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Use of Intravenous Methohexital As a Sedative in Pediatric Emergency Departments

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Use of Intravenous Methohexital As a Sedative in Pediatric Emergency Departments ARTICLE Use of Intravenous Methohexital as a Sedative in Pediatric Emergency Departments Hanan Sedik, MD Objective: To evaluate the effectiveness and safety of Results: Data are reported from a total of 55 patients. intravenous methohexital as a sedative in children un- The doses administered ranged from 0.5 mg/kg to 2.0 dergoing emergency computed tomographic scans. mg/kg (mean±SD, 1±0.5 mg/kg). Onset of sedation was rapid (mean±SD, 1±0.4 minutes), sedation was brief Design: Case series. (mean±SD, 12±5 minutes), and the mean±SD length of the drug’s effects was 14±6 minutes. Sedation was effec- Setting: An urban pediatric emergency department at tive in most cases, and only a few patients had compli- a level I trauma center. cations. Participants: Patients receiving intravenous metho- hexital for sedation to undergo emergency computed to- Conclusion: Intravenous methohexital is a short- mographic scans. acting and effective sedative for use in pediatric emer- gency departments to obtain computed tomographic Methods: Descriptive data were generated, including de- scans. mographics, doses administered, times of sedation, out- comes, and complications. Arch Pediatr Adolesc Med. 2001;155:665-668 OMPUTED tomographic duration of action, methohexital may be (CT) scans are fre- an attractive option for sedation in chil- quently performed on an dren. Rapid induction and speed of recov- emergent basis in pediat- ery make it ideal in situations where a brief ric emergency depart- effect is desired, such as CT scans. Al- Cments (PEDs). Infants and young chil- though in our institution intravenous (IV) dren often require sedation for CT scans methohexital has been used as a sedative to be completed successfully. The dura- to obtain CT scans, data in the literature tion of CT scans may vary from 5 to 30 remain sparse about its use in PEDs. minutes, depending on the type of scan The objective of this study was to and the need for additional imaging. Dif- evaluate the effectiveness and safety of IV ferent classes of medications have been methohexital in achieving sedation in used to achieve sedation in children for pediatric patients undergoing emergency this purpose. These include chloral CT scans, and to document our experi- hydrate (both orally and rectally), barbi- ence with the use of methohexital in our turates such as pentobarbital, benzodiaz- PED. epines such as midazolam, and narcotics like meperidine (alone or in combination RESULTS with promethazine) and chlorproma- zine.1-9 Most of these medications have There were a total of 55 patients, 35 in phase From the Division of Pediatric long induction and recovery times that 1 and 20 in phase 2. Twenty-two sedations Emergency Medicine, Henry extend patients’ length of stay in the were performed in phase 2 because 2 pa- Ford Hospital, Detroit, Mich. emergency department. tients required additional scans. There was Hanan Sedik, MD, is now at Methohexital is an ultrashort-acting no statistical difference between patients in the Division of Pediatric Emergency Medicine, Boston barbiturate, producing few cumulative ad- phase 1 compared with those in phase 2 in Medical Center, and at the verse effects and a more rapid recovery regard to age, weight, race, scan type, total 10-13 Department of Pediatrics, than other barbiturates. Because of its dose given, and dose in mg/kg (P ..05 for Boston University School of quick onset, predictable physiological ef- all), although there were more boys in phase Medicine, Boston, Mass. fects, minimal complication rate, and short 2 (85% vs 43%, P=.002). (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, JUNE 2001 WWW.ARCHPEDIATRICS.COM 665 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 PATIENTS AND METHODS While the patient was on the CT scan table, 1% metho- hexital sodium solution was administered through a stan- dard IV catheter followed by a 3-mL saline flush. At the We conducted this study in 2 phases. In phase 1, we ret- principal investigator’s discretion, doses were titrated to rospectively reviewed medical records of patients in whom achieve sedation, marked by an adequate state of motion- IV methohexital had been used to achieve sedation to ob- lessness that allowed the start and completion of the scan. tain CT scans. In phase 2, we prospectively studied the use The initial dose was 0.5 mg/kg, titrated up using incre- of IV methohexital to achieve sedation for the same pro- ments of 0.5 mg/kg to a maximal dose of 2.0 mg/kg. No cedure. additional sedatives were used. Documentation of the dose of methohexital and PHASE 1 times of administration, onset of sedation (marked by motionlessness without stimulation), start of scan, end of After approval