Pediatric Chloral Hydrate Poisonings and Death Following Outpatient Procedural Sedation

Abstract

Introduction Chloral hydrate has been used medicinally since the 1800 s as a sedative hypnotic, most commonly for procedural sedation. As it is administered orally and available in a liquid formulation, it is used almost exclusively in pediatric patients despite many safer and more effective alternative agents being available. Case Series We present three cases of pediatric chloral hydrate poisoning, all occurring following procedural sedation in outpatient clinic settings and presenting to the emergency department. The ages ranged from 15 months to 4 years of age and all required resuscitation. Unfortunately, the 4-yearold died. Conclusion Choral hydrate is associated with significant adverse effects, including death, and safer alternatives for pediatric procedural sedation should be sought and utilized. There are a number of more effective sedative agents with more predictable pharmacokinetic and safety profiles than chloral hydrate including parenteral and oral agents. The practice of pre-procedure sedation should be performed only in a supervised setting where cardiorespiratory monitoring can occur in all cases.

Safety and efficacy of chloral hydrate for procedural sedation in paediatric ophthalmology: a systematic review and meta-analysis

“…This concern mostly refers to the immediate effect of CH and its potential cardiopulmonary complications that pose a direct threat to life 2 22. The commonest AE in paediatric sedation is hypoxia, and CH has actually the advantage of not inducing significant respiratory depression 36.…”

“…Concerns have been raised about severe adverse events (AE) related to its use, mainly as a result of overdosage2 and in some countries (eg, the USA) it is not included in the list of approved drugs. However, recent studies reveal that some paediatric ophthalmology units use it routinely in hospital-based outpatient nurse-led clinics and report large series with no severe side effects 3 4.…”

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

“…Transportation in a car safety seat poses a particular risk for infants who have received medications known to have a long half-life, such as chloral hydrate, intramuscular pentobarbital, or phenothiazine because deaths after procedural sedation have been reported. 62,63,238,242,256,257 Consideration for a longer period of observation shall be given if the responsible person's ability to observe the child is limited (eg, only 1 adult who also has to drive). Another indication for prolonged observation would be a child with an anatomic airway problem, an underlying medical condition such as significant obstructive sleep apnea (OSA), or a former preterm infant younger than 60 weeks' postconceptional age.…”

A randomised controlled trial of oral chloral hydrate vs. intranasal dexmedetomidine before computerised tomography in children

“…Chloral hydrate is not recommended for children older than 4 years or younger children with neurodevelopmental disorders because of the increased rates of adverse events and treatment failure . Severe morbidity and death have been associated with chloral hydrate . Similar problems have not been identified with dexmedetomidine .…”