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Ettinger NA, Kiskaddon A, McNeely L, Craycraft J, Rogers A, Achuff BJ, Guffey D, Musick M. Retrospective observational study of chloral hydrate use in mechanically-ventilated pediatric intensive care unit (PICU) patients 2012-2017. Front Pharmacol 2023; 14:1111528. [PMID: 37214459 PMCID: PMC10192606 DOI: 10.3389/fphar.2023.1111528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/06/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction: Chloral hydrate (CH) has long been utilized as a pediatric procedural sedation agent. However, very little is published describing CH use in a pediatric intensive care unit (PICU) setting. The aim of this retrospective observational cohort study was to investigate and describe the use of CH in mechanically-ventilated, critically ill children at a large pediatric tertiary referral hospital. Methods: Data were extracted from the hospital electronic medical record and a locally maintained registry of all children admitted to the PICU between 2012 and 2017. Patients admitted to the cardiovascular ICU were not included in this review. The clinical and pharmacy data for 3806 consecutive PICU admissions of mechanically-ventilated, critically ill children were examined. Results: 283 admissions received CH during their first ICU stay. CH-exposed children were younger (16 months vs. 35 months, p < 0.001), the median total dose of CH (indexed to duration of ventilation) was 11 mg/kg/day, the median time to first CH dose was 3 days and more CH doses were administered at night (1112 vs. 958, p < 0.001). We constructed a propensity score to adjust for the differences in patients with and without CH exposure using logistic regression including variables of age, sex, diagnosis, and PRISM3 score. After adjustment, the median length of mechanical ventilation was 5 days longer in the CH-exposed group (95% Confidence Interval [CI] 4-6) compared to unexposed CH patients. Similarly, the median length of ICU duration was 9.4 days longer (95% CI 7.1-11.6) and median length of hospital admission duration was 13.2 days longer (95% CI 7.8-18.6) in CH-exposed patients compared to CH-non-exposed. After adjustment, CH-exposed patients had a 9% higher median exposure to HFOV (95% CI 3.9-14.6), but did not have higher median exposures to new tracheostomy (95% CI -0.4-2.2) or ECMO (95% CI -0.2-5.0). Discussion: As part of an extended sedation regimen in mechanically-ventilated and critically ill children, CH is associated with somewhat higher complexity of illness and longer ICU durations.
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Affiliation(s)
- Nicholas A. Ettinger
- Division of Pediatric Critical Care, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Amy Kiskaddon
- Department of Pharmacy, All Children’s Hospital, Johns Hopkins University School of Medicine, St. Petersburg, FL, United States
| | - Lindsay McNeely
- Division of Pediatric Critical Care, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA, United States
| | | | - Amber Rogers
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Barbara-Jo Achuff
- Division of Pediatric Critical Care, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, United States
| | - Matthew Musick
- Division of Pediatric Critical Care, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
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Joffe AR, Hogan J, Sheppard C, Tawfik G, Duff JP, Garcia Guerra G. Chloral hydrate enteral infusion for sedation in ventilated children: the CHOSEN pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:290. [PMID: 29178963 PMCID: PMC5702481 DOI: 10.1186/s13054-017-1879-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/30/2017] [Indexed: 11/24/2022]
Abstract
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. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1879-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada. .,4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Jessica Hogan
- Department of Nursing, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Cathy Sheppard
- Department of Nursing, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Gerda Tawfik
- Department of Pharmacy, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Jonathan P Duff
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
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Chen ML, Chen Q, Xu F, Zhang JX, Su XY, Tu XZ. Safety and efficacy of chloral hydrate for conscious sedation of infants in the pediatric cardiovascular intensive care unit. Medicine (Baltimore) 2017; 96:e5842. [PMID: 28072745 PMCID: PMC5228705 DOI: 10.1097/md.0000000000005842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
This study evaluates the safety and efficacy of chloral hydrate administration for the conscious sedation of infants in the pediatric cardiovascular intensive care unit (PCICU).We conducted a retrospective review of the charts of 165 infants with congenital heart disease who received chloral hydrate in our PCICU between January 2014 and December 2014. Chloral hydrate was administered orally or rectally to infants using doses of 50 mg/kg. We collected and analyzed relevant clinical parameters.The overall length of time to achieve sedation was ranged from 5 to 35 min (10.8 ± 6.2 min); the overall mean duration of sedation was ranged from 15 to 60 min (33.5 ± 11.3 min); and the overall mean length of time to return to normal activity was 10 min to 6 h (34.3 ± 16.2 min). The length of the PCICU stay was ranged from 3 to 30 days (8.2 ± 7.1 days). Physiologically, there were no clinically significant changes in heart rate, mean arterial pressure, respiratory rate, or peripheral oxygen saturation before, during, or after use of the chloral hydrate. There were no significant differences regarding sedative effects in the subgroups (cyanotic vs acyanotic group, with pulmonary infection vs without pulmonary infection group, and with pulmonary hypertension vs without pulmonary hypertension group).Our experience suggests that chloral hydrate is a safe and efficacious agent for conscious sedation of infants in the PCICU.
