AMERICAN ACADEMY OF PEDIATRICS Reappraisal of Lytic Cocktail/Demerol, Phenergan, and Thorazine (DPT) for the Sedation of Children

The importance of premedication for pediatric patients undergoing surgical procedures dates to the classic work of Waters,’ who believed that children were as entitled as adults to have premedication. The recommended premedication was morphine with scopolamine. Later, phenothiazines were believed to be useful as anesthetic premedications because of their sedative and vasodilator effects.2’ These observations led to the combination of a narcotic with a phenothiazine, which induced deep sedation (sleeping) in the child and allowed easy separation from his or her parents before administration of the anesthetic. The narcotic provided a base of analgesia whereas the phenothiazine lowered the blood pressure and blunted the pressor responses to surgical stimulation. The combination of meperidine (Demerol), promethazine (Phenergan), and chiorpromazine (Thorazine), commonly referred to as DPT, has been used for more than 20 years as a sedative and analgesic cocktail for pediatric patients.2 Although the combination of a narcotic with phenothiazine was first developed to provide preanesthetic sedation for patients about to undergo general anesthesia, its primary use in children has been outside of the operating room. The DPT combination has been used as a primary sedative for infants and young children Undergoing radiologic procedures (computed tomography, magnetic resonance imaging, and contrast studies). It has been used as a sedative/analgesic for invasive procedures (suturing, bone marrow aspirations, cardiac catheterization, and renal biopsy). The precise mixture of constituents in the cocktail used for children varies somewhat from institution to institution.3’4 Original descriptions refer to a formulation including 25 mg/mL of meperidine, 6.5 mg/mL of promethazine, and 6.5 mg/mL of chlorpromazine, with a recommended dose of 0.1 mL/kg of body weight. Recent sources refer to a formulation consisting of a 2:1:1 mixture, with what amounts to a l-mL/kg dosage recommendation.3’4 In fact, dosage recommendations may vary by a factor of 10. No proprietary mixtures are available, so the solution must be prepared locally. Intramuscular injection has been the most common route of administration; how-