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Chloral hydrate enteral infusion for sedation in ventilated children: the CHOSEN pilot study
Ari R Joffe1,2, Jessica Hogan3, Cathy Sheppard3
1Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada. ari.joffe@ahs.ca.
Insights
Continuous enteral infusion of chloral hydrate (CH) is a feasible and effective sedation method for ventilated pediatric patients. This novel delivery approach showed a 95% feasibility rate with potential benefits in fluid balance.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology and Therapeutics
- Sedation and Analgesia
Background:
- Critically ill children requiring mechanical ventilation often need sedation.
- Chloral hydrate (CH) is used for intermittent sedation, but continuous enteral delivery is a novel approach.
- Assessing the feasibility and safety of continuous enteral CH infusion in this population is important.
Purpose of the Study:
- To evaluate the feasibility of a novel continuous enteral chloral hydrate (CH) infusion method for sedating ventilated young children.
- To compare outcomes of continuous enteral CH infusion with historical controls.
Main Methods:
- A prospective study enrolled children under 12 years old receiving mechanical ventilation and intermittent CH.
- Patients received a CH loading dose followed by a continuous enteral infusion via syringe pump.
- Feasibility was defined as successful infusion without discontinuation due to adverse events; outcomes were compared to matched historical controls.
Main Results:
- Continuous enteral CH infusion was feasible in 95% of patients (20/21).
- One adverse event (duodenal ulcer perforation) occurred in a patient with confounding factors.
- The method demonstrated effective sedation titration and reduced the need for PRN (as needed) doses compared to controls, with less positive fluid balance.
Conclusions:
- Continuous enteral infusion of chloral hydrate (CH) is a feasible and effective method for sedating ventilated pediatric patients.
- This method may be associated with improved fluid balance.
- Further investigation is needed to clarify the potential risk of duodenal perforation.
Background:
We aimed to test a novel method of delivery of chloral hydrate (CH) sedation in ventilated critically ill young children.
Methods:
Children < 12 years old, within 72 hours of admission, who were ventilated, receiving enteral tube-feeds, with intermittent CH ordered were enrolled after signed consent. Patients received a CH loading-dose of 10 mg/kg enterally, then a syringe-pump enteral infusion at 5 mg/kg/hour, increasing to a maximum of 9 mg/kg/hour. Cases were compared to historical controls matched for age group and Pediatric Risk of Mortality score (PRISM) category, using Fisher's exact test and the t test. The primary outcome was feasibility, defined as the use of an enteral CH continuous infusion without discontinuation attributable to a pre-specified potential harm.
Results:
There were 21 patients enrolled, at age 11.4 (12.1) months, with bronchiolitis in 10 (48%), a mean Pediatric Logistic Organ Dysfunction (PELOD) score of 6.2 (5.2), and having received enteral CH continuous infusion for 4.5 (2.2) days. Infusion of CH was feasible in 20/21 (95%; 95% CI 76-99%) patients, with one (5%) adverse event of duodenal ulcer perforation on day 3 in a patient with croup receiving regular ibuprofen and dexamethasone. The CH infusion dose (mg/kg/h) on day 2 (n = 20) was 8.9 (IQR 5.9, 9), and on day 4 (n = 11) was 8.8 (IQR 7, 9). Days to titration of adequate sedation (defined as ≤ 3 PRN doses/shift) was 1 (IQR 0.5, 2.5), and hours to awakening for extubation was 5 (IQR 2, 9). Cases (versus controls) had less positive fluid balance at 48 h (-2 (45) vs. 26 (46) ml/kg, p = 0.051), and a decrease in number of PRN sedation doses from 12 h pre to 12 hours post starting CH (4.7 (3.3) to 2.6 (2.8), p = 0.009 versus 2.9 (3.9) to 3.4 (5), p = 0.74). There were no statistically significant differences between cases and controls in inotrope scores, signs or treatment of withdrawal, or PICU days.
Conclusions:
Delivering CH by continuous enteral infusion is feasible, effective, and may be associated with less positive fluid balance. Whether there is a risk of duodenal perforation requires further study.
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