from our institutional review board, we re- scan, end of sedation (marked by patients either starting viewed medical records of 653 children younger than 6 years to move or cry, simultaneously or on stimulation), and who came to our PED between January 1990 and Febru- return to a presedation state (marked by return of vital ary 1998 and required CT scans. Of those, 35 patients were signs and mental status) were all reported on the sedation identified in whom IV methohexital was used to achieve flow sheets. sedation. From these records, we collected data on demo- Subjects were monitored continuously throughout graphics, type of CT scan done, dose of methohexital given, the procedure by the principal investigator and an accom- and complications. panying nurse. Documentation of vital signs included heart rate; respiratory rate and pulse oximetry were done PHASE 2 at 1- to 2-minute intervals throughout the procedure. Presedation and postsedation blood pressure was Between March 1998 and September 1998, all patients included in the documented vital signs. Complications who came to our PED requiring emergency CT scans and and interventions were also documented. In case of seda- falling into the age group that might require sedation tion failure, IV ketamine was used to achieve conscious were invited to participate in the study. Inclusion criteria sedation to obtain the CT scans. The criterion for discon- were patients meeting the American Society of Anesthesi- tinuation of monitoring was a return to a presedation ologists class 1 or 2 criteria, parental consent, and the level of consciousness. need for sedation to undergo the CT scan. Exclusion cri- teria were abnormalities of the airway or the cardiorespi- STATISTICAL ANALYSIS ratory system, a history of hypersensitivity to barbitur- ates, and patients who received any sedatives or hypno- The primary end points were the percentage of patients who tics within 6 hours of the CT scan. All patients had exist- remained motionless throughout their CT scans, as a mea- ing IV lines for reasons other than the purpose of the sure of effectiveness of the medication, and percentage of study. patients experiencing complications, as a measure of drug The institutional review board approved the research safety. protocol, study design, and consent forms. We followed Descriptive statistics were generated, including per- guidelines published by the American Academy of Ped- centage distributions, means, and SDs where appropriate. iatrics for monitoring patients during and after sedation Data from phases 1 and 2 were examined separately and for diagnostic and therapeutic procedures.14 Sedation flow then compared for differences between the 2 groups using sheets were created documenting patients’ demogra- the x2 test, t test, and Kruskal-Wallis test where appropri- phics, type of scan, and presedation vital signs (including ate. Analysis was performed using Stata 6.0 (Stata Corp, heart rate, respiratory rate, blood pressure, and pulse College Station, Tex) and SAS 6.12 (SAS Institute Inc, Cary, oximetry). NC) statistical software. In phase 1, the mean±SD patient age was 28±24 For patients in phase 2, where prospective design months, and 43% were boys. The mean±SD weight was allowed more data collection, the mean onset of seda- 16±13 kg. Of the CT scans performed, 80% were for the tion was 1 minute, and the mean adequate sedation time head, 9% were for the abdomen, and 11% were both head was 12 minutes. Although the mean scan time was 9 min- and abdominal. The mean±SD dose of methohexital given utes, the mean total procedure time was 15 minutes, as was 1±0.4 mg/kg, and the mean±SD total dose was 20±18 demonstrated in the Table. mg/kg. There were no data on dose titration in phase 1 Only 2 patients (,1%) failed to be sedated, patients. All 35 patients remained motionless for the CT whereas the remaining 20 patients remained motion- scans to be completed. No complications were re- less for the CT scans to be completed. Three patients ported, and no interventions were needed. (,1%) had a transient drop in their pulse oximetry that In phase 2, the mean±SD patient age was 26±17 ranged from 93% to 94% on room air, and were months, and 85% were boys. The mean±SD weight was counted as complications. Those patients required 12±4 kg, and 91% of the CT scans performed were for only a chin lift maneuver to bring their pulse oximetry the head. The mean±SD dose of methohexital given was to a value higher than 95%, and remained stable 1±0.5 mg/kg, and the mean±SD total dose was 14±7.5 throughout the procedure. No other complications mg/kg. were observed. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, JUNE 2001 WWW.ARCHPEDIATRICS.COM 666 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 COMMENT Times of Sedations in Phase 2 of the Study* Methohexital use as an induction agent has been well documented in the anesthesia literature.
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