Original contributionPremedication with intravenous low-dose ketamine suppresses fentanyl-induced cough
Introduction
Fentanyl is often used as a premedicant during induction of general anesthesia (GA) owing to its rapid onset, short duration, intense analgesia, reduced cardiovascular depression, and low histamine release [1], [2]. However, intravenous (IV) administration of fentanyl elicits cough, with frequency ranging from 28% to 65% [3], [4], [5], [6], [7], [8]. Coughing is undesirable during induction of anesthesia and is associated with adverse effects from elevated intracranial, intraocular, and intra-abdominal pressures [4], [5], [6], [7], [8], [9]. Tweed and Dakin [9] reported a case of explosive cough after peripheral IV injection of fentanyl that produced multiple conjunctival and periorbital petechiae. Prevention of fentanyl-induced cough is an important clinical implication.
A number of studies have been conducted to reduce the incidence of fentanyl-induced cough using readily available anesthetic adjuncts (eg, propofol, lidocaine, ephedrine, atropine, and midazolam, with varying success). Kamei et al reported that excitatory amino acids and N-methyl-d-aspartate (NMDA) receptor antagonists are capable of modulating the cough reflex [10]. Intravenous ketamine, an NMDA antagonist, has well-known potent analgesic and bronchodilatory effects [11], [12], [13], [14]. In our experience, the incidence of fentanyl-induced cough seems to be attenuated with ketamine. Thus, we conducted the present study to examine the effect of low-dose ketamine on fentanyl-induced cough.
Section snippets
Materials and methods
This study was approved by the Tri-service General Hospital's institutional review board. Written, informed consent was obtained from all patients before they were enrolled into this randomized, prospective, double-blind, placebo-controlled study. Three hundred sixty ASA physical status I and II patients aged between 18 and 65 years and scheduled for elective surgery during GA, were randomly assigned to one of two groups of 180 patients each, using computer-generated random numbers. Based on a
Results
There were no differences between the two groups in demographic data (Table 1). The hemodynamic data (BP, HR, and Spo2) were also similar and there was no significant difference between groups in baseline or after fentanyl injection (Table 2). After the IV fentanyl bolus injection, patients in the placebo group (39/180, 21.6%) showed a significantly higher frequency of cough than in the ketamine pretreatment group (13/180, 7.2%; P < 0.05), and the onset time of cough was significantly longer in
Discussion
The major finding in the present study is that pretreatment with ketamine 0.15 mg/kg IV reduced the frequency of fentanyl-induced cough from 21.6% to 7.2% and delayed the onset time of cough.
In our previous series, the frequency of fentanyl-induced cough in the placebo group was 18% at the fentanyl dose of 1.5 μg/kg, with an injection time of less than 5 seconds [15]; the frequency of fentanyl-induced cough in our control group was lower than the previously reported range of 28% to 65% [3], [4]
Acknowledgments
The authors thank Dr J. A. Lin for support in conducting this study.
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