chloral hydrate PO for little ones...

Pediatric Critical Care Columnist · Apr 20, 2007

We use an ocean of chloral hydrate in our PICU, in all age groups and for a variety of sedation needs. It's sedating without depressing the respiratory system and the effect lasts at least an hour. It has no analgesic properties, and it's more effective for inducing sleep than maintaining it. If you give it diluted with at least the same volume of water (lowering the osmolality), then it works almost as fast as an IV med for sedation. It can be given orally, via NG/NJ/OG/GT or PR (use a feeding tube, instill it as high up as you can and get a grip on those little cheeks so it's retained long enough to work.) However, it packs quite a hangover since it's metabolized into alcohol. I give Tylenol with every second dose. It may cause a transient drop in BP, usually only a small one, and it typically hits about 20 minutes after the dose is given and lasts about 10 minutes. Oh, and it tastes HORRIBLE!!!!!

BrnEyedGirl, BSN, MSN, RN, APRN · Apr 21, 2007

thank you jan!

I have recently transfered to ER from tele/stepdown,.haven't cared for little ones since nursing school,.they make me nervous!! We often have 2-5yr olds that need a CT/MRI and refuse to be cooperative,.occasionally w/a bit of extra time you can convince these kids "it isn't going to hurt, it doesn't take very long, and it's better than a "shot" to help them stay still",.some of these kids are much more difficult!! PO meds are a great option,.I just wasn't sure about the amount of sedation,.and then no IV access in case something went wrong!!

Thanks again!!

Pediatric Critical Care Columnist · Apr 21, 2007

We use it on kids with central access, peripheral access, iffy access and no access. I once gave 800 mg (8mL, about 30 mg/kg) PR to a developmentally delayed 8 year old girl who had no access and no cooperative intentions. She was going for an MRI and needed sedation, obviously. The plan originally was to use IV sedation, but no one could get an IV on her. So we used chloral, got the MRI, transferred her out to the peds floor once she woke up and it was all good.

If you're only going to be using it for procedural sedation, I think it'll be safe as houses. As I said, we use a boatload of the stuff in our hemodynamically unstable CV patients. I can't think of more than a couple of times that the BP drop was significant enough and prolonged enough to require intervention. Usually we just ride it out.

BrnEyedGirl, BSN, MSN, RN, APRN · Apr 22, 2007

Thanks sooooo much for your help!!!!! I didn't think about diluting it the other night when I gave it,.suprised the little monster even took it,.he did then said "yukky" so I gave him some water to wash it down with!! Do you mix it with water?,.or juice? It actually didn't help a whole lot with him,.he fell asleep rather quickly,.like 20 minutes, but as soon as we put him on the CT table he woke up screaming,.finally got out the papoos (sp) and after fighting for 20 minutes he went back to sleep,.really felt sorry for his Mom at that point,..but he kept breathing, sats were ok,.HR ok,.no porblems other than thinking I should have given him more!!,..Does it help to give a second dose or maybe just use a larger does to begin with?....I will feel better about it next time,.thanks again for the info!!!

Pediatric Critical Care Columnist · Apr 23, 2007

It works better if you dilute it before you give it. You can disguise it in juice, but have to make sure they drink it all. I use water for putting it through feeding tubes, then flush it through with more water. How big a dose did you give? The 20 minutes onset of effect is about right for undiluted chloral; it's more like 10 or less when diluted. The sedative dose is usually 25 to 50 mg per kg given 30 minutes before the procedure, and may be repeated in 30 minutes at half the dose if not effective. Max dose is 1000 mg. Because many of our kids are already on intravenous sedation we use chloral for breakthrough at doses of 10 to 20 mg per kg q3h and increase the doses by no more than 50 % at a time to a maximum of 50 mg per kg.

With your guy, it might have been the papoose that caused his problem. Most kids that age resent being restrained and get vigorously indignant about it. I bet he relaxed after he got out and that's when he went back to sleep.

BrnEyedGirl, BSN, MSN, RN, APRN · Apr 23, 2007

Next time I'll mix it in something,..he was a big 3yr old, 22kg,.I gave 500mg,..pharmacy gave me 250mg/5ml syrup,.was afraid I wasn't going to get 10ml down him,.which is part of why I didn't want to dilute it,...sounds like I could have given more,..like I said earlier,.wasn't real comfortable with it so may have been a bit too conservative,...restraining him was the last resort,.poor little guy,.he actually fell back to sleep after he fought the retraints, guess he finally figured out we weren't gonna remove them till the test was done,...FYI he did have a small fx w/small bleed,.didn't send him to OR, but did send him to peds for the night.

Pediatric Critical Care Columnist · Apr 23, 2007

That was a fairly conservative dose... 22.7 mg/kg. The 50 mg/mL concentration isn't what we use, ours is 100 mg/mL, so I would say you wouldn't need to dilute yours down as much to decrease its osmo. 10 mL seems like a lot, but an adult's average swallow is around 45 mL, so really it's not that much. I'm glad the youngster was okay.