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DOI: 10.1148/radiol.2472062087
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(Radiology 2008;247:528-534.)
© RSNA, 2008

Pediatric Imaging

Is Propofol a Safe Alternative to Pentobarbital for Sedation during Pediatric Diagnostic CT?1

Steven E. Zgleszewski, MD, David Zurakowski, PhD, Paulette J. Fontaine, BS, Margaret D'Angelo, BSN, RN, and Keira P. Mason, MD

1 From the Departments of Anesthesia (S.E.Z., D.Z., K.P.M.) and Radiology (D.Z., P.J.F., P.D., K.P.M.), Children's Hospital Boston, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115. From the 2005 RSNA Annual Meeting. Received December 7, 2006; revision requested February 19, 2007; revision received September 12; accepted September 28; final version accepted October 29. Address correspondence to S.E.Z. (e-mail: steven.zgleszewski{at}childrens.harvard.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATIONS FOR PATIENT CARE
 References
 
Purpose: To prospectively compare the incidence of adverse respiratory events, the need for airway interventions, and the recovery time after propofol sedation with similar data from a retrospective review of data obtained in patients who underwent pentobarbital sedation.

Materials and Methods: This HIPAA-compliant study was conducted with institutional review board approval and parental informed consent. The hospital sedation committee approved a 2-month pilot program of propofol sedation as a potential alternative to pentobarbital sedation. Parents were given the choice of having their child sedated with intravenously administered propofol or pentobarbital. Fifty-two patients (18 female, 34 male; mean age, 2.9 years ± 2.4 [standard deviation]) received propofol. An equal number of patients (21 female, 31 male; mean age, 2.5 years ± 1.7) who previously received pentobarbital were included. The sample sizes provided 80% power to detect differences in airway manipulations, adverse respiratory events, and recovery time between the groups by using the Fisher exact test and the Student t test. A two-tailed P value of less than .05 indicated a significant difference.

Results: Patients sedated with propofol underwent significantly more airway manipulations to relieve obstruction than did patients sedated with pentobarbital (23% vs 0%, P < .001). More adverse respiratory events occurred in the propofol group than in the pentobarbital group (12% vs 0%, P = .03). Patients in the propofol group had a faster recovery profile than did patients in the pentobarbital group (34 minutes ± 17 vs 100 minutes ± 30, P < .001).

Conclusion: Propofol is associated with a significantly greater incidence of adverse respiratory events than is pentobarbital.

© RSNA, 2008


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATIONS FOR PATIENT CARE
 References
 
Neonates, infants, and toddlers undergoing computed tomography (CT) often require sedation to minimize motion artifacts. In 2005, our radiology department performed 12 815 CT studies, of which 491 required nurse-administered sedation. In 1993, the radiology sedation committee established a computerized database to track medications administered, patient demographics, and adverse events. This database enables us to develop and modify sedation guidelines, perform quality assurance, review existing protocols, and develop new protocols. All sedatives are administered according to a protocol, and all protocols are approved by both the radiology sedation committee and the hospital sedation committee (1).

Currently, all children older than 1 year receive intravenous pentobarbital for diagnostic CT studies (2). Children younger than 1 year who are unable to receive an oral medication also receive intravenous pentobarbital.

Propofol is an ultrashort-acting sedative-hypnotic that the American Society of Anesthesiologists (ASA) classifies as an anesthetic agent and recommends be administered only by anesthesiologists (3). Propofol administration by nonanesthesiologists for procedural sedation is described in the adult gastroenterology literature (4–6). The Standards of Practice Committee of the American Society of Gastrointestinal Endoscopy recognizes propofol as a sedative appropriate for use by gastroenterologists (7). In emergency medicine, there are also published reports of propofol administration by nonanesthesiologists for both pediatric and adult procedural sedations (8–10). The American College of Emergency Physicians sedation guidelines do not specifically restrict the use of propofol. The major advantage of propofol over pentobarbital is the short-acting profile (t1/2, 10–30 minutes), which should reduce recovery time and return the patient to clinical baseline status faster than the longer-acting pentobarbital (half-life, 24–36 hours).

