Expert: Ronald Levy, M.D. - 8/8/2010

Question
Dear Dr. Levy,

I apologize in advance for the length of this post, but I want to be sure to give you an accurate history of my daughter's reactions to sedatives.

In April 2009, my daughter (23 months old at the time) had an emergency MRI (with and w/o contrast) of her brain at a well-known pediatric hospital.  Initially, the doctor was concerned that my daughter had a serious issue with her brain (tumor), and was hesitant to fully sedate her.  He opted to give her Versed (nasally) at first, so she was lethargic enough for them to take just a few MRI scans to rule out anything major that would prevent him from fully sedating her.  That 'mini-MRI' showed nothing, and so they proceeded with the original MRI as planned.  She was sedated without complication.  Thankfully, the results of the MRI were not concerning; however, after the completion of the MRI, she had what the doctor called a "bad wake-up".  She awoke in less than an hour after being sedated (just enough time to complete the MRI).  For the next 2-3 hours (when most kids are still sleeping after sedation), my daughter cried and screamed while I tried to keep her safe, as she hadn't yet regained muscle control and was flailing around.  The recovery room nurse told me that this reaction was probably due to the Versed that she was given.  (Unfortunately, I didn't save the discharge paperwork, so the only drug I know she was given via IV was Nembutal.  I am unsure of amount that was administered or if any other sedatives were given intravenously.)

In August 2009, she had another MRI of her brain (to look for any changes) at the same hospital.  I insisted that she not be given Versed this time.  She was sedated without complication (Fentanyl 10 mcg Intravenous; Nembutal 65 mg) and slept the 'standard' 2 hours after the MRI was done.  When she awoke, she was a bit groggy and still lacked muscle control but otherwise behaved normally (no screaming or crying).

My daughter had her third (and final) MRI of her brain in July 2010, at age 3.  Since her 2nd MRI sedation went so well, I again requested that Versed not be administered.  After starting the IV, the nurse (under a doctor's supervision) administered Robinul, Nembutal and Fentanyl.  However, my daughter became increasingly agitated while being given the medication (crying, screaming for me but not seeing me right in front of her, scratching, pinching, biting, etc.).  I was terrified by this as my daughter was clearly scared, confused and didn't even know I was there to comfort her.  I was also worried that she might fall out of the bed (she's only 36 pounds but was writhing around so much, two nurses weren't safely able to hold her down).  Against their wishes, I got into bed with my daughter to try to offer her comfort and keep her safe.

For the next 30 minutes, the nurses kept calling the doctor for permission....then giving my daughter more sedative in her IV.  During this time period, she was given:  60 mcg Robinul, 90 mg Nembutal and 15 mcg Fentanyl.  At that time, I was told that this was the maximum dosage they could give based on her weight.  My daughter would occasionally appear asleep for 1-2 minutes, only to wake up screaming and kicking again if there was any movement or sound at all.

I was told that my options were either to allow them to give Versed (1 mg through her IV) or they were going to call this a "failed sedation" and reschedule her for an MRI under general anesthesia.  I opted to allow them to give her Versed, which had an immediate sedative effect.  They then proceeded with her MRI.

She had another "bad wake-up" at the end of the MRI.  Though she wasn't violent (as she had been while administering the sedative), she was screaming, crying and generally confused.  This lasted for about 40 minutes in the recovery room, and then she surprisingly fell asleep on my lap.  She slept for over an hour, and woke up fairly pleasant.

Before we were released that day, I was told by the doctor that it probably wasn't Versed that caused the reactions (in both the first and third MRI), but was instead Nembutal that was the likely culprit.  He suggested Propofol be given instead if she needs to be sedated in the future.

My questions:

1 - If Nembutal is the culprit, how could she have had no negative reaction to it when it was given in 8/09?

2 - If Nembutal did cause her problems with sedation, are there any other drugs (sedative or otherwise) that she has an increased chance of having an adverse reaction to?  (Her occupational therapist told me that she believes people with a sensitivity to Nembutal are also prone to having difficulty consuming even small amounts of alcohol.)

3 - In your experience, based on my descriptions above, do you agree that Nembutal, not Versed, likely caused my daughter's adverse reactions?

4 - Can these type of drug reactions/sensitivities get worse over time?  And if so, do you recommend that she wear a medical bracelet?  (My daughter Ehlers-Danlos Syndrome, so has extremely loose joints and mildly low muscle tone.  She is prone to falling and has had a few nasty falls to the head.  I hope she won't need to be sedated again for any medical tests, but I realize the possibility is there if she has a serious fall.)

Thank you in advance for you assistance.

Sincerely,
Jenn

Answer
1 - If Nembutal is the culprit, how could she have had no negative reaction to it when it was given in 8/09?

This is not an allergic reaction so it does not need to happen every timne. Nembutal can cause agitation in some patients but it is not predictable or consistent.


2 - If Nembutal did cause her problems with sedation, are there any other drugs (sedative or otherwise) that she has an increased chance of having an adverse reaction to?  (Her occupational therapist told me that she believes people with a sensitivity to Nembutal are also prone to having difficulty consuming even small amounts of alcohol.)

No because, again, it is not an allergic reaction. If she needs sedation again, I would recommend Propofol instead of Nembutal. It is a sedative and also an anxiolytic.


3 - In your experience, based on my descriptions above, do you agree that Nembutal, not Versed, likely caused my daughter's adverse reactions?

Yes.


4 - Can these type of drug reactions/sensitivities get worse over time?  And if so, do you recommend that she wear a medical bracelet?  (My daughter Ehlers-Danlos Syndrome, so has extremely loose joints and mildly low muscle tone.  She is prone to falling and has had a few nasty falls to the head.  I hope she won't need to be sedated again for any medical tests, but I realize the possibility is there if she has a serious fall.)

The do not get worse over time and there is no need for a medic alert bracelet for this. Hope this helps,

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston