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Jornal de Pediatria

Print version ISSN 0021-7557

J. Pediatr. (Rio J.) vol.83 no.4 Porto Alegre July/Aug. 2007

http://dx.doi.org/10.1590/S0021-75572007000500018 

LETTERS TO THE EDITOR

 

Gamma-hydroxybutyrate for sedation in children

 

 

Dear Editor,

We read with interest the article by Mencia et al. on analgesia and sedation in children.1 In addition to the plethora of drugs discussed by the authors, we would like to add our experience on the use of gamma-hydroxybutyrate (GHB) for sedation in children.2 GHB was first introduced into clinical anesthesia in 1960. Although it reliably induces sedation without significantly depressing respiratory or cardiocirculatory parameters, it has been unpopular because of its prolonged duration of action. Recent clinical studies suggest a revaluation of its use in critical care medicine and general anesthesia.3 Clinical trials with GHB-induced sedation in children have shown good results, but so far only limited data are available.2,4

In our prospective randomized trial, we showed that GHB induces deep sedation (Ramsay score 5) in children undergoing MRI studies. GHB was associated with vomiting despite the prior administration of an antiemetic. This may in part be attributable to the fact that GHB sedation was used in pediatric cancer patients, making them more prone to this side effect because of concurrent chemo- and radiotherapy. Although none of our GHB-sedated patients aspirated during the study, the physician should be aware of this possibility. Moreover, none of our patients required administration of physostigmine, a short-acting anticholinesterase agent, to treat prolonged sedation.

We conclude that GHB sedation is a reasonable alternative for children undergoing noninvasive diagnostic procedures. Pediatricians that are not familiar with potent short-acting sedative drugs (propofol, remifentanyl, etc.) may consider it for deep sedation in pediatric patients.

 

References

1. Mencia SB, Lopez-Herce JC, Freddi N. Analgesia and sedation in children: practical approach for the most frequent situations. J Pediatr (Rio J). 2007;83(2 Suppl):S71-82.

2. Meyer S, Gottschling S, Georg T, Lothschutz D, Graf N, Sitzmann FC. Gamma-hydroxybutyrate versus chlorprothixene/ phenobarbital sedation in children undergoing MRI studies. Klin Padiatr. 2003;215:69-73.

3. Kleinschmidt S, Schellhase C, Mertzlufft F. Continuous sedation during spinal anaesthesia: gamma-hydroxybutyrate vs. propofol. Eur J Anaesthesiol. 1999;16:23-30.

4. Poschl J, Kolker S, Bast T, Brussau J, Ruef P, Linderkamp O, et al. [Gamma-hydroxybutyric acid sedation in neonates and children undergoing MR Imaging]. Klin Padiatr. 2006;[Epub ahead of print].

 

 

S. Meyer
The Centre for Newborn Care, Medical School, The Canberra Hospital, Australian National University, Canberra, Australia

S. Gottschling
Department of Pediatrics and Neonatology, University Hospital of the Saarland, Saarbrücken, German

L. Gortner
Department of Pediatrics and Neonatology, University Hospital of the Saarland, Saarbrücken, Germany

 


 

Authors' reply

 

 

We read with interest the comments made by Dr. S. Meyer et al.1 about the use of gamma-hydroxybutyrate (GHB) for sedation in children. We have not had any experience with this sedative drug in children. In the medical literature, there are few references other than these authors to the use of GHB in children. The use of GHB is not included in sedation guidelines for children.2 It has been unpopular because it induces deep sedation, has prolonged duration of action and is associated with vomiting.

Pediatric sedation practice involves a large number of pediatric subspecialists using a variety of sedation strategies and tools. Most employed drugs are still propofol, midazolam and ketamine, although there are new strategies coming up.3 The effectiveness and safety of this practice needs careful scrutiny. Recent studies concerning depth of sedation have suggested reconsidering systems that employ moderate sedation for painful procedures in children.

Dexmedetomidine sedation delivered by pediatricians is rapidly increasing and has provided adequate sedation in most children. Dexmedetomidine could be an alternative reliable sedative drug in selected patients because it causes fewer cardiorespiratory effects.4 Similarly, nitrous oxide for pediatric sedation, while promising, will require careful study as its use increases. Fauroux et al.5 demonstrated the improved efficacy of sedation, pain control, and safety of premixed 50% nitrous oxide and oxygen for fiberoptic bronchoscopy in children.

Finally, discharge criteria for children who have been sedated should advance along with the drugs and techniques used for sedation during a procedure. The application of specific criteria in this area is a significant improvement over subjective measures that have been used in the past.

 

References

1. Meyer S, Gottschling S, Georg T, Lothschutz D, Graf N, Sitzmann FC. Gamma-hydroxybutyrate versus chlorprothixene/ phenobarbital sedation in children undergoing MRI studies. Klin Padiatr. 2003;215:69-73.

2. Playfor S, Jenkins I, Boyles C, Choonara I, Davies G, Haywood T, et al. Consensus guidelines on sedation and analgesia in critically ill children. Intensive Care Med. 2006;32:1125-36.

3. Cravero JP, Blike GT. Pediatric sedation. Curr Opin Anaesthesiol. 2004;17:247-51.

4. Koroglu A, Teksan H, Sagir O, Yucel A, Toprak HI, Ersoy OM. A comparison of the sedative, hemodynamic, and respiratory effects of dexmedetomidine and propofol in children undergoing magnetic resonance imaging. Anesth Analg. 2006;103:63-7.

5. Fauroux B, Onody P, Gall O, Tourniaire B, Koscielny S, Clément A. The efficacy of premixed nitrous oxide and oxygen for fiberoptic bronchoscopy in pediatric patients: a randomized, double-blind, controlled study. Chest. 2004;125:315-21.

 

 

Santiago Mencía
Jesús López-Herce
Sección de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón de Madrid, Madrid, España


Department of Pediatrics and Neonatology, University Hospital of the Saarland, Saarbrücken, Germany