Use of a remifentanil-propofol mixture for pediatric flexible fiberoptic bronchoscopy sedation

Background: Flexible fiberoptic bronchoscopy is an important diagnostic tool for pediatric pulmonologists. Because of its favorable respiratory profile, ketamine has become a popular sedative for this procedure, but may be associated with unpleasant emergence reactions in the older child. Remifentanil is a newer, ultra-short acting opioid that has been shown to provide effective sedation and cough suppression for fiberoptic bronchoscopy when combined with intermittent propofol boluses. However, delivery of these agents as a combined, single infusion has not been described. Methods: Children greater than or equal to2 years of age undergoing fiberoptic bronchoscopy were enrolled. Remifentanil was mixed in a single syringe with undiluted propofol giving final drug concentrations of 10 mg.ml(-1) of propofol and 15-20 mug.ml(-1) of remifentanil. Sedation was induced with a bolus of approximately 0.1 ml.kg(-1) of this mixture and maintained by titrating the drip throughout the procedure. Vital signs, sedative effectiveness, recovery patterns, and complications were prospectively recorded. Results: Fifteen patients aged 9.0 +/- 5.3 years were sedated. Sedation was induced with 1.2 +/- 0.4 mg.kg(-1) propofol (2.4 +/- 0.8 mug.kg(-1) remifentanil) and maintained with 4.1 +/- 1.8 mg.kg(-1).h(-1) propofol (0.13 +/- 0.06 mug.kg(-1).min(-1) remifentanil). Five patients received low-dose ketamine to augment sedation. The maximal decrease in respiratory rate was 6.1 +/- 5.3 b.min(-1) (27.6 +/- 21%) and no patient became hypoxemic. All procedures were completed easily without significant complication. Patients recovered to baseline 13.3 +/- 8.5 min following infusion discontinuation. Conclusions: A remifentanil/propofol mixture provided effective sedation and rapid recovery in pediatric patients undergoing fiberoptic bronchoscopy.