Propofol use in children for magnetic resonance (MR) imaging is associated with upper airway narrowing that occurs throughout the entire upper airway and is most pronounced in the hypopharynx at the level of the epiglottis, with increasing depth of propofol anesthesia (11). To our knowledge, these imaging findings have never been corroborated with clinical findings of airway obstruction or compromise. Thus, the purpose of our study was to prospectively compare the incidence of adverse respiratory events, the need for airway interventions, and the recovery time after propofol sedation with similar data from a retrospective review of data obtained in patients who underwent pentobarbital sedation.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATIONS FOR PATIENT CARE
 References
 
Patients and Database
Our radiology sedation program has institutional review board approval to compile and use the quality assurance database, both retrospectively and prospectively, to ensure safety and efficacy and to monitor modifications in sedation protocols. Data are entered with parental informed consent. In our study, data review was compliant with the Health Insurance Portability and Accountability Act, and the database administrator (P.J.F.) deidentified all data prior to review.

Both the department of radiology and the hospital sedation committee approved a pilot program to determine if intravenous propofol sedation could be an alternative to intravenous pentobarbital sedation. The current literature suggests that propofol may have a superior recovery profile and a similar safety profile compared with those of pentobarbital (12,13). Our radiology sedation committee mandated that we complete a quality assurance report 2 months after we initiated the program. During this 2-month trial, parents were given the choice of having their child sedated with propofol or pentobarbital, and they were advised of the potential risks and benefits of both sedatives. Parents were informed that propofol sedation was induced in a pilot program, that its intent was to improve sedation practice, and that outcome data would be evaluated over a 2-month period and in the future. All parents provided signed informed consent and indicated their sedative choice. The mean age of the 104 patients (39 female, 65 male) in the study was 2.7 years ± 2.1 (standard deviation). Of the 65 patients who underwent diagnostic CT imaging during the pilot study, 52 (18 female, 34 male; mean age, 2.9 years ± 2.4) received propofol. An equal number of consecutive children (21 female, 31 male; mean age, 2.5 years ± 1.7) who received pentobarbital prior to initiation of the propofol pilot study were included in our study, and their records were reviewed retrospectively.

Data Gathering
The radiology nursing staff or physicians who provided immediate care to the sedated patient collected and recorded specific information related to each sedation procedure. This information was transcribed into a computerized database (FileMakerPro, version 2.1; Claris, Cupertino, Calif) by a designated staff member (P.J.F.). The database contains information on patient demographics; diagnosis; examination duration, type, and date; fasting duration; sedative type and dose administered (measured in milligrams per kilogram of body weight); ASA physical status classification; duration of recovery room stay; and adverse events (14). Adverse events were defined as unplanned events that occurred during sedative administration, immediately after the procedure, or after discharge from the radiology department (up to 24 hours after sedation) (1).

Any adverse events and airway manipulations necessary to relieve airway obstruction were documented for both the pentobarbital group and the propofol group. The types of adverse events varied (Table 1). An airway event was defined as any adverse respiratory event (need for resuscitation or abnormal oxygen saturation) or any airway manipulation (jaw thrust, chin lift, shoulder roll, oropharyngeal airway, or nasal trumpet) required to relieve clinical signs of airway obstruction.


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  		Table 1. Types of Adverse Events

 
Pentobarbital and Propofol Sedation Protocols
A radiology nurse screened all candidates prior to the procedure to determine whether they had any medical conditions that would disqualify them from receiving a nurse-administered sedative (Fig 1) (14).


Figure 1
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  		Figure 1: List of contraindications to nurse-administered sedation.

 
Our sedation policies and guidelines incorporate recommendations from the American Academy of Pediatrics for sedation and analgesia (15,16). All patients met our institutional guidelines for nurse-administered sedation. At our institution, all pentobarbital sedatives are administered by a radiology nurse under the supervision of a physician (radiologist, pediatrician, or anesthesiologist). Per our protocol, any patients older than 1 year and infants who were unable to receive an oral medication received pentobarbital intravenously (2). In our pilot program, the hospital sedation committee mandated that without an established safety profile in the hands of nurses, an anesthesiologist needed to administer propofol.

The pentobarbital protocol began with intravenous administration of 1–2 mg/kg pentobarbital. The Ramsay sedation score (RSS) is a clinically derived scale used to quantify depth of sedation in children. An RSS of 4 (moderate) or 5 (deep) is generally accepted as an adequate sedation depth for diagnostic CT imaging. The difference between an RSS of 4 and an RSS of 5 is clear, and the RSS can be determined on the basis of whether a patient has a brisk (RSS 4) or sluggish (RSS 5) response to a loud auditory stimulus. Sedation was titrated to an RSS of 4 or 5. If an RSS of 4 or 5 was not achieved with the initial bolus, repeat boluses of 1–2 mg/kg pentobarbital were given at 1–2-minute intervals. (Pentobarbital was diluted in normal saline to a maximum dose of 10 mg/mL.) Maximum total dose was 6 mg/kg or 200 mg. Patients who receive barbiturate therapy for seizures may be refractory to the indicated doses of pentobarbital and can receive a dose of up to 9 mg/kg. Occasionally, patients may require intravenous fentanyl, midazolam, or both if sedation with pentobarbital alone is insufficient to render the patient motionless (1). Patients who required fentanyl or midazolam were excluded from the retrospective review of the data obtained in the 52 patients who received pentobarbital. All patients in this sedation group received only pentobarbital.

