Downloaded from http://journals.lww.com/transplantjournal by BhDMf5ePHKbH4TTImqenVAHxkFJp/XpPk1L/H3vMGwqMxG9jwOd8eJPG+b4DlKuAX44qu/vwzmc= on 07/29/2018 CLINICAL TRANSPLANTATION Sedative Drug Requirements during Bronchoscopy Are Higher in Cystic Fibrosis after Lung Transplantation Prashant N. Chhajed, 1,3 Christina Aboyoun, 1 Trupti P. Chhajed, 1 Monique A. Malouf, 1 Gordon A. Harrison, 2 Michael Tamm, 1 Jo ¨rg D. Leuppi, 1 and Allan R. Glanville 1 Background. We noted that patients with cystic fibrosis tended to need higher doses of sedatives during bronchoscopy. We undertook this study to assess the sedative drug doses administered during bronchoscopy in lung transplant recipients and to assess if there is a change in the dosage requirements over time following lung transplantation. Methods. In all, 773 transbronchial biopsy procedures performed via flexible bronchoscopy were analyzed in 140 consecutive lung transplant recipients. Conscious sedation was achieved with intermittent boluses of intravenous midazolam and fentanyl. Intravenous propofol boluses of 10 to 30 mg were administered when optimal sedation was not achieved with midazolam doses of 0.20 to 0.25 mg/kg and fentanyl 2 to 2.5 micrograms/kg. Results. Mean doses of midazolam and fentanyl administered were 0.150.07 mg/kg (range 0.02 to 0.44 mg/kg) and 1.80.8 micrograms/kg (range 0.1 to 6.67 micrograms/kg) respectively. Midazolam and fentanyl doses administered to patients with cystic fibrosis were the highest compared to those with other disease types (P0.0001). Examining the sedative doses administered over time following transplantation, there was a significant linear (P0.001) and quadratic (P=0.0023) effect of time for midazolam and a significant linear (P=0.003) and a trend (P=0.08) for a quadratic effect for fentanyl. Propofol was effectively used in seven lung transplant recipients in whom adequate sedation could not be achieved with high doses of midazolam and fentanyl. Conclusions. There is an increase in sedative drug requirement with time for both midazolam and fentanyl after transplantation, which is significantly higher in patients with cystic fibrosis. Keywords: Bronchoscopy, Midazolam, Fentanyl, Propofol, Lung transplantation. (Transplantation 2005;80: 1081–1085) T he combination of local anesthetic and sedative drugs is now administered routinely to patients undergoing flex- ible bronchoscopy to facilitate examination of the tracheo- bronchial tree, carry out the necessary diagnostic or interven- tional procedures and provide patient comfort (1–3). Local anesthesia of the airways is achieved with topical lignocaine. Benzodiazepines and opioids are routinely used for the pur- pose of sedation during bronchoscopy (4). The untoward ef- fects of benzodiazepines and opioids include respiratory and myocardial depression, hypotension and bronchospasm (5). When used together these drugs may act synergistically war- ranting caution and careful monitoring during the procedure (5). Lung transplant recipients undergo several bronchos- copy procedures and therefore need to be well sedated (2). In our clinical experience, we noted that patients with cystic fi- brosis (CF) tended to need higher doses of sedatives during bronchoscopy. To our knowledge there are no data in the literature which describe the sedative drug requirements dur- ing flexible bronchoscopy in lung transplant recipients. We undertook this study to assess the sedative drug doses admin- istered during flexible bronchoscopy in lung transplant recip- ients and to assess if there is a change in the dosage require- ments over time following lung transplantation. MATERIALS AND METHODS We analyzed 773 transbronchial biopsy (TBB) proce- dures performed via flexible bronchoscopy in 140 consecu- tive lung transplant recipients (male:female, 71:69). We in- cluded only TBB procedures to maintain a uniform cohort of procedures for purposes of comparison. A TBB procedure was excluded if combined with any other procedure such as pleurodesis or gastrointestinal endoscopy, patient receiving ventilator support or if the patient died within the first 3 months following lung transplantation. Reasons for trans- plantation included emphysema 46 (33%), CF 42 (30%), id- iopathic pulmonary fibrosis (IPF) 25 (18%), pulmonary hy- 1 Lung Transplant Unit, St. Vincent’s Hospital, Sydney, Australia. 2 Department of Critical Care Medicine and Anaesthesia, St. Vincent’s Hos- pital, Sydney, Australia. 3 Address correspondence to: Prashant N. Chhajed, M.D., DNB, FCCP, Pul- monary Medicine, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland. E-mail: pchhajed@uhbs.ch. Selected results from this study were presented in abstract form at the 2003 International Conference of the American Thoracic Society, Seattle, WA. Received 2 January 2005. Revision requested 21 March 2005. Accepted 14 April 2005. Copyright © 2005 by Lippincott Williams & Wilkins ISSN 0041-1337/05/8008-1081 DOI: 10.1097/01.tp.0000176925.13074.90 Transplantation • Volume 80, Number 8, October 27, 2005 1081