Simple instructions for partial sleep deprivation prior to pediatric EEG reduces the need for sedation

Efficacy and safety of chloral hydrate in auditory brainstem response test: A systematic review and single-arm meta-analysis

OBJECTIVES

To evaluate the safety and efficacy of chloral hydrate in auditory brainstem response (ABR) tests.

SETTING AND DESIGN

In this study, the authors systematically searched both English (Embase, PubMed, and Web of Science) and Chinese (Chinese National Knowledge Infrastructure, Wanfang Data, and VIP Chinese Science) databases. Two authors independently performed data extraction and quality assessment. The pooled sedation failure rate and the pooled incidence of adverse events were calculated via a random-effects model. Sensitivity and subgroup analyses were performed to explore the sources of heterogeneity, and the PRISMA guideline was followed.

PARTICIPANTS

Patients with ABR tests receiving chloral hydrate sedation.

MAIN OUTCOME MEASURES

The pooled sedation failure rate and the pooled incidence of adverse events.

RESULTS

A total of 23 clinical studies were included in the final analysis. The pooled sedation failure rate of patients who received chloral hydrate sedation before ABR examination was 10.0% [95% confidence interval (CI) (6.7%, 15.0%), I2 = 95%, p < .01]. There were significant differences in the prevalence of sedation failure between sample sizes greater than 200 and those less than or equal to 200 (5.6% vs. 19.6%, p < .01) and between the studies that reported sleep deprivation and those that did not report sleep deprivation (7.1% vs. 18.9%, p < .01). The pooled incidence of adverse events was 10.32% [95% CI (5.83%, 14.82%), I2 = 98.1%, p < .01].

CONCLUSIONS

Chloral hydrate has a high rate of sedation failure, adverse events, and potential carcinogenicity. Therefore, replacing its use in ABR tests with safer and more effective sedatives is warranted.

Correlation between the actual sleep time 24 hours prior to an examination and the time to achieve chloral hydrate sedation in pediatric patients in South Korea: a prospective cohort study

PURPOSE

This study investigated correlations between the actual sleep time 24 hours prior to an examination and the time to achieve chloral hydrate sedation in pediatric patients.

METHODS

With parental consent, 84 children who were placed under moderate or deep sedation with chloral hydrate for examinations from November 19, 2020 to July 9, 2022 were recruited.

RESULTS

Patients' average age was 19.9 months. Pediatric neurology patients and those who underwent electroencephalography took significantly longer to achieve sedation with chloral hydrate. There was a negative correlation between the time to achieve sedation and actual sleep time within 24 hours prior to the examination. Positive correlations were found between the actual sleep time 24 hours prior to the examination and the second dose per weight, as well as between the sedation recovery time and awake hours before the examination.

CONCLUSION

Sleep restriction is not an effective adjuvant therapy for chloral hydrate sedation in children, and sedation effects vary according to pediatric patients' characteristics. Therefore, it would be possible to reduce the unnecessary efforts of caregivers who restrict children's sleep for examinations. It is more important to educate parents about safe sedation than about sleep restriction.

Efficacy of Liposomal Melatonin in sleep EEG in Childhood: A Double Blind Case Control Study

Electroencephalography (EEG) is pivotal in the clinical assessment of epilepsy, and sleep is known to improve the diagnostic yield of its recording. Sleep-EEG recording is generally reached by either partial deprivation or by administration of sleep-inducing agents, although it is still not achieved in a considerable percentage of patients. We conducted a double-blind placebo-controlled study, involving a hundred patients between 1 and 6 years old, randomized into two groups: Group 1 received liposomal melatonin (melatosome) whereas Group 2 received a placebo. Sleep latency (SL), defined as the time span between the onset of a well-established posterior dominant rhythm, considered as a frequency of 3 to 4 Hz, increasing to 4-5 Hz by the age of 6 months, to 5-7 Hz by 12 months, and finally to 8 Hz by 3 years, and the first EEG sleep figures detected, were measured for each patient. A significant difference in SL was observed (10.8 ± 5 vs. 18.1 ± 13.4 min, p-value = 0.002). Within each group, no differences in sleep latency were detected between genders. Furthermore, no difference in EEG abnormality detection was observed between the two groups. Our study confirmed the efficacy and safety of melatonin administration in sleep induction. Nonetheless, liposomal melatonin presents a greater bioavailability, ensuring a faster effect and allowing lower dosages. Such results, never before reported in the literature, suggest that the routine employment of melatonin might improve clinical practice in neurophysiology, reducing unsuccessful recordings.

