moderate pain could have developed. Certain studies suggest that pretreatment with lidocaine, fentanyl, sufentanil, or esmolol can alleviate the pain on injection of rocuronium.1921 When applying priming with rocuronium, the use of these palliative measures should be considered. We therefore conclude that intravenous rocuronium (0.06 mg/ kg) administered 30 seconds before the use of fentanyl can suppress the cough reflex induced by fentanyl, thus avoiding FIC.
Acknowledgments This work was supported by grants from the Taichung Armed Forces General Hospital of Taiwan.
References 4. Discussion The major finding of this study is that pretreatment with intravenous rocuronium (0.06 mg/kg) was able to reduce the incidence of FIC from 23.1% to 8.5% and lower the severity of coughing. These results are consistent with those of a previous study by Oshima et al,10 who demonstrated that the absence of a priming dose of vecuronium was a significant independent risk factor for the development of FIC. This suggests preventive efficacy of a priming dose of vecuronium for FIC. Although intravenous rocuronium was able to reduce the incidence of FIC, as demonstrated in the present study, the actual mechanism by which rocuronium achieves this result remains unknown. Many theories have proposed for the mechanisms by which FIC is generated. These include the stimulation of vagal Cfiber receptors, citric acid stimulating C-fibers in the airway,4 the release of histamine, sudden adduction of the vocal cords or supraglottic obstruction by soft tissue,11 or deformation of the tracheobronchial wall stimulating irritant receptors that leads to reflex bronchoconstriction and cough.1214 A muscle relaxant is usually applied to treat vocal cord spasms or muscle rigidity secondary to the use of members of the fentanyl family.9 The preventive effect of a priming muscle relaxant for this condition had not been proven until a recent study15 revealed that priming with rocuronium or vecuronium reduced the incidence of difficult ventilation secondary to muscle rigidity after the use of remifentanil during anesthesia induction. In addition, pretreatment with, or the concomitant use of, pancuronium significantly decreases the incidence and severity of fentanyl-mediated rigidity.16 This suggests that a priming dose of muscle relaxant has a forestalling effect on fentanyl-induced muscle rigidity. Furthermore, our study showed that muscle relaxant priming has a preventive effect on FIC induced by vocal cord spasms. Previous research suggests that priming with rocuronium or vecuronium leads to the development of partial neuromuscular blockage with serious complications (regurgitation and severe muscle weakness) following administration.17,18 When priming with muscle relaxant for patients is decided upon, anesthesiologists should cautiously guard against these complications. None of the patients in our study developed serious complications from the priming. Further investigation is required to determine the ideal priming dose and waiting time.
1. Bovill JG, Sebel PS, Stanley TH. Opioid analgesics in anesthesia: with special reference to their use in cardiovascular anesthesia. Anesthesiology 1984;61: 731e55. 2. Grell FL, Koons RA, Denson JS. Fentanyl in anesthesia: a report of 500 cases. Anesth Analg 1970;49:523e32. 3. Bohrer H, Fleischer F, Werning P. Tussive effect of a fentanyl bolus administered through a central venous catheter. Anaesthesia 1990;45:18e21. 4. Lin JA, Yeh CC, Lee MS, Wu CT, Lin SL, Wong CS. Prolonged injection time and light smoking decrease the incidence of fentanyl-induced cough. Anesth Analg 2005;101:670e4. 5. Horng HC, Wong CS, Hsiao KN, Huh BK, Kuo CP, Cherng CH, et al. Pre-medication with intravenous clonidine suppresses fentanyl-induced cough. Acta Anaesthesiol Scand 2007;51:862e5. 6. Phua WT, Teh BT, Jong W, Lee TL, Tweed WA. Tussive effect of a fentanyl bolus. Can J Anaesth 1991;38:330e4. 7. Tweed WA, Dakin D. Explosive coughing after bolus fentanyl injection. Anesth Analg 2001;92:1442e3. 8. Benthuysen JL, Smith NT, Sanford TJ. Physiology of alfentanil-induced rigidity. Anesthesiology 1986;64:440e6. 9. Richardson SP, Egan TD. The safety of remifentanil by bolus injection. Expert Opin Drug Saf 2005;4:643e51. 10. Oshima T, Kasuya Y, Okumura Y, Murakami T, Dohi S. Identification of independent risk factors for fentanyl-induced cough. Can J Anaesth 2006;53:753e8. 11. Agarwal A, Azim A, Ambesh S, Bose N, Dhiraj S, Sahu D, et al. Salbutamol, beclomethasone or sodium chromoglycate suppress coughing induced by iv fentanyl. Can J Anaesth 2003;50:297e300. 12. Tanaka M, Maruyama K. Mechanisms of capsaicin and citric-acid-induced cough reflexes in Guinea pigs. J Pharmacol Sci 2005;99:77e82. 