SummaryOne hundred and ten male patients scheduled for coronary artery bypass grafting were allocated randomly into one of three groups. Patients in group A received fentanyl7 pg/kg via a central venous catheter, those in group B were given fentanyl7 pgikg through a peripheral venous cannula, and patients in group C received sterile water via a central venous catheter. In group A , 45.9% of patients coughed after injection of fentanyl; the mean onset time .from the end of fentanyl administration to the beginning of coughing was 10.6 seconds. Only one patient in group B and no patient in the control group exhibited a cough response ( p < 0.0001). We hypothesise that fentanyl can evoke the pulmonary chemoreflex. Key wordsAnaesthetics, intravenous; fentanyl. Complications; cough.The opioid agonist fentanyl has been used as an anaesthetic adjunct as well as the sole anaesthetic for almost two decades.'-3 Common side effects of fentanyl such as respiratory depression have been reported and studied in detail.-Lately, the focus has shifted to the discussion of complications such as chest-wall and extremely rare seizures associated with fentanyl administration.'&'* This clinical study deals with a side effect of fentanyl which has not been reported previously. Materials and methodsOne hundred and fifty male patients scheduled for coronary artery bypass grafting gave their informed consent to participate in this institutionally approved study. Exclusion criteria were poor left ventricular function, critical left mainstem stenosis and a history of pulmonary disease including coughing. Patients were premedicated with midazolam 0.1 mg/kg intramuscularly 30 minutes before arrival in the operating room. One peripheral venous cannula was placed in the dorsum of the hand before induction of anaesthesia, and a central venous catheter was inserted via an antecubital vein using intravascular electrocardiography."-I5 Both procedures were completed successfully in 1 1 1 patients. Baseline haemodynamic variables and the degree of sedation were recorded. One patient was eliminated from the study because of unexpected coughing before randomisation. The remaining 110 patients were allocated randomly into one of three groups. Patients in group A (n = 37) received a bolus of fentanyl 7 pg/kg administered through the central venous catheter over one second. Patients in group B (n = 37) were given fentanyl 7 pg/kg through the peripheral venous line, also over one second. Sterile water in an amount equivalent to the corresponding volume of fentanyl was administered to patients in group C (n = 36) via the central venous catheter, again over one second. All injectates were at room temperature.All patients were observed carefully in order to detect a cough response after injection of fentanyl or sterile water. The onset time from the end of bolus administration until the beginning of coughing was measured using a stopwatch. Where appropriate, the coughing intensity was recorded. The degree of sedation at the time of injection was noted simultan...

A 63-year-old man underwent distal oesophagectomy and proximal gastrectomy. Postoperatively, controlled ventilation was necessary for 53 days because of anastomotic leakage. Multiple sedative regimens proved to be inadequate. By contrast, a fentanyl-midazolam combination with continuous supplementation of clonidine 0.014 micrograms kg-1 min-1 (1.44 mg 70 kg-1 24 h-1) was very effective in terms of sedation and pain relief. During combined fentanyl-midazolam and clonidine infusion, cardiovascular depression gradually developed over several days necessitating the institution of a dobutamine infusion (dose: 8-12 micrograms kg-1 min-1). Four attempts of abrupt clonidine withdrawal were followed by sympathetic overshoot reactions consisting of tachycardia, hypertension, agitation, and sweating. Discontinuation of clonidine was finally possible after a 12-day weaning period.

Literature references show that the continuous thermodilution method is not only valid for intensive-care long-term measurement of cardiac output with approximately stationary haemodynamics, but also-as our results prove-valid if haemodynamics are not usually stationary, such as during coronary artery bypass surgery. The pros of the continuous thermodilution method are that no additional equipment is required apart from the standard equipment used in intensive-care medicine and cardio-anaesthesiology: that there is no stress caused by volume; and that manipulation is safe because no calibration routine is needed and also because measurement and analysis techniques are fully automated. Hence, we are of the opinion that the intraoperative use of this cardiac output measurement technique during open heart surgery is clinically indicated.

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