• Ryan Louer, Renee C McKinney, Samer Abu-Sultaneh, Riad Lutfi, and Kamal Abulebda.
• Indiana University School of Medicine, Indianapolis, IN.
• PM R. 2019 Dec 1; 11 (12): 1320-1325.

BackgroundPediatric patients with cerebral palsy often undergo intramuscular botulinum toxin (BoNT-A) injections. These injections can be painful and may require procedural sedation. An ideal sedation protocol has yet to be elucidated.ObjectiveTo investigate the safety and efficacy of a propofol and ketamine based sedation protocol in pediatric patients with cerebral palsy requiring BoNT-A injections.DesignRetrospective chart review.SettingThe sedations took place in a procedural sedation suite at a tertiary children's hospital from February 2013 through September 2017.Patients164 patients with diagnoses of cerebral palsy undergoing propofol and ketamine based sedation for injections with botulinum toxin A.MethodsAn initial bolus of 0.5 mg/kg ketamine followed by a 2 mg/kg bolus of propofol was administered with supplemental boluses of propofol as needed to achieve deep sedation during the intramuscular BoNT-A injections.Main Outcome MeasurementsPropofol dosages, adverse events, serious adverse events, and sedation time parameters were reviewed.Results345 sedations were successfully performed on 164 patients. The median total dose of propofol was 4.7 mg/kg (interquartile range [IQR]: 3.5, 6.3). Adverse events were encountered in 10.1% of procedures including hypoxemia responsive to supplemental oxygen (9.6%) and transient apnea (1.4%). The mean procedure time, recovery time, and total sedation time were 10, 11 and 33 minutes, respectively. With regard to patient variables, including age, weight, dose of propofol, sedation time, and Gross Motor Function Classification System classification, there was no association with increased incidence of adverse events.ConclusionOur sedation protocol of propofol and ketamine is safe and effective in children with cerebral palsy undergoing procedural sedation for intramuscular injections with BoNT-A. The adverse events encountered appeared to be related to airway and respiratory complications secondary to musculoskeletal deformities, emphasizing the importance of airway monitoring and management in these patients.LevelIV.© 2019 American Academy of Physical Medicine and Rehabilitation.

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