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 ≥2 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 μg·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 μg·kg^-1 remifentanil) and maintained with 4.1 ± 1.8 mg·kg^-1·h^-1 propofol (0.13 ± 0.06 μg·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.