Patients in the propofol group were sedated by one of four anesthesiologists (S.E.Z., K.P.M.), all of whom had 5–12 years of experience with administration of this drug. The protocol began with intravenous administration of a 1–2 mg/kg propofol bolus (Diprivan; Astra Zeneca Pharmaceuticals, Wilmington, Del). After waiting 30–50 seconds, repeat 1 mg/kg boluses were administered until an RSS of 4 or 5 was attained. Once the goal RSS was attained, continuous infusion of propofol was titrated between 150 and 200 mcg/kg per minute and adjusted as needed until the imaging procedure was complete. Once the procedure was complete, as confirmed by the radiologist, infusion was discontinued.

Statistical Analysis
Rates of airway manipulations, adverse events, and airway events were compared between the two groups by using the Fisher exact test for binary proportions. Exact 95% confidence intervals (CIs) were calculated by using the Wilson method, with continuity correction to account for low cell counts (ie, <5 cells) (17,18). The groups also were compared with respect to mean age, weight, and recovery and examination times with the unpaired Student t test. Subgroup analysis was performed to compare differences in recovery and examination times between the groups separately for patients who underwent examination of the head, neck, or both, as well as for those who underwent other examinations. The Pearson {chi}2 test was used to compare distributions of sex and ASA status between the two groups. Additionally, the {chi}2 test with Yates correction was used to assess the relationship between ASA status and airway events in the propofol group (19).

Multiple stepwise linear regression analysis with the backward selection procedure was used to compare recovery and examination times between groups, while adjusting for age, weight, sex, ASA status, type of CT examination (head and/or neck vs other types), and occurrence of an airway event to assess whether the type of drug used affected recovery and examination times independent of these other six covariates (20). Continuous data are presented in terms of the mean and standard deviation, since age and recovery and examination times followed a normal Gaussian-shaped distribution, as evaluated with the Kolmogorov-Smirnov test. Data analysis was performed by using an SPSS software package (version 14.0; SPSS, Chicago, Ill). Power analysis indicated that a minimum sample size of 50 patients in each group would provide 80% power for detecting a mean difference of 60 minutes in recovery time and 5 minutes in examination time with an unpaired Student t test and for constructing a 95% CI with an upper limit of 10% above the empirical rates for each of the two sedation groups (nQuery Advisor, version 6.0; Statistical Solutions, Saugus, Mass). All reported P values are two tailed.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATIONS FOR PATIENT CARE
 References
 
Comparison of Group Characteristics
Mean weight of the 104 patients in the study was 14.3 kg ± 6.5. ASA status was as follows: level 1, 31 patients (30%); level 2, 52 patients (50%); and level 3, 21 patients (20%). Sixty-six patients (63%) underwent head CT, neck CT, or both, whereas 38 patients (37%) underwent thoracic CT, abdominal CT, pelvic CT, and/or spinal CT. There were no significant differences (P > .25 for all) in characteristics (age, weight, and ASA status) between the patients stratified according to the sedative they received (Table 2).


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  		Table 2. Characteristics of Pediatric Patients Undergoing Sedation with Either Propofol or Pentobarbital for CT

 
Airway Manipulations and Adverse Events
Twelve patients in the propofol group (23%) had airway events, whereas none of the patients in the intravenous pentobarbital group had an airway event (P < .001, Fisher exact test) (Fig 2). The 95% CIs for the observed proportion of airway events were 13% and 37% for propofol and 0% and 9% for pentobarbital. Six of the twelve patients underwent airway manipulation and experienced an adverse respiratory event. The total number of adverse events did not differ significantly between the groups (Table 3): An adverse event occurred in six patients (12%; 95% CI: 5%, 24%) in the propofol group (four occurred during sedation and two occurred during recovery) and in two patients (4%; 95% CI: 1%, 14%) in the intravenous pentobarbital group (both occurred during recovery). However, the number of adverse respiratory events differed significantly between the two groups (Table 3): In the propofol group, six patients (12%; 95% CI: 5%, 24%) had an adverse respiratory event (five oxygen desaturations and one need for positive pressure ventilation), whereas none of the patients in the intravenous pentobarbital group had an adverse respiratory event (95% CI: 0%, 9%). Since all 12 airway manipulations were performed in the propofol group, we evaluated the association between the presence of an airway event and the ASA level by using subgroup analysis and {chi}2 analysis with Yates correction for continuity (19). We observed no significant association between these variables (P = .54), which suggested that the occurrence of an airway event was independent of ASA level (ie, disease severity).