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Anderson M, Egunsola O, Cherrill J, Millward C, Fakis A, Choonara I. A prospective study of adverse drug reactions to antiepileptic drugs in children. BMJ Open 2015; 5:e008298. [PMID: 26033949 PMCID: PMC4458612 DOI: 10.1136/bmjopen-2015-008298] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To prospectively determine the nature and rate of adverse drug reactions (ADRs) in children on antiepileptic drugs (AEDs) and to prospectively evaluate the effect of AEDs on behaviour. SETTING A single centre prospective observational study. PARTICIPANTS Children (<18 years old) receiving one or more AEDs for epilepsy, at each clinically determined follow-up visit. PRIMARY AND SECONDARY OUTCOMES Primary outcome was adverse reactions of AEDs. Behavioural and cognitive functions were secondary outcomes. RESULTS 180 children were recruited. Sodium valproate and carbamazepine were the most frequently used AEDs. A total of 114 ADRs were recorded in 56 of these children (31%). 135 children (75%) were on monotherapy. 27 of the 45 children (60%) on polytherapy had ADRs; while 29 (21%) of those on monotherapy had ADRs. The risk of ADRs was significantly lower in patients receiving monotherapy than polytherapy (RR: 0.61, 95% CI 0.47 to 0.79, p<0.0001). Behavioural problems and somnolence were the most common ADRs. 23 children had to discontinue their AED due to an ADR. CONCLUSIONS Behavioural problems and somnolence were the most common ADRs. Polytherapy significantly increases the likelihood of ADRs in children. TRAIL REGISTRATION NUMBER EudraCT (2007-000565-37).
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Affiliation(s)
- Mark Anderson
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Oluwaseun Egunsola
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Janine Cherrill
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Claire Millward
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Apostolos Fakis
- Department of Research and Development, Royal Derby Hospital, Derby, UK
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
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Pan Q, Liu Y, Zhu X, Liu H. Chloral hydrate-dependent reduction in the peptidoglycan-induced inflammatory macrophage response is associated with lower expression levels of toll-like receptor 2. Exp Ther Med 2014; 7:1305-1310. [PMID: 24940429 PMCID: PMC3991540 DOI: 10.3892/etm.2014.1587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 02/21/2014] [Indexed: 12/24/2022] Open
Abstract
The aim of this study was to investigate the effect and mechanism of action of chloral hydrate on the peptidoglycan (PGN)-induced inflammatory macrophage response. The effect of chloral hydrate on the production of tumor necrosis factor α (TNF-α) and interleukin-6 (IL-6) by murine peritoneal macrophages with PGN-stimulation was investigated. In addition, RAW264.7 cells transfected with a nuclear factor-κB (NF-κB) luciferase reporter plasmid stimulated by PGN were used to study the effect of chloral hydrate on the levels NF-κB activity. Flow cytometry and western blotting were performed to investigate the expression levels of toll-like receptor 2 (TLR2) in the treated RAW264.7 cells. It was identified that chloral hydrate reduced the levels of IL-6 and TNF-α produced by the peritoneal macrophages stimulated with PGN. The levels of NF-κB activity of the RAW264.7 cells stimulated by PGN decreased following treatment with chloral hydrate, which was associated with a reduction in the expression levels of TLR2 and reduced levels of TLR2 signal transduction. These data demonstrate that chloral hydrate reduced the magnitude of the PGN-induced inflammatory macrophage response associated with lower expression levels of TLR2.
