50% effective concentration of sevoflurane for immobility in cerebral palsy children undergoing botulinum toxin injection

This prospective study aimed to determine the optimum end-tidal sevoflurane concentration required for immobility during botulinum toxin injection in spontaneously breathing children with cerebral palsy (CP). METHODS: Twenty-three children with spastic CP, aged 3 to 12 years, with American Society of Anesthesiologists (ASA) physical status I and II, scheduled to receive botulinum toxin type A injection were enrolled in the study. After induction of deep sedation using pre-filled 8% sevoflurane in oxygen and maintenance of the predetermined end-tidal sevoflurane concentration, the botulinum toxin was injected in spontaneously breathing children. The response to the botulinum toxin injection was classified as “movement” or “no movement” by an independent investigator who was blinded to the predetermined end-tidal sevoflurane concentration and bispectral index (BIS) value. The end-tidal sevoflurane concentration was predetermined, initiating at 2.0% with 0.2% as a step size in the next patient depending on the previous patient’s response using the modified Dixon’s up-and-down method. RESULTS: Of 21 children, 12 (57.1%) showed “no movement” in response to the botulinum toxin injection. By Dixon’s up-and-down method, the 50% effective end-tidal concentration (EC(50)) of sevoflurane for successful botulinum toxin injection was 1.76 ± 0.15% (95% CI 1.62–1.90). Based on the dose‐response curve using probit analysis, the predicted EC(50) and 95% effective end-tidal concentrations (EC(95)) of sevoflurane without movement were 1.77% (95% CI 1.59–2.35) and 2.09% (95% CI 1.89–5.80), respectively. CONCLUSION: Botulinum toxin injection can be successfully accomplished at an end-tidal sevoflurane concentration of 1.76 ± 0.15% in 50% of spontaneously breathing children with CP aged 3–12 years.