WHEN Portland District Health anaesthetist Peter Reid made a casual remark to colleague Jun Parker one day about how a change in his technique had led to patients sneezing before surgery, little did the pair imagine what that would lead to – what could be a world-first discovery.

Pending further studies – for which the pair have approval but as yet no means of going ahead – that could well be the case.

The discovery centres around the use of the well-known opioid fentanyl in the anaesthetic process for patients receiving nasal plastic surgery in conjunction with regular anaesthetic drug propofol.

“I mentioned to Jun I was getting sneezing in my patients all of a sudden because I changed my technique,” Dr Reid said.

“I was using fentanyl, and then I wasn’t using it.

“We talked about it and I thought ‘wait a minute, I wonder if fentanyl stops the sneezing’.

“Jun looked up the literature, there was nothing – in eye surgery it happens very infrequently with injections around the eye but no one has ever published anything on nasal injections.

“We started making careful observations and documenting it (the pair provide sedation separately) in our notes and fentanyl appeared to be the factor”.

Fentanyl was not known as an anti-sneezing drug, but as an anti-coughing drug.

Sneezing could be considered dangerous in both exposing the patient to risk of facial and eye injuries from the needle used for the injection to needle stick injuries for those giving it as well as the spread of viral droplets such as the coronavirus.

Dr Parker said it was time to find out what was going on.

“We started collecting data and retrospectively analysed, with the help of Professor Michael Bailey (renowned medical statistician and Portland District Health board member), that data,” he said.

Drs Reid and Parker reviewed the data from patients that they had performed anaesthesia on at Portland hospital for nasal plastic surgery between January 2018 and November 2019.

A significant number of patients who received propofol-only anaesthesia sneezed while those who received fentanyl in addition to propofol did not.

Of the many other datasets collected and analysed, no other factors appeared to contribute to this phenomenon apart from the anaesthetic drugs used.

That led the doctors to recommend anaesthetists also give fentanyl along with propofol during nasal local anaesthetic injections.

Their findings – the paper was also co-authored by Professor Bailey – have just been published in the latest issue of the US-based Journal of Opioid Management, one of the foremost publications in its field.

If the names propofol and fentanyl sound vaguely familiar, it’s because they probably are.

Dr Parker said propofol was the most commonly-used anaesthetic drug – it became more widely-known due to causing the death of singer Michael Jackson in 2009.

Dr Reid acknowledged the controversy around fentanyl – it has been responsible for the highest number of drug overdose deaths in the US in recent years, and has been manufactured illicitly as well.

“Fentanyl has been used ever since I’ve entered anaesthetic practice in the early 70s, it’s a short-acting opioid,” he said.

“It’s safe in the hands of anaesthetists because we know the problems with it.”

Dr Parker said the Portland anaesthetic department was also at the forefront of opioid-free anaesthesia.

“We have published both sides so are well placed to provide expert opinions about the use of opioids in anaesthetic practice,” he said.

However, further studies were required to find out whether the findings were related to the amount of sedation the patients were given or if they were because fentanyl was also given, as well as if there were any further side effects.

“Retrospective studies fall short of proving a scientific discovery although we think we know this for a fact,” Dr Parker said.

To that end, Drs Parker and Reid applied through the Barwon Health Human Research and Ethics Committee for permission to carry out a randomised control trial, where they would be randomly given either one of two doses of fentanyl or none at all (the control group).

Randomised control trials are considered by health authorities the best way to study the safety and effectiveness of new treatments.

“It’s the most rigorous form of clinical research to assess the scientific validity of a hypothesis,” Dr Parker said.

“You need to specifically submit applications and ours has gone through several layers of complicated processes in order to go ahead.”

That application was successful in 2021 but they are waiting on approval from PDH for a research assistant that is vital for the trial.

Dr Parker said such trials were usually only done in large centres “with research teams and assistants” and with those in charge of the research given time to do it.

“This is a big deal for us,” he said.

Dr Reid said Portland was in a unique position.

“We haven’t done a randomised control trial yet, it would be wonderful to do it,” he said.

“I think one of the most important things when you do research it’s the practice of your peers that changes from what you’ve done.

“This has the potential to change the practice of other anaesthetists when doing this sort of surgery.”

Dr Reid said small hospitals were not generally known for producing such important research, though Portland had punched well above its weight previously.

“For a hospital this size the anaesthetic department is producing research which normally is attributed to major teaching hospitals in a major city,” he said.