Analysis of Risk Factors for Chloral Hydrate Sedative Failure with Initial Dose in Pediatric Patients: a Retrospective Analysis

BACKGROUND

Although chloral hydrate has been used as a sedative for more than 100 years, dozens of studies have reported that it has inconsistent sedative effects and high sedation failure rates with initial dose. The high failure rates may lead to repeated administration of sedatives, guardians' dissatisfaction, parental anxiety, increasing medical workload as well as leading to an increase of adverse events. Our aim is to identify the risk factors associated with chloral hydrate sedative failure with initial dose in children undergoing noninvasive diagnostic procedures.

METHODS

Pediatric patients who underwent chloral hydrate sedation for noninvasive diagnostic procedures at our institution between 1 December 2019 and 1 January 2021 were retrospectively analyzed. Data collected included patients' age, gender, weight, sedation history, sedation failure history, type of procedures, initial dose of choral hydrate, sleep deprivation, sedation failure with initial dose, and sedative duration. The initial dose was classified into three levels: reduced dose (< 40 mg/kg), standard dose (40-60 mg/kg), and high dose (> 60 mg/kg). The patients were divided into three cohorts according to the different initial doses.

RESULTS

A total of 15,922 patients were included in the analysis; 1928 (12.1%) were not well-sedated after administering the initial dose of chloral hydrate. The highest sedative failure was observed in the reduced dose group. By multivariate regression, we identified that heavier weight, patients with a history of sedation or a history of sedation failure, and patients who received magnetic resonance imaging (MRI) or more than one procedure simultaneously were associated with an increased odds of sedation failure at the initial dose. However, outpatients, patients undergoing hearing screening, and patients with sleep deprivation were favored regarding chloral hydrate sedative success.

CONCLUSION

An alternative drug or drug combination is necessary in patients with heavier weight, those with a sedation history or sedation failure history, and those undergoing an MRI or more than one procedure simultaneously, whereas chloral hydrate is an appropriate sedation option for outpatients, patients undergoing hearing screening, and those with sleep deprivation.

Sleep deprivation did not enhance the success rate of chloral hydrate sedation for non-invasive procedural sedation in pediatric patients

Study objective

In Asian countries, oral chloral hydrate is the most commonly used sedative for non-invasive procedures. Theoretically, mild sleep deprivation could be considered as one of assisted techniques. However, there is no consensus on sleep deprivation facilitating the sedation during non-painful procedures in children. The aim of our study is to analyze the clinical data of children undergoing non-invasive procedural sedation retrospectively and to evaluate the association between mild sleep deprivation and sedative effects in non-invasive procedures.

Measurements

Consecutive patients undergoing chloral hydrate sedation for non-invasive procedures between December 1, 2019 to June 30, 2020 were included in this study. The propensity score analysis with 1: 1 ratio was used to match the baseline variables between patients with sleep deprivation and non-sleep deprivation. The primary outcome was the failure rate of sedation with the initial dose. The secondary outcomes included the failure rate of sedation after supplementation of chloral hydrate, the incidence of major and minor adverse events, initial and supplemental dose of chloral hydrate, and the length of sedation time.

Main results

Of the 7789 patients undergoing chloral hydrate sedation, 6352 were treated with sleep deprivation and 1437 with non-sleep deprivation. After propensity score matching, 1437 pairs were produced. The failure rate of sedation with initial chlorate hydrate was not significantly different in two groups (8.6% [123/1437] vs. 10.6% [152/1437], p = 0.08), nor were the failure rates with supplemental chlorate hydrate (0.8% [12/1437] vs. 0.9% [13/1437], p = 1) and the length of sedation time (58 [45, 75] vs. 58 [45, 75] min; p = 0.93).

Conclusions

The current results do not support sleep deprivation have a beneficial effect in reducing the pediatric chloral hydrate sedation failure rate. The routine use of sleep deprivation for pediatric sedation is unnecessary.

Sedation protocol with fasting and shorter sleep leads to magnetic resonance imaging success

BACKGROUND

Young children undergoing magnetic resonance imaging (MRI) require sedation. In June 2013, Tokyo Metropolitan Ohtsuka Hospital (TMOH) introduced an oral sedation protocol for young children undergoing MRI; the protocol included instructions on fasting before sedation, and recommended a shorter duration of sleep the night before MRI. We compared the MRI success rate before and after the introduction of this protocol.

METHODS

The eligible subjects were children under 3 years old who underwent MRI by appointment at TMOH between October 2012 and March 2014, under sedation with triclofos sodium. All those who underwent MRI in or after June 2013 were enrolled prospectively as a post-protocol group. All patients who underwent MRI before June 2013 were enrolled retrospectively as a pre-protocol group, with data collected from chart review.

RESULTS

Seventy-four patients were enrolled in the post-protocol group, and 42 in the pre-protocol group. The MRI success rate was significantly higher in the post-protocol group than in the pre-protocol group (98.7% vs 88.1%), as was the rate of on-time starting of MRI (86.5% vs 71.4%). The post-protocol group woke up earlier on the day of examination (6:18 a.m. vs 6:43 a.m.), resulting in a significantly longer time between awakening and the beginning of sedation (289.8 min vs 265.9 min), and a significantly shorter average duration of sleep on the previous night (504.8 min vs 532.3 min).

CONCLUSIONS

Implementation of a hospital-wide sedation protocol for young children undergoing MRI significantly improved the MRI success rate.

Efficacy of the Sequential Administration of Melatonin, Hydroxyzine, and Chloral Hydrate for Recording Sleep EEGs in Children

Sedation of children for electroencephalography (EEG) recordings is often required. Chloral hydrate (CH) requires medical clearance and continuous monitoring. To try to reduce personnel and time resources associated with CH administration, a new sedation policy was formulated. This study included all children who underwent an EEG during a consecutive 3-month period following the implementation of the new sedation policy, which consists of the sequential administration of melatonin, hydroxyzine (if needed), and CH (if needed). The comparator group included all children with a recorded EEG during a consecutive 3-month period when the sedation policy consisted of the sole administration of CH. A total of 803 children with a mean age of 7.9 years (SD = 5.1, range = 0.5-17.7 years) were included. Sleep EEG recordings were obtained in 364 of 385 children (94.6%) using the old sedation policy and in 409 of 418 children (97.9%) using the new one. With the new sedation policy, the percentage of children requiring CH dropped from 37.1% to 6.7% (P < .001). Time to sleep onset and duration of sleep were not significantly different between the 2 policies. The new sedation policy was very well tolerated. The new sedation policy is very safe, is highly efficacious in obtaining sleep EEG recordings, and will result in substantial saving of time and personnel resources.

Feasibility of sleep-deprived EEG in children

BACKGROUND

Non-sedated EEG recording in children can be technically challenging, particularly when behavioral disorders are present. We aimed to assess the feasibility and the efficacy of non-sedated sleep-deprived EEG in children with behavioral disorders and in young children.

METHODS

We retrospectively reviewed the EEG recordings and computerized medical records of all pediatric inpatients at least 2-month-old that had a sleep-deprived EEG during a 5-year period between 2009 and 2014.

