Comparison of cerebral oxygen desaturation events between children under general anesthesia and chloral hydrate sedation - a randomized controlled trial

BACKGROUND

During pediatric general anesthesia (GA) and sedation, clinicians aim to maintain physiological parameters within normal ranges. Accordingly, regional cerebral oxygen saturation (rScO₂) should not drop below preintervention baselines. Our study compared rScO₂ desaturation events in children undergoing GA or chloral hydrate sedation (CHS).

METHODS

Ninety-two children undergoing long auditory assessments were randomly assigned to two study arms: CHS (n = 40) and GA (n = 52). Data of 81 children (mean age 13.8 months, range 1-36 months) were analyzed. In the GA group, we followed a predefined 10 N concept (no fear, no pain, normovolemia, normotension, normocardia, normoxemia, normocapnia, normonatremia, normoglycemia, and normothermia). In this group, ENT surgeons performed minor interventions in 29 patients based on intraprocedural microscopic ear examinations. In the CHS group, recommendations for monitoring and treatment of children undergoing moderate sedation were met. Furthermore, children received a double-barreled nasal oxygen cannula to measure end-tidal carbon dioxide (etCO₂) and allow oxygen administration. Chloral hydrate was administered in the parent's presence. Children had no intravenous access which is an advantage of sedation techniques. In both groups, recommendations for fasting were followed and an experienced anesthesiologist was present during the entire procedure. Adverse event (AE) was a decline in cerebral oxygenation to below 50% or below 20% from the baseline for ≥1 min. The primary endpoint was the number of children with AE across the study arms. Secondary variables were: fraction of inspired oxygen (F_IO₂), oxygen saturation (S_pO₂), etCO₂, systolic and mean blood pressure (BP), and heart rate (HR); these variables were analyzed for their association with drop in rScO₂ to below baseline (%drop_rScO₂).

RESULTS

The incidence of AE across groups was not different. The analysis of secondary endpoints showed evidence that %drop_rScO₂ is more dependent on HR and F_IO₂ than on BP and etCO₂.

CONCLUSIONS

This study highlights the strong association between HR and rScO2 in children aged < 3 years, whereas previous studies had primarily discussed the role of BP and etCO₂. Prompt HR correction may result in shorter periods of cerebral desaturation.

TRIAL REGISTRATION

The study was retrospectively registered with the German Clinical Trials Registry (DRKS00024362, 04/02/2021).

The safety and efficacy of a nurse-led sedation service using Chloral Hydrate for auditory brainstem response testing

BACKGROUND

There is a growing number of pediatric procedures requiring sedation outside the operating room. Among these are auditory brainstem response (ABR) tests, the gold standard for objective hearing evaluation in infants and toddlers. Recently, a nurse-led pediatric sedation service based on a structured protocol has been developed for ABR testing.

OBJECTIVES

To retrospectively analyze the safety and efficacy of the pediatric nurse-led sedation protocol (PNLSP) in a tertiary medical center using Chloral Hydrate (CH) in children undergoing ABR testing.

METHODS

Data from medical charts of children who underwent sedation for ABR testing between January 2014 and December 2017, were retrieved. Analysis of sedation success/failure rates, sleep induction time (SIT), sleep duration time (SDT), and adverse events (AE), was performed.

FINDINGS

1348 children with a mean age of 13.4 months (range 3-42 months), classified by the American Society of Anesthesiologists Physical Status Classification System (ASA score) 1-3, were included in the analysis. All children received a fixed dose of 75 mg / kg CH orally or rectally. Sedation success rate was 98.7% and enabled completion of ABR testing. Failure to sedate was evident in 17 children (1.3%), all classified as ASA score 1-2. Median SIT and SDT were 25 and 100 min, respectively. Mild AE occurred in 9 children (0.67%), none of which required further intervention.

CONCLUSIONS

Findings support the use of a structured PNLSP using CH as safe and efficient. The suggested protocol is an effective alternative for general anesthesia (GA) for ABR testing in healthy young children.

Efficacy and safety of intranasal dexmedetomidine versus oral chloral hydrate as sedatives for pediatric patients: a systematic review and meta-analysis

This study was designed to review published literature to determine the efficacy and safety of intranasal dexmedetomidine versus oral chloral hydrate (CH) for sedation in pediatric patients based on qualified studies. We searched the PubMed, Cochrane, and Embase databases for qualified studies published before March 2021. For each study, we analyzed the relative risk or weighted mean difference combined with a 95% CI. Fourteen studies including 3749 pediatric patients were included in this meta-analysis. Compared with oral CH, intranasal dexmedetomidine significantly increased the success rate of sedation and decreased the duration and latency of sedation, time of recovery from sedation, and total sedation time. Compared with oral CH, intranasal dexmedetomidine significantly decreased the incidence of adverse events, including vomiting, but increased the incidence of bradycardia. In conclusion, intranasal dexmedetomidine provides better sedation than oral CH for pediatric patients with good safety; however, the incidence of bradycardia is increased.

Intranasal dexmedetomidine for sedation in children; a review

Dexmedetomidine is an α2 adrenoreceptor agonist that may be administered by the intranasal route as a sole sedative agent in children. It is odourless, colourless and tasteless and is formulated in a concentration of 100µg.ml^-1. We performed a review of published randomised controlled trials in order to determine the efficacy of intranasal dexmedetomidine for sedation in children. Fourteen trials were eligible for inclusion in the review and contained a total of 1809 patients ranging in age from one month to 14 years. Intranasal dexmedetomidine was administered in a dose range of 1-4µg.kg^-1 and was compared with various other sedatives. Dexmedetomidine was administered by either drops or a mucosal atomiser device. The procedures ranged from non-painful examinations such as magnetic resonance imaging scans and transthoracic echocardiography to painful procedures such as dentistry and venous cannulation. Administration of 2µg.kg^-1 appears to be the optimal dose.

Comparison of intranasal midazolam, intranasal ketamine, and oral chloral hydrate for conscious sedation during paediatric echocardiography: results of a prospective randomised study

OBJECTIVE

There are several agents used for conscious sedation by various routes in children. The aim of this prospective randomised study is to compare the effectiveness of three commonly used sedatives: intranasal ketamine, intranasal midazolam, and oral chloral hydrate for children undergoing transthoracic echocardiography.

METHODS

Children who were referred to paediatric cardiology due to a heart murmur for transthoracic echocardiography were prospectively randomised into three groups. Seventy-three children received intranasal midazolam (0.2 mg/kg), 72 children received intranasal ketamine (4 mg/kg), and 72 children received oral chloral hydrate (50 mg/kg) for conscious sedation. The effects of three agents were evaluated in terms of intensity, onset, and duration of sedation. Obtaining high-quality transthoracic echocardiography images (i.e. absence of artefacts) were regarded as successful sedation. Side effects due to medications were also noted.

RESULTS

There was no statistical difference in terms of sedation success rates between three groups (95.9, 95.9, and 94.5%, respectively). The median onset of sedation in the midazolam, ketamine, and chloral hydrate was 14 minutes (range 7-65), 34 minutes (range 12-56), and 40 minutes (range 25-57), respectively (p < 0.001 for all). However, the median duration of sedation in study groups was 68 minutes (range 20-75), 55 minutes (range 25-75), and 61 minutes (range 34-78), respectively (p = 0.023, 0.712, and 0.045). Gastrointestinal side effects such as nausea and vomiting were significantly higher in the chloral hydrate group (11.7 versus 0% for midazolam and 2.8% for ketamine, respectively, p = 0.002).

CONCLUSION

Results of our prospectively randomised study indicate that all three agents provide adequate sedation for successful transthoracic echocardiography. When compared the three sedatives, intranasal midazolam has a more rapid onset of sedation while intranasal ketamine has a shorter duration of sedation. Intranasal ketamine can be used safely with fewer side effects in children undergoing transthoracic echocardiography.

Efficacy of chloral hydrate oral solution for sedation in pediatrics: a systematic review and meta-analysis

Objective

Chloral hydrate (CH), as a sedation agent, is widely used in children for diagnostic or therapeutic procedures. However, it has not come into the market and is currently only used as hospital preparation in China. This review aims to systematically evaluate the efficacy of CH in children of all age groups for sedation before medical procedures.

Materials and methods

Seven electronic databases and three clinical trial registry platforms were searched and the deadline was September 2018. Randomized controlled trials (RCTs) evaluating the efficacy of CH for sedation in children were included by two reviewers. The extracted information included success rate of sedation, sedation latency and sedation duration. The Cochrane risk of bias tool was applied to assess the risk of bias. The outcomes were analyzed by Review Manager 5.3 software and expressed as relative risks (RR) or Mean Difference (MD) with 95% confidence interval (CI). Heterogeneity was assessed with I-squared (I²) statistics.

Results

A total of 24 RCTs involving 3564 children of CH for sedation were included in the meta-analysis. Compared to placebo group, CH group had a significant increase in success rate of sedation when used for painless and painful procedure (RR=4.15, 95% CI [1.21, 14.24], P=0.02; RR=1.28, 95% CI [1.17, 1.40], P<0.01), which included 22 and 455 children for this analysis, respectively. Compared to midazolam group, CH group had a significant increase in success rate of sedation (RR=1.63, 95% CI [1.48, 1.79], I²=0%, P<0.00001), sedation latency (MD=13.29, 95% CI [11.42, 15.16], I²=0%, P<0.00001) and sedation duration (MD=17.52, 95% CI [10.3, 24.71], I²=0%, P<0.05), which included 1052, 710 and 727 children for this analysis, respectively. Compared to diazepam, there was no significant difference in success rate of sedation (RR=0.93, 95% CI [0.80, 1.08], I²=52%, P=0.32), which included 230 children for this analysis. Compared to dexmedetomidine, there was no significant difference in the success rate of sedation (RR=0.92, 95% CI [0.80, 1.06], I²=48%, P=0.27) and sedation latency (RR=-1.09, 95% CI [-2.45, 0.26], I²=26%, P=0.11), which included 512 and 371 children for this analysis, respectively. Compared to barbiturates, there was no significant difference in the success rate of sedation (RR=1.03, 95% CI [0.94, 1.13], I²=50%, P=0.58) and sedation duration (MD=-0.72, 95% CI [-1.78, 0.34], I²=38%, P=0.18), which included 749 and 210 children for this analysis, respectively.

Conclusions

From the extrapolation of the existing literature, CH oral solution is an appropriate effective alternative for sedation in pediatrics.

Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate

Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine's impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.