(992) Protocol-Driven Approach Using Chloral Hydrate in Difficult-to-Sedate Patients in the PICU

Introduction: Sedation is an important component in the management of critically ill pediatric patients receiving invasive interventions such as mechanical ventilation. Chloral hydrate is one of the oldest enteral sedative/hypnotic drugs known, but its use fell out of favor due to safety concerns. The major concerns with chloral hydrate are related to respiratory depression, hemodynamic compromise and death in unmonitored outpatient settings. Our objective was to determine the frequency of adverse effects after the administration of chloral hydrate in children on multiple sedative/analgesics using a protocol-based approach.

Methods: Our retrospective cohort study included children < 18 years old admitted to the pediatric ICU of our children’s hospital from March 2019 to December 2023 who received chloral hydrate during their admission. We identified hourly vital signs, rhythm documentation, number of emesis, and baseline respiratory support as well as any change following receipt of a dose following hospital guidelines (patients had to be on three or more sedation/opioid medications and only given at night for induction of sleep). Descriptive analyses were used.

Results: A total of 544 doses of chloral hydrate were given to 104 patients during the study period. 27 patients (25%) who received chloral hydrate were < 1 year of age. 72 of the doses were repeat doses within a 24-hour period. 211 doses (39%) had a concomitant diagnosis of respiratory failure and 111 (20%) had a cardiac-related co-morbidity. Baseline respiratory support during dose receipt were as follows: 77% were on invasive mechanical ventilation, 2% bilevel mask ventilation, 8% heated high flow nasal cannula, and 5% room air. None of the patients needed escalation in respiratory support modality in the 12 hours after receipt of a dose. There were no episodes of hypotension nor arrhythmias noted 6 hours after administration of a dose, however 12 patients (11%) experienced emesis.

Conclusions: When administered using a protocol-driven approach in a monitored setting, chloral hydrate was not associated with any of its expected adverse effects such as hemodynