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PM R. 2019 Feb 13. doi: 10.1002/pmrj.12146. [Epub ahead of print]

Safety and efficacy of a propofol and ketamine based procedural sedation protocol in children with cerebral palsy undergoing botulinum toxin A injections.

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Indiana University School of Medicine, Indianapolis, IN.
Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN.



Pediatric patients with cerebral palsy (CP) 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.


To investigate the safety and efficacy of a propofol and ketamine based sedation protocol in pediatric patients with cerebral palsy requiring BoNT-A injections.


This is a retrospective chart review of children with CP undergoing propofol and ketamine based sedation for injections with botulinum toxin A.


The sedations took place in a procedural sedation suite at a tertiary children's hospital from Feb 2013 through Sept 2017.


164 patients with diagnoses of cerebral palsy were included in this study.


An 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.


Propofol dosages, adverse events, serious adverse events, and sedation time parameters were reviewed.


345 sedations were successfully performed on 164 patients. The median total dose of propofol was 4.7 mg/kg (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.


Our 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. Level III This article is protected by copyright. All rights reserved.


Cerebral palsy; developmental disorders; pediatrics; procedural sedation; propofol


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