13. Bennett JA, Abrams JT, VanRiper DF, Horrow JC. Difficult or impossible ventilation after sufentanil-induced anesthesia is caused primarily by vocal cord closure. Anesthesiology 1997;87:1070e4. 14. Agarwal A, Gautam S, Nath SS, Gupta D, Singh U. Comparison of the incidence and severity of cough induced by sufentanil and fentanyl: a prospective, randomised, double-blind study. Anesthesia 2007;62:1230e2. 15. Nakada J, Nishira M, Hosoda R, Funaki K, Takahashi S, Matsura T, et al. Priming with rocuronium or vecuronium prevents remifentanil-mediated muscle rigidity and difficult ventilation. J Anesth 2009;23:323e8. 16. Bailey PL, Wilbrink J, Zwanikken P, Pace NL, Stanley TH. Anesthetic induction with fentanyl. Anesth Analg 1985;64:48e53. 17. Aziz L, Jahangir SM, Choudhury SN, Rahman K, Ohta Y, Hirakawa M. The effect of priming with vecuronium and rocuronium on young and elderly patients. Anesth Analg 1997;85:663e6. lu B, Cebelli V, Kelebek N, Uçkunkaya N, Kutlay O. Comparison of 18. Yavas¸caog different priming techniques on the onset time and intubating conditions of rocuronium. Eur J Anaesthesiol 2002;19:517e21. 19. Singh M, Chauhan H, Rath GP, Prabhakar H, Bithal PK, Dash HH. Effect of narcotic pretreatment on pain after rocuronium injection: a randomized, double-blind controlled comparison with lidocaine. J Anesth 2007;21: 510e2. 20. Yavascaoglu B, Kaya FN, Ozcan B. Esmolol pretreatment reduces the frequency and severity of pain on injection of rocuronium. J Clin Anesth 2007;19:413e7. 21. Cheong KF, Wong WH. Pain on injection of rocuronium: influence of two doses of lidocaine pretreatment. Br J Anaesth 2000;84:106e7.
Contents lists available at SciVerse ScienceDirect
Acta Anaesthesiologica Taiwanica journal homepage: www.e-aat.com
Original Article
Priming dose of intravenous rocuronium suppresses fentanyl-induced coughing Huei-Chi Horng 1, Bo-Feng Lin 2, Ting-Chuan Wang 3, Shinn-Long Lin 2, Wen-Jinn Liaw 2, Hung-Jui Wang 1, Chih-Shung Wong 4 * 1
Department Department Department 4 Department 2 3
of of of of
Anesthesiology, Taichung Armed Forces General Hospital, Taichung, Taiwan Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan Medical Research, Cathay General Hospital, Taipei, Taiwan Anesthesiology, Cathay General Hospital, Taipei, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 July 2012 Received in revised form 12 September 2012 Accepted 17 September 2012
Objectives: An intravenous bolus of fentanyl often induces a cough reflex. This study investigates whether priming with rocuronium can effectively attenuate fentanyl-induced coughing. Methods: The study involved 260 participants, aged between 18 and 80 years of age, who were undergoing various elective surgeries. They were randomly assigned to two groups. Patients in the study group (the rocuronium group) were treated with intravenous (IV) 0.06 mg/kg rocuronium, whereas those in the control group were treated with the same volume of normal saline. Fentanyl (1.5 mg/kg IV, given over 2 seconds) was administered 30 seconds after the injection of rocuronium or normal saline. We recorded the number of coughs for 1 minute after the fentanyl injection. Results: Patients in the rocuronium group showed a significantly lower incidence of coughing (8.5% vs. 23.1%, in the control group; p < 0.05) and a milder severity of cough in comparison with the patients in the control group. Conclusion: Pretreatment with IV rocuronium (0.06 mg/kg) suppressed the cough reflex induced by fentanyl. Therefore, priming with rocuronium may be a clinically useful method for preventing fentanylinduced cough. Copyright Ó 2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
Key words: cough; fentanyl; neuromuscular nondepolarizing agents: rocuronium bromide
1. Introduction Fentanyl is widely used for analgesia and anesthesia because of its rapid onset of action, intense analgesic effect, lower cardiovascular depressive effect, and low histamine release.1,2 However, fentanyl-induced coughing (FIC) often occurs. According to previous reports, the incidence of FIC can be as high as 65% depending on the given dose, infusion route, and speed of infusion.35 Although the cough reflex is usually transient and self-limiting, it should be avoided in situations of elevated intracranial, intraocular, or intra-abdominal pressure, and with unstable hemodynamics.6,7 The cause of FIC is unclear. One hypothesis is that vocal cord spasms might induce coughing because of fentanyl-induced muscle rigidity and histamine release.8 Muscle relaxants are commonly
* Corresponding author. Department of Anesthesiology, Cathay General Hospital, 280 Renai Road, Section 4, Taipei, Taiwan. E-mail address: [email protected] (C.-S. Wong).