Figure 2
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  		Figure 2: Graph shows percentages of airway events in the propofol (23%) and intravenous pentobarbital (0%) groups. The percentage of airway events is significantly higher in the propofol group (P < .001, Fisher exact test). The upper limit of the 95% CI for the observed proportion of airway events is 37% for the propofol group and 9% for the intravenous pentobarbital group.

 

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  		Table 3. Airway Manipulations and Adverse Events according to the Type of Sedation

 
Recovery Times
Mean recovery times were significantly shorter with propofol than with pentobarbital (34 minutes ± 17 vs 100 minutes ± 31, P < .001) when all patients in each group were considered (Fig 3). Subgroup analysis revealed similar results when only those patients who underwent head CT, neck CT, or both were considered (32 minutes ± 16 vs 100 minutes ± 27, P < .001) and when patients who underwent a study other than head and/or neck CT were considered (38 minutes ± 17 vs 99 minutes ± 38, P < .001). When multiple stepwise linear regression analysis was used to test differences in recovery time between the two sedatives used, the model indicated that recovery time was significantly shorter when propofol was used (P < .001); this finding was independent of age (P = .95), weight (P = .98), sex (P = .99), ASA level (P = .97), examination type (P = .99), and occurrence of an airway event (P = .87).


Figure 3
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  		Figure 3: Graph shows mean recovery times in the two sedation groups (52 patients in each group). Mean recovery time was 34 minutes ± 17 in the propofol group and 100 minutes ± 31 in the pentobarbital group (P < .001, Student t test). Error bars denote the standard deviation.

 
Mean examination times were significantly longer with use of propofol than with use of intravenous pentobarbital (16 minutes ± 8 vs 9 minutes ± 4, P < .001) for all patients in each group; subgroup analysis enabled us to determine that this was true for patients who underwent head and/or neck studies and those who underwent other types of examinations (Fig 4). Multiple linear regression analysis results showed that the following four variables were significant independent predictors of examination time: type of sedative used (P < .001), patient weight (P = .015), examination type (P = .02), and occurrence of an airway event (P = .045). Significantly longer examination times were observed in patients who were sedated with propofol, those who were heavier, those who underwent an imaging study other than head or neck CT, and those who experienced an airway event. Age, sex, and ASA level did not influence examination time (P > .25 for all comparisons).


Figure 4
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  		Figure 4: Graph shows mean examination times in the two sedation groups for all patients stratified according to examination type. For all 104 patients (All, n = 52 per group), mean examination time was 16 minutes ± 8 in the propofol group and 9 minutes ± 4 in the intravenous pentobarbital group (P < .001, Student t test). Similarly, examination time was significantly longer in the propofol group than in the pentobarbital group for head and/or neck (HAN) CT (15 minutes ± 8 [n = 32] vs 8 minutes ± 4 [n = 34], respectively; P < .001) and for other CT examinations (Others), including thoracic, abdominal, pelvic, and spinal examinations (18 minutes ± 8 [n = 20] vs 11 minutes ± 5 [n = 18] , respectively; P < .001). Error bars denote the standard deviation.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
ADVANCES IN KNOWLEDGE
 IMPLICATIONS FOR PATIENT CARE
 References
 
Sedation is an evolving practice that advances as trials of new sedation agents and protocols are instituted and existing protocols are replaced. Our computerized database has enabled the radiology sedation committee to perform quality assurance, review outcome data, and evaluate modifications to the sedation protocols. By conducting pilot studies with alternative sedation techniques (21) and analyzing the results with a database, we have been able to establish new protocols (14) and improve existing ones (2,22).

