A Prospective Study of 2 Sedation Regimens in Children: Chloral Hydrate, Meperidine, and Hydroxyzine Versus Midazolam, Meperidine, and Hydroxyzine

Abstract

The aim of this study was to compare both the behavioral and physiological effects of 2 drug regimens in children: chloral hydrate (CH), meperidine (M), and hydroxyzine (H) (regimen A) versus midazolam (MZ), M, and H (regimen B). Patients between 24 and 54 months of age were examined by crossover study design. Behavior was analyzed objectively by the North Carolina Behavior Rating System and subjectively through an operator and monitor success scale. Physiological data were recorded every 5 minutes and at critical points throughout the appointment. Sixteen patients completed this study. No significant differences in behavior were noted by the North Carolina Behavior Rating System or the operator and monitor success scale. A quiet or annoyed behavior was observed 93% and 90% of the time for regimen A and regimen B, respectively. Using the operator and monitor success scale, 63% of regimen A and 56% of regimen B sedations were successful. No statistically significant differences were noted in any of the physiological parameters between the 2 regimens. Ten episodes of hemoglobin desaturation were detected with regimen A sedations. There were no differences between the sedative drug regimens CH/M/H and MZ/M/H for behavioral outcomes or physiological parameters.

Dental Sedation in Children

“…First, the depth of sedation is often greater than recommended for moderate sedation, resulting in concerns and reports of respiratory complications. Furthermore, the elimination half-lives of chloral hydrate, 8-10 h [26] and hydroxyzine, 9-20 h, markedly exceed that of midazolam [27].…”

“…Two recent studies identified the increased risks of postsedation complications after these long-acting drugs [23,26]. The greater elimination half-lives of chloral hydrate and hydroxyzine increased somnolence in children after the procedure, which is a concern after the children are discharged from the office [23].…”

Clinical Sedation Regimens

“…Examples might include a dose range of 0.3-0.75, 1.0-1.5, and 1.0 mg/kg of midazolam, meperidine, and hydroxyzine, respectively. One study compared the two "high-dose" triple combinations (i.e., chloral versus midazolam) and found little difference in behaviors [ 29 ]. Yet the rate of quiet behaviors was relatively high suggesting a good sedation outcome.…”

The Direction of Pediatric Sedation: A Contemporary and Historical Look at its Science, Art, Strengths and Shortcomings

“…Trapp [26] (1982) suggested the oral dosage be extended from 50-70 mg/kg because of frequently experienced failure of 50 mg/ kg hypnotic dose to effectively sedate most apprehensive patients. Several studies [37][38][39][40][41][42][43][44][45][46] followed which explored the effectiveness of elevation (and reduction) in its dosage, most of which reported enhanced sedation, but not without increased incidence of emesis, prolonged somnolence, and airway concerns.…”

“…Hasty et al [38] prospectively in one of the rare well-designed and controlled studies to date reported similar results. The regimen of CH-hydroxyzinemeperidine has since been among the most studied and utilized until recent times [35,[37][38][39][40][41][42][43][44][45][46].…”