used to treat this disorder.9 We hypothesized that priming with muscle relaxants could prevent or suppress FIC and ventured to investigate whether the muscle relaxant rocuronium could effectively attenuate FIC. 2. Materials and methods After the study (no. TC100-05) had been approved by the ethical committee of Tri-Service General Hospital, written informed consent was obtained from each patient. This randomized, prospective, placebo-controlled study involved 260 American Society of Anesthesiologists (ASA) physical status Grade IeIII patients, aged between 18 and 80 years, who were undergoing general anesthesia for various elective surgeries at Taichung Armed Forces General Hospital. Exclusion criteria included a history of asthma, chronic cough, smoking, an upper respiratory tract infection in the previous 2 weeks, medication containing angiotensinconverting enzyme inhibitors, and anesthetic premedication.
1875-4597/$ e see front matter Copyright Ó 2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.aat.2012.12.003
148
H.-C. Horng et al.
Fig. 1. Flow diagram for the trial.
Using a computer-generated table of random numbers, patients were randomly assigned to two groups to receive either rocuronium or normal saline. Intraoperative monitory included pulse oximetry, noninvasive blood pressure, and electrocardiography. A freely running intravenous line was established on the dorsum of either hand. All patients were given oxygen via a face mask, and premedication was omitted. The patients were then given the designated medications intravenously in accordance with the protocol; that is, patients in the rocuronium group were given rocuronium at 0.06 mg/kg, and those in the control group were given the same volume of normal saline 30 seconds before intravenous injection of the fentanyl bolus (1.5 mg/kg, given over 2 seconds). Following the fentanyl injection, an anesthetist who was blind to the treatment recorded the number of coughs for 1 minute. The severity of coughing was graded as mild (1e2 times), moderate (3e5 times), or severe (>5 times) based on the number of coughs within the 1 minute following the fentanyl injection. Assisted mask ventilation with oxygen was applied if oxygen desaturation occurred (SpO2 < 90%). For estimation of the sample size, the pilot study we performed showed that the treatment of rocuronium could cause a 15% reduction in the incidence of FIC (in each group of 20 patients). With a ¼ 0.05 and b ¼ 0.1, we required an enrollment of 100 patients for each group; we therefore aimed to recruit 130 patients for each group to compensate for any dropouts. All data were presented as means standard deviations or as percentages. The demographic characteristics of the patients in both groups were evaluated with the Student t test for continuous variables and Chi-square test for categorical variables. The incidence of FIC was analyzed using the Chi-square test, and severity
was analyzed with the ManneWhitney U test. A value of p < 0.05 was considered statistically significant.zxz 3. Results From March 2011 to October 2011, we evaluated 298 consecutive patients. Thirty-eight patients were excluded from the study due to violation of the exclusion criteria or refusal to participate. Therefore, 130 patients in each group were subjected to further statistical analysis (Fig. 1). No significant differences were found between the two groups for the demographic data, including age, ASA status, body height, and gender, although body weight was found to differ (Table 1). Following the fentanyl bolus, patients in the rocuronium group showed a significantly lower incidence of coughing than those in the control group (8.5% vs. 23.1%; p < 0.05) (Table 2). The Table 1 Patient characteristics. Parameters
Age (y), mean SD Sex (M/F), n ASA status (I/II/III), n Weight (kg), mean SD Height (cm), mean SD
Groups Control group (n ¼ 130)
Rocuronium group (n ¼ 130)
43.92 20.13 80/50 59/51/20 63.21 12.18 163.12 8.76
48.42 17.90 67/63 43/52/35 66.85 13.09 162.22 8.02
p
0.058 0.104 0.087 0.021 0.390
There were no significant differences between the groups by Student t test for continuous variables, and by Chi-square test for categorical variables (p > 0.05), except for weight. ASA ¼ American Society of Anesthesiologists physical status; SD ¼ standard deviation.