RESULTS

We present the data of 261 children, 142 (54%) boys, mean age 7.9 ± 4.9 years, 67 (26%) aged 0.5-4 years. Behavioral disorders were reported in 38 (15%) of the patients. Mean recording duration was 50.8 ± 12.5 min, and mean sleep duration- 31.8 ± 15.2 min. Thirty-seven (14%) patients slept less than 15 min during the EEG, including 19 (7%) patients with no sleep during the recording. Sleep duration and the presence of interictal epileptiform discharges did not significantly differ between children with/without behavioral disorders and in those younger/older than 4 years. Patients that did not fall asleep during the EEG did not differ from the others regarding presence of behavioral disorders or age.

CONCLUSIONS

These results suggest that non-sedated sleep-deprived EEG is feasible in young children and in those with behavioral disorders. Further studies are needed in order to better characterize the etiologies of sleepless pediatric sleep-deprived EEG recordings.

Chloral hydrate sedation in radiology: retrospective audit of reduced dose

BACKGROUND

Chloral hydrate (CH) is safe and effective for sedation of suitable children.

OBJECTIVE

The purpose of this study was to assess whether adequate sedation is achieved with reduced CH doses.

MATERIALS AND METHODS

We retrospectively recorded outpatient CH sedations over 1 year. We defined standard doses of CH as 50 mg/kg (infants) and 75 mg/kg (children >1 year). A reduced dose was defined as at least 20% lower than the standard dose.

RESULTS

In total, 653 children received CH sedation (age, 1 month-3 years 10 months), 42% were given a reduced initial dose. Augmentation dose was required in 10.9% of all children, and in a higher proportion of children >1 year (15.7%) compared to infants (5.7%; P < 0.001). Sedation was successful in 96.7%, and more frequently successful in infants (98.3%) than children >1 year (95.3%; P = 0.03). A reduced initial dose had no negative effect on outcome (P = 0.19) or time to sedation. No significant complications were seen.

CONCLUSION

We advocate sedation with reduced CH doses (40 mg/kg for infants; 60 mg/kg for children >1 year of age) for outpatient imaging procedures when the child is judged to be quiet or sleepy on arrival.

The effect of melatonin on sedation of children undergoing magnetic resonance imaging

BACKGROUND

Melatonin may induce a natural sleepiness and improve predictability of sedation drugs. We have investigated its clinical value in children sedated for magnetic resonance imaging.

METHODS

In a stratified randomized double-blind study, 98 children received either melatonin or placebo 10 min before they were sedated with a standard oral regimen. Children >5 and <15 kg received chloral hydrate and those >or=15 and <40 kg had a combination of temazepam with droperidol (T&D). The doses of melatonin were 3 and 6 mg, respectively. One observer recorded the time taken to reach criteria for deep sedation, sedation failure and other sedation-related events.

RESULTS

In the chloral hydrate group (n=50) 50% were deeply sedated by 31 min after melatonin and 40 min after placebo (P=0.57). There were zero and 1 failures, respectively. The geometric mean time taken to reach deep sedation was 39 min in both subgroups. In the T&D group (n=48) 50% were deeply sedated by 70 min in both subgroups (two failures in each); geometric mean times were 68 and 71 min, respectively (P=0.58). Children closed their eyes slightly earlier after melatonin (respective geometric means 42 vs 48, P=0.17), and took slightly longer to achieve discharge criteria (146 vs 135, P=0.47).

CONCLUSION

In these doses and clinical conditions, melatonin did not contribute to sedation of children.

The management of infants and children for painless imaging

The ability of a child to remain sufficiently immobile for painless imaging depends upon their behaviour and the imaging itself. Anaesthesia allows imaging to be optimised but it is expensive, scarce and inappropriate for many situations. Fortunately, sedation and behavioural techniques are sufficiently successful for the majority of scanning, and success rates are high provided that suitable children are selected. Sedation, however, administered by non-anaesthetists, may have catastrophic complications such as airway obstruction. Current UK recommendations demand that any sedation technique has a 'wide margin of safety', but in addition to this, safety is dependent on trained, skillful and experienced staff. Magnetic resonance imaging frightens many children and special planning is necessary for sedation and anaesthesia. When planning an imaging service for children, all the management techniques should be considered in order to achieve maximum efficiency, quality and safety.