Pentobarbital vs chloral hydrate for sedation of children undergoing MRI: Efficacy and recovery characteristics

Background: Chloral hydrate (CH) sedation for magnetic resonance imaging (MRI) is associated with significant failure rates, adverse events and delayed recovery. Pentobarbital (PB), reportedly produces successful sedation in 98% of children undergoing diagnostic imaging. This study compared the efficacy, adverse events and recovery characteristics of CH vs PB in children undergoing MRI. Methods: With Institutional Review Board approval and written consent, children were randomly assigned to receive intravenous (i.v.) PB (maximum 5 mg·kg^-1 in incremental doses) or oral CH (75 mg·kg ^-1) prior to MRI. Sedation was augmented with 0.05 mg·kg ^-1 doses of i.v. midazolam (maximum 0.1 mg·kg^-1) as necessary. Adverse effects, including hypoxaemia, failed sedation, paradoxical reactions and behavioural changes, the return of baseline activity, and parental satisfaction were documented. The quality of MRI scans was evaluated by a radiologist blinded to the sedation technique. Results: PB facilitated an earlier onset of sedation (P = 0.001), higher sedation scores (P = 0.01), and less need for supplemental midazolam compared with CH. Severe hypoxaemia occurred in two children (6%) in the PB group. Fourteen per cent of the PB group experienced a paradoxical reaction, 9% sedation failure and 11% major motion artefact, compared with 0% (P = 0.05), 3 and 2% (P = NS), respectively, in the CH group. CH and PB were both associated with a high incidence of motor imbalance, and agitation. However, children who received PB had a slower return to baseline activity (P = 0.04). Conclusions: Although PB facilitated a quicker sedation onset and reduced the requirement for supplemental sedation, it produced a higher incidence of paradoxical reaction and prolonged recovery with a similar failure rate compared with CH.