propofol
This child has signs and symptoms concerning for a serious intracranial lesion such as hemorrhage. Computed tomography of the head is necessary to determine the injury; however, the child will not remain still without some sort of chemical sedation. Imaging is a non- painful procedure, which affects sedation choices.
The literature on pediatric sedation is evolving with different authors listing different groups of medications as their primary versus alternate choices. However, some trends are emerging: propofol and ketamine have the least side effects and are now consistently recommended over pentabarbital and midazolam (associated with hypotension and respiratory depression). The reviews are somewhat more mixed for etomidate, with some authors listing etomidate alongside propofol and ketamine versus others (incl. the 2012 clinical policy on emergency department sedation) only giving it a B grade for etomidate, due to it being associated with mild to severe myoclonic movements in 20 – 40% of patients, which is obviously not helpful when obtaining a CT scan.
The reviews for other agents vary more from author to author, with rectal methohexital and dexmedetomidine being listed by some authors as acceptable primary choices, and others warning about their less favorable safety profile (respiratory depression, and also bradycardia and fatal medication errors in the case of dexmedetomidine).
Nitrous oxide is not an appropriate choice because it requires self-administration, which a 6-month-old baby will not be able to do. Fentanyl will not necessarily result in immobilization and should be reserved for painful procedures.
References:
Godwin SA, Burton JH, Gerardo CJ, et al; American College of Emergency Physicians. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2): 247-58.
Burbulys D, et al. Procedural sedation and analgesia (chapter 4). In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed., 2014.
Macias CG, Chumpitazi CE. Sedation and anesthesia for CT: emerging issues for providing high-quality care. Pediatr Radiol. 2011 Sep;41 Suppl 2:517-22. Epub 2011 Aug 17.
Baxter AL, et al. Etomidate versus pentobarbital for computed tomography sedations: report from the Pediatric Sedation Research Consortium. Pediatr Emerg Care. 2007;23(10):690
Srinivasan M, et al. Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions. J Pediatr. 2012;160(5):801. Epub 2011 Dec 16.
Eich C, et al: Low-dose S-ketamine added to propofol anesthesia for magnetic resonance imaging in children is safe and ensures faster recovery—a prospective evaluation. Paediatr Anaesth 2011; 21: 176
Mallory MD, Baxter AL, Kost SI: Propofol vs pentobarbital for sedation of children undergoing magnetic resonance imaging: Results from the Pediatric Sedation Research Consortium. Paediatr Anaesth 2009; 19:601-611.