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Affiliation(s)
- Qingjun Pan
- Institute of Nephrology, Affiliated Hospital of Guangdong Medical College, Zhangjiang, Guangdong 524001, P.R. China
| | - Yuan Liu
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, SAR 999077, P.R. China
| | - Xuezhi Zhu
- Guangdong Yuehai Feed Group Co. Ltd., Zhangjiang, Guangdong 524001, P.R. China
| | - Huafeng Liu
- Institute of Nephrology, Affiliated Hospital of Guangdong Medical College, Zhangjiang, Guangdong 524001, P.R. China
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Mansour MGE, Bendary S. Hospital-acquired pneumonia in critically ill children: Incidence, risk factors, outcome and diagnosis with insight on the novel diagnostic technique of multiplex polymerase chain reaction. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2012. [DOI: 10.1016/j.ejmhg.2012.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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da Silva PSL, Passos RMA, Waisberg DR. Withdrawal treatment with clonidine after prolonged use of chloral hydrate in a pediatric intensive care patient. Paediatr Anaesth 2011; 21:1082-3. [PMID: 21981100 DOI: 10.1111/j.1460-9592.2011.03630.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Pan Q, Liu Y, Zheng J, Lu X, Wu S, Zhu P, Fu N. Protective effect of chloral hydrate against lipopolysaccharide/D-galactosamine-induced acute lethal liver injury and zymosan-induced peritonitis in mice. Int Immunopharmacol 2010; 10:S1567-5769(10)00183-9. [PMID: 20685261 DOI: 10.1016/j.intimp.2010.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Revised: 05/17/2010] [Accepted: 05/18/2010] [Indexed: 11/19/2022]
Abstract
In recent years, certain anesthetics have been shown to have protective effects against acute inflammation in experimental animals, an observation that may yield new options for adjunctive treatment of acute inflammation. In this study, we investigated the effects of chloral hydrate (CH) on the acute inflammatory response in BALB/c mice using lipopolysaccharide/D-galactosamine (LPS/D-GalN)-induced acute lethal liver injury and zymosan A-induced peritonitis models. The survival of mice following LPS/D-GalN treatment was significantly improved by a single injection with chloral hydrate, which could be administered simultaneously or as late as 3h after challenge with LPS/D-GalN; liver injury was also attenuated. A sharp rise in serum levels of MCP-1, IL-6 and TNF-alpha was attenuated or delayed after chloral hydrate treatment. Furthermore, the mechanism by which chlorate hydrate inhibits inflammation was associated with an attenuated increase in nuclear factor kappaappaB (NF-kappaB) activity in NF-kappaB-RE-luc mice upon LPS/D-GalN treatment. In mice with acute peritonitis, leukocyte number and protein concentration in peritoneal exudates peaked with a 16h lag, and serum levels of MCP-1, IL-6 and TNF-alpha were significantly lower at certain time points in the chloral hydrate-treated group compared to those in the normal saline (NS)-treated control group. In addition, chloral hydrate treatment in vitro attenuated the upregulation of TNF-alpha and IL-6 by peritoneal macrophages and NF-kappaB activity in RAW264.7 cells stimulated with LPS, suggesting that monocytes/macrophages may be a target of chloral hydrate. These results indicate that chloral hydrate has a protective effect against LPS/D-GalN-induced acute lethal liver injury in mice, which may be associated with an inhibition of NF-kappaB activity and delays in proinflammatory cytokine production. However, this phenomenon was not associated with levels of serum corticosterone. Chloral hydrate also attenuated the inflammatory response in zymosan A-induced acute peritonitis, a model of mild inflammation. In conclusion, treatment with only a single injection of chloral hydrate could significantly attenuate acute inflammation in mice treated with LPS/D-GalN and zymosan A. These effects are also likely associated with the inhibition of NF-kappaB activity.
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Affiliation(s)
- Qingjun Pan
- Department of Immunology, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, PR China
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