Despite the safety and effectiveness of pentobarbital when used for sedation, there are several major disadvantages associated with its continued use. It is a long-acting drug, and its use can lead to prolonged sedation, increased time in the recovery room, and discharge from the hospital before full recovery to baseline clinical status has occurred. Paradoxical hyperactivity that prolongs recovery time and distresses parents and caregivers alike is seen in approximately 1% of sedated patients. Furthermore, pentobarbital is a potential respiratory depressant that could lead to oxygen desaturation or necessitate airway resuscitation (23). A short-acting alternative sedative could shorten recovery time, lower the adverse event rate, and decrease the number of failed sedations. Propofol is widely used to induce and maintain anesthesia. It is also used to induce deep sedation for both MR and CT studies (13,24,25), mainly because of its advantages, which include rapid onset, rapid recovery time, absence of paradoxical hyperactivity, and absence of nausea or vomiting.

We have shown that recovery time with propofol sedation is significantly reduced when compared with recovery time with pentobarbital sedation and that this change is independent of other variables. Despite the improvement in recovery time, we also confirmed that there was potential for respiratory depression and adverse airway events at the doses needed to maintain motionless conditions for CT imaging studies (26,27). The incidence of adverse airway events and the subsequent need for airway expertise to relieve symptoms of airway obstruction were significantly greater in the propofol group than in the pentobarbital group. Our clinical findings are consistent with imaging findings that have shown the upper airway narrows with increasing depth of propofol anesthesia in children, thereby predisposing the patient to airway obstruction, especially when patients are placed in the supine position (11).

An unanticipated result was that examination times were significantly longer for propofol sedation than for pentobarbital sedation. This could be explained by the significantly greater number of airway events in the propofol group. Titration of propofol to an RSS of 4 or 5 with a constant depth of sedation can be difficult because of the ease with which a patient can drift from moderate to deep sedation. All patients in both groups were sedated until they were motionless. It is possible that airway events in the propofol group were caused in part by a transient increase in the depth of sedation at the beginning of sedation or during the course of sedation. An airway event would require the physician to stop the examination and perform an intervention, thereby lengthening the examination time. However, examination times with propofol were shown to be significantly longer than those with pentobarbital independent of age, sex, patient weight, examination type, or occurrence of an airway event.

Our study had some limitations. Our results are specific to CT only, as MR imaging was not performed. MR imaging requires a longer sedation time in a noisier environment, which would most likely necessitate an increased propofol dose. Thus, we would anticipate either a similar or an increased number of airway events for MR imaging performed with propofol sedation. In addition, although we detected a significant difference between the number of airway events that occurred with propofol sedation and the number of airway events that occurred with pentobarbital sedation, it would be difficult to capture and estimate a true event rate in the pediatric population in any individual study. In our study, there was imprecision with respect to the estimation of a true proportion of airway events. There was adequate power to compare all parameters between the two sedation groups; however, larger sample sizes are required to estimate the true proportion of airway events with greater precision.

In conclusion, even if propofol is to be used as a sedative for painless CT imaging studies, it should be used only by personnel with expertise in the recognition and management of a compromised airway. A propofol sedation program staffed by physicians with expertise in this area would likely benefit from the shorter recovery profile of propofol. However, in view of our findings, pentobarbital should not be replaced with propofol for nurse-administered sedation at this time.


   ADVANCES IN KNOWLEDGE
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
IMPLICATIONS FOR PATIENT CARE
 References
 


   IMPLICATIONS FOR PATIENT CARE
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATIONS FOR PATIENT CARE
References
 


   FOOTNOTES
 

Abbreviations: ASA = American Society of Anesthesiologists • CI = confidence interval • RSS = Ramsay sedation score

Author contributions: Guarantors of integrity of entire study, S.E.Z., D.Z., K.P.M.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, S.E.Z., D.Z., K.P.M.; clinical studies, S.E.Z., P.D., K.P.M.; statistical analysis, D.Z., P.J.F.; and manuscript editing, S.E.Z., D.Z., K.P.M.

