Intended for healthcare professionals


Fentanyl is not best anaesthetic induction agent in rapid sequence intubation

BMJ 1998; 317 doi: (Published 14 November 1998) Cite this as: BMJ 1998;317:1386

Avoid fentanyl-induced "wooden chest syndrome" in the emergency department.

EDITOR - Taylor and Marsh correctly point out that "fentanyl, even
in high doses, has only ever been shown to consistently produce
unconsciousness in critically ill patients." They discourage the use this
opioid as the sole anaesthetic induction agent in rapid sequence
intubation in the emergency department.(1) The authors, however, fail to
address the main reason for not using high doses of fentanyl in the
emergency department.
Numerous reports have documented the "wooden chest syndrome" associated
with the use of large doses of opioids for induction of general
anaesthesia.(2) This condition is characterised by increased muscle tone
progressing to severe stiffness, particularly in the thoracic and
abdominal muscles, sometimes leading to difficult ventilation. Hypoxemia,
hypertension, pulmonary hypertension, respiratory acidosis and increased
intracranial pressure may supervene.
One study demonstrated the occurrence of unconsciousness only in subjects
who developed fentanyl-induced rigidity, while subjects not developing
rigidity remained awake and responsive.(3) Thus, the use of fentanyl to
achieve unconsciousness should be discouraged mainly because, if
unconsciousness is achieved, truncal rigidity will probably occur.

1. Taylor I, Marsh DF. Fentanyl is not best anaesthetic induction
agent in rapid sequence intubation. BMJ 1998;317:1386

2. Scamman FL. Fentanyl-O2-N2O rigidity and pulmonary compliance. Anesth
Analg 1983; 62:332-335

3. Streisand JB, Bailey PL, LeMaire L, Ashburn MA, Tarver SD, Varvel J,
Stanley TH. Fentanyl-induced rigidity and unconsciousness in human
volunteers. Incidence, duration, and plasma concentrations. Anesthesiology

Competing interests: No competing interests

30 November 1998
Jose Eduardo Tanus-Santos
Research Fellow
Heitor Moreno
Department of Pharmacology - State University of Campinas