Rocuronium attenuates fentanyl-induced coughing
149
Table 2 Incidence and severity of cough. Variables
Incidence of cough, n (%) Severity of cough, n (%)a Mild Moderate Severe
Groups
p
Control group (n ¼ 130)
Rocuronium group (n ¼ 130)
30 (23.1%)
11 (8.5%)
0.037
21 (16.2%) 4 (3.0%) 5 (3.9%)
7 (5.5%) 4 (3.0%) 0 (0%)
0.001
A significant difference between the groups was observed for incidence of cough using the Chi-square test, and severity of cough using the ManneWhitney U test. a Severity of cough ¼ number of coughs observed at 1 minute of fentanyl injection: mild (1e2), moderate (3e5), and severe (>5).
rocuronium group also had a lower severity of cough (Table 2). No patient in either group suffered from hypoxemia, apnea, truncal rigidity, nausea, vomiting, or other adverse effects.
Many patients have reported pain on injection of rocuronium.19 Although none of the patients in this study complained of severe pain, mild or moderate pain could have developed. Certain studies suggest that pretreatment with lidocaine, fentanyl, sufentanil, or esmolol can alleviate the pain on injection of rocuronium.1921 When applying priming with rocuronium, the use of these palliative measures should be considered. We therefore conclude that intravenous rocuronium (0.06 mg/ kg) administered 30 seconds before the use of fentanyl can suppress the cough reflex induced by fentanyl, thus avoiding FIC.
Acknowledgments This work was supported by grants from the Taichung Armed Forces General Hospital of Taiwan.
References 4. Discussion The major finding of this study is that pretreatment with intravenous rocuronium (0.06 mg/kg) was able to reduce the incidence of FIC from 23.1% to 8.5% and lower the severity of coughing. These results are consistent with those of a previous study by Oshima et al,10 who demonstrated that the absence of a priming dose of vecuronium was a significant independent risk factor for the development of FIC. This suggests preventive efficacy of a priming dose of vecuronium for FIC. Although intravenous rocuronium was able to reduce the incidence of FIC, as demonstrated in the present study, the actual mechanism by which rocuronium achieves this result remains unknown. Many theories have proposed for the mechanisms by which FIC is generated. These include the stimulation of vagal Cfiber receptors, citric acid stimulating C-fibers in the airway,4 the release of histamine, sudden adduction of the vocal cords or supraglottic obstruction by soft tissue,11 or deformation of the tracheobronchial wall stimulating irritant receptors that leads to reflex bronchoconstriction and cough.1214 A muscle relaxant is usually applied to treat vocal cord spasms or muscle rigidity secondary to the use of members of the fentanyl family.9 The preventive effect of a priming muscle relaxant for this condition had not been proven until a recent study15 revealed that priming with rocuronium or vecuronium reduced the incidence of difficult ventilation secondary to muscle rigidity after the use of remifentanil during anesthesia induction. In addition, pretreatment with, or the concomitant use of, pancuronium significantly decreases the incidence and severity of fentanyl-mediated rigidity.16 This suggests that a priming dose of muscle relaxant has a forestalling effect on fentanyl-induced muscle rigidity. Furthermore, our study showed that muscle relaxant priming has a preventive effect on FIC induced by vocal cord spasms. Previous research suggests that priming with rocuronium or vecuronium leads to the development of partial neuromuscular blockage with serious complications (regurgitation and severe muscle weakness) following administration.17,18 When priming with muscle relaxant for patients is decided upon, anesthesiologists should cautiously guard against these complications. None of the patients in our study developed serious complications from the priming. Further investigation is required to determine the ideal priming dose and waiting time.
1. Bovill JG, Sebel PS, Stanley TH. Opioid analgesics in anesthesia: with special reference to their use in cardiovascular anesthesia. Anesthesiology 1984;61: 731e55. 2. Grell FL, Koons RA, Denson JS. Fentanyl in anesthesia: a report of 500 cases. Anesth Analg 1970;49:523e32. 3. Bohrer H, Fleischer F, Werning P. Tussive effect of a fentanyl bolus administered through a central venous catheter. Anaesthesia 1990;45:18e21. 4. Lin JA, Yeh CC, Lee MS, Wu CT, Lin SL, Wong CS. Prolonged injection time and light smoking decrease the incidence of fentanyl-induced cough. Anesth Analg 2005;101:670e4. 5. Horng HC, Wong CS, Hsiao KN, Huh BK, Kuo CP, Cherng CH, et al. Pre-medication with intravenous clonidine suppresses fentanyl-induced cough. Acta Anaesthesiol Scand 2007;51:862e5. 6. Phua WT, Teh BT, Jong W, Lee TL, Tweed WA. Tussive effect of a fentanyl bolus. Can J Anaesth 1991;38:330e4. 7. Tweed WA, Dakin D. Explosive coughing after bolus fentanyl injection. Anesth Analg 2001;92:1442e3. 8. Benthuysen JL, Smith NT, Sanford TJ. Physiology of alfentanil-induced rigidity. Anesthesiology 1986;64:440e6. 9. Richardson SP, Egan TD. The safety of remifentanil by bolus injection. Expert Opin Drug Saf 2005;4:643e51. 10. Oshima T, Kasuya Y, Okumura Y, Murakami T, Dohi S. Identification of independent risk factors for fentanyl-induced cough. Can J Anaesth 2006;53:753e8. 11. Agarwal A, Azim A, Ambesh S, Bose N, Dhiraj S, Sahu D, et al. Salbutamol, beclomethasone or sodium chromoglycate suppress coughing induced by iv fentanyl. Can J Anaesth 2003;50:297e300. 12. Tanaka M, Maruyama K. Mechanisms of capsaicin and citric-acid-induced cough reflexes in Guinea pigs. J Pharmacol Sci 2005;99:77e82. 13. Bennett JA, Abrams JT, VanRiper DF, Horrow JC. Difficult or impossible ventilation after sufentanil-induced anesthesia is caused primarily by vocal cord closure. Anesthesiology 1997;87:1070e4. 14. Agarwal A, Gautam S, Nath SS, Gupta D, Singh U. Comparison of the incidence and severity of cough induced by sufentanil and fentanyl: a prospective, randomised, double-blind study. Anesthesia 2007;62:1230e2. 15. Nakada J, Nishira M, Hosoda R, Funaki K, Takahashi S, Matsura T, et al. Priming with rocuronium or vecuronium prevents remifentanil-mediated muscle rigidity and difficult ventilation. J Anesth 2009;23:323e8. 16. Bailey PL, Wilbrink J, Zwanikken P, Pace NL, Stanley TH. Anesthetic induction with fentanyl. Anesth Analg 1985;64:48e53. 17. Aziz L, Jahangir SM, Choudhury SN, Rahman K, Ohta Y, Hirakawa M. The effect of priming with vecuronium and rocuronium on young and elderly patients. Anesth Analg 1997;85:663e6. lu B, Cebelli V, Kelebek N, Uçkunkaya N, Kutlay O. Comparison of 18. Yavas¸caog different priming techniques on the onset time and intubating conditions of rocuronium. Eur J Anaesthesiol 2002;19:517e21. 19. Singh M, Chauhan H, Rath GP, Prabhakar H, Bithal PK, Dash HH. Effect of narcotic pretreatment on pain after rocuronium injection: a randomized, double-blind controlled comparison with lidocaine. J Anesth 2007;21: 510e2. 20. Yavascaoglu B, Kaya FN, Ozcan B. Esmolol pretreatment reduces the frequency and severity of pain on injection of rocuronium. J Clin Anesth 2007;19:413e7. 21. Cheong KF, Wong WH. Pain on injection of rocuronium: influence of two doses of lidocaine pretreatment. Br J Anaesth 2000;84:106e7.