Authors stated no financial relationship to disclose.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ADVANCES IN KNOWLEDGE
 IMPLICATIONS FOR PATIENT CARE
 References
 

  1. Karian VE, Burrows PE, Zurakowski D, Connor L, Poznauskis L, Park Mason K. The development of a pediatric radiology sedation program. Pediatr Radiol 2002;32:348–353.[CrossRef][Medline]
  2. Mason KP, Zurakowski D, Connor L, et al. Infant sedation for MR imaging and CT: oral versus intravenous pentobarbital. Radiology 2004;233:723–728.[Abstract/Free Full Text]
  3. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004–1017.[CrossRef][Medline]
  4. Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases. Gastrointest Endosc 2003;57:664–671.[CrossRef][Medline]
  5. Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients: a prospective, controlled study. Am J Gastroenterol 2003;98:1751–1757.[Medline]
  6. Rex DK, Overley C, Kinser K, et al. Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases. Am J Gastroenterol 2002;97:1159–1163.[CrossRef][Medline]
  7. Faigel DO, Baron TH, Goldstein JL, et al. Guidelines for the use of deep sedation and anesthesia for GI endoscopy. Gastrointest Endosc 2002;56:613–617.[CrossRef][Medline]
  8. Green SM, Krauss B. Propofol in emergency medicine: pushing the sedation frontier. Ann Emerg Med 2003;42:792–797.[CrossRef][Medline]
  9. Bassett KE, Anderson JL, Pribble CG, Guenther E. Propofol for procedural sedation in children in the emergency department. Ann Emerg Med 2003;42:773–782.[CrossRef][Medline]
  10. Guenther E, Pribble CG, Junkins EP Jr, Kadish HA, Bassett KE, Nelson DS. Propofol sedation by emergency physicians for elective pediatric outpatient procedures. Ann Emerg Med 2003;42:783–791.[CrossRef][Medline]
  11. Evans RG, Crawford MW, Noseworthy MD, Yoo SJ. Effect of increasing depth of propofol anesthesia on upper airway configuration in children. Anesthesiology 2003;99:596–602.[CrossRef][Medline]
  12. Pershad J, Wan J, Anghelescu DL. Comparison of propofol with pentobarbital/midazolam/fentanyl sedation for magnetic resonance imaging of the brain in children. Pediatrics 2007;120:e629–e636.[Abstract/Free Full Text]
  13. Usher AG, Kearney RA, Tsui BC. Propofol total intravenous anesthesia for MRI in children. Paediatr Anaesth 2005;15:23–28.[CrossRef][Medline]
  14. Mason KP, Sanborn P, Zurakowski D, et al. Superiority of pentobarbital versus chloral hydrate for sedation in infants during imaging. Radiology 2004;230:537–542.[Abstract/Free Full Text]
  15. American Academy of Pediatrics Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992;89:1110–1115.[Abstract/Free Full Text]
  16. Committee on Drugs, Section on Anesthesiology. Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics 1985;76:317–321.[Abstract/Free Full Text]
  17. Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998;17:857–872.[CrossRef][Medline]
  18. Medina LS, Zurakowski D. Measurement variability and confidence intervals in medicine: why should radiologists care? Radiology 2003;226:297–301.[Abstract/Free Full Text]
  19. Rosner B. Hypothesis testing: categorical data. In: Fundamentals of biostatistics. 6th ed. Belmont, Calif: Duxbury, 2006; 393, 401.
  20. Vittinghoff E, Glidden DV, Shiboski SC, McCulloch CE. Regression methods in biostatistics. New York, NY: Springer, 2005.
  21. Chung T, Hoffer FA, Connor L, Zurakowski D, Burrows PE. The use of oral pentobarbital sodium (Nembutal) versus oral chloral hydrate in infants undergoing CT and MR imaging: a pilot study. Pediatr Radiol 2000;30:332–335.[CrossRef][Medline]
  22. Mason KP, Zurakowski D, Karian VE, Connor L, Fontaine PJ, Burrows PE. Sedatives used in pediatric imaging: comparison of IV pentobarbital with IV pentobarbital with midazolam added. AJR Am J Roentgenol 2001;177:427–430.[Abstract/Free Full Text]
  23. Sanborn PA, Michna E, Zurakowski D, et al. Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology 2005;237:288–294.[Abstract/Free Full Text]
  24. Frankville DD, Spear RM, Dyck JB. The dose of propofol required to prevent children from moving during magnetic resonance imaging. Anesthesiology 1993;79:953–958.[Medline]
  25. Funk W, Taeger K. Anaesthesia for magnetic resonance imaging/computed tomography. Curr Opin Anaesthesiol 2000;13:429–432.[CrossRef][Medline]
  26. Reeves ST, Havidich JE, Tobin DP. Conscious sedation of children with propofol is anything but conscious. Pediatrics 2004;114:e74–76.[Abstract/Free Full Text]
  27. Powers KS, Nazarian EB, Tapyrik SA, et al. Bispectral index as a guide for titration of propofol during procedural sedation among children. Pediatrics 2005;115:1666–1674.[Abstract/Free Full Text]




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