Treatment of pentobarbitol sodium (Nembutal) hyperactivity: a new approach

Pediatr Radiol (2000) 30: 204 Springer-Verlag 2000 LETTER TO THE EDITOR

Christopher Bunt Richard Towbin

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C. Bunt Department of Radiology, University of Michigan, Children's Hospital of Pittsburgh, Pennsylvania, USA

R. Towbin Radiology and Pediatrics Department, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

R. Towbin, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA

Treatment of pentobarbitol sodium (Nembutal) hyperactivity: a new approach

Received: 23 July 1999 Accepted: 2 August 1999

Sir, Proper sedation of the pediatric patient is essential for obtaining high-quality imaging examinations and performing interventional procedures. This sedation is usually achieved using pentobarbital sodium alone or in combination.

In approximately 1 % of cases, pento-barbital sodium (Nembutal) causes paradoxical hyperactivity [13]. This reaction is similar to the hyperactivity seen in children with attention deficit hyperactivity disorder (ADHD), leaving the patient agitated and restless.

Stimulants have been used to treat ADHD since 1937 [4]. While most treatments have centered on amphetamines, caffeine has also been successfully used to treat ADHD. As a result of this experience, it appeared that the paradoxical reaction secondary to pentobarbital could be treated in a similar fashion. We have found that caffeine administered orally in Mountain Dew (a soft drink) can be effective.

In the past 2 years we have treated 25 children ranging in age from 14 months to 11 years for 26 episodes of paradoxical hyperactivity after injection of pentobarbital (mean dose 4.36 mg/kg). Of the 25 children treated, 24 calmed down within 1090 min of ingestion. Each child received 112 oz (mean 3.5 oz) of Mountain Dew (mean 8.6 mg/kg caffeine).

Barbituates affect the reticular activating system. Slovis and colleagues suggest that paradoxical hyperactivity does not occur with Versed or fentanyl administration[3]. While the mechanism of action of stimulants remains unknown, evidence suggests their effects on hyperactivity are produced by a combined effect on dopa-mine and nonadrenergic-dependant pathways in the CNS [5]. The currently accepted mechanism of action of caffeine is a blockade of methyl-xanthine sensitive adenosine receptors [6]. Adenosine promotes the onset of slow-wave sleep, reduced vigilance, effects opposite those of caffeine.

Mountain Dew is readily available and is an excellent source of caffeine, 4.6 mg/oz. Patients readily drink this preparation. Children who develop paradoxical hyper-activity may be offered a can (12 oz). If necessary, the liquid may be given by NG tube. Alternatively, although not in our subgroup, caffeine may be given intravenously or orally (20 mg/kg). Our experience suggests that paradoxical hyperactivity can be treated with orally administered Mountain Dew (or other high-caffeine sodas).