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Paper text:
a 32-year - old man ( height 168 cm , weight 66 kg ) was presented for a hand - assisted laparoscopic left nephrectomy for renal cell carcinoma .
he was also diagnosed with diabetes mellitus 6 months ago , and his blood sugar levels have been well controlled by metformin .
he fasted for more than 8 hours before surgery and was given no sedative or opioid premedication .
when arriving at an operating room , the patient was monitored with an electrocardiogram , a non - invasive arterial blood pressure monitor and a pulse oximeter .
anesthesia was induced intravenously with thiopental sodium 350 mg , following preoxygenation with 100% oxygen . after confirming the loss of consciousness and self respiration
mask ventilation was performed without difficulty , and he did not show any signs of airway irritation including cough .
vecuronium 10 mg was given for neuromuscular block , and then fentanyl 100 g was administered .
after a few seconds after the injection of fentanyl , the patient began to cough suddenly and vigorously .
coughing has persisted for about 30 seconds until he vomited a large volume of greenish fluid around the face mask .
his head was immediately turned to the left and head down tilt of the table was applied . when vomiting ceased , after suctioning of the oral cavity and oropharynx , endotracheal intubation was achieved .
during this episode , the arterial oxygen saturation transiently decreased to 93% , but soon recovered to 98% .
a nasogastric tube was placed , and nearly 100 ml of bile - stained gastric fluid was drained .
a small amount of greenish fluid was aspirated out of the endotracheal tube . then , the surgery started with the patient in the right lateral decubitus position .
after peritoneal insufflation with carbon dioxide ( co2 ) , the peak inspiratory pressure increased from 21 to 26 mmhg .
his arterial oxygen saturation has gradually fallen from 98 to 92% since the introduction of co2 .
although no more gastric fluids or secretions were suctioned through the endotracheal tube , a coarse crackle was heard throughout the right lung field on auscultation .
the patient was placed on 100% oxygen and positive end - expiratory pressure of 5 mmhg was applied .
an arterial blood gas analysis , checked at this time on a fio2 of 1.0 and an etco2 of 37 , was as follows : ph 7.334 , pao2 82.2 mmhg , paco2 44.2 mmhg , bicarbonate 24.9 meq / l and sao2 95.4% .
the total anesthetic time was 255 minutes and blood loss was estimated at 300 ml .
the patient was transferred to the intensive care unit and his arterial oxygen saturation which ranged between 93 and 95% with mechanical ventilation with a fio2 of 1.0 .
chest radiography taken postoperatively has shown patchy consolidation at the right lower lung field and decreased volume of the right lung , suggestive of pulmonary aspiration and atelectasis ( fig .
1 ) . fiberoptic bronchoscopic examination revealed a large amount of bile - stained fluid and some undigested food particles around the trachea , right main bronchus and lower lobar bronchi , which was aspirated and removed .
suction through the endotracheal tube and chest percussions were also frequently applied . on the next day ,
his temperature dropped to 36.5 and a radiologic improvement on the chest x - ray was observed .
supplemental oxygen was delivered via the nasal prong at a rate of 3 l / min .
over the ensuing five days , mild cough and sputum left over were relieved , the arterial hypoxemia resolved and pulmonary infiltration was much improved ( fig .
these theories include inhibition of the central sympathetic tone and reflex bronchoconstriction , pulmonary chemoreflexes mediated by vagal c - fiber receptors near pulmonary vessels or irritant receptors ( rapidly adapting receptors ) , stimulation of irritant receptors following the constriction of the tracheal smooth muscles and deformation of the tracheobronchial wall , vocal cord spasms , and release of histamine or neuropeptides from prejunctional -opioid receptors .
although fic can bring about adverse events associated with increased intracranial , intraocular or intraabdominal pressures , in most cases , it lasts for a moment and scarcely does any harm to patients .
tweed and dakin   described a case of conjunctival and periorbital petechiae produced by explosive coughing after bolus injection of fentanyl .
made a report on a significant airway obstruction accompanying intravenous fentanyl injection and vigorous cough in a child with arteriovenous malformation of the tongue and hypopharynx .
, we can speculate that heavy cough , provoked by intravenous administration of fentanyl , has raised patient 's intraabdominal pressure and caused vomiting , pulmonary aspiration and pneumonia .
the fact that he has coughed soon after the injection of fentanyl and there was no other known causative factor of the cough supports our assumption .
patient 's bronchoscopic findings of undigested food particles around the trachea and bronchi , despite more than eight hours of fast suggest that his gastric emptying must have been delayed .
his anxiety about the surgery , as well as a history of diabetes mellitus , might contribute to slow gastric emptying .
this case suggests that fic should be avoided in certain groups of patients on whom it may have a detrimental effect .
these patients include those with raised intracranial or intraocular pressure , severe airway responsiveness , and increased risk of vomiting or aspiration .
intravenous administration of dexmedetomidine , lidocaine , ephedrine or priming dose of fentanyl , and aerosol inhalation of salbutamol , beclomethasone or sodium chromoglycate proved to be helpful [ 1,2,4 - 6 ] .
in addition , the use of a priming dose of vecuronium can be readily applied during induction of anesthesia .
although fic is mostly temporary and insignificant , it can lead to critical adverse events in patients with risk factors .
although fentanyl - induced cough is generally transient and benign , it can give rise to serious problems in patients to whom increasing intracranial , intraocular or intraabdominal pressures may create dangerous situations . 
 this case demonstrates aspiration pneumonia as a complication , exhibiting severe cough induced by intravenous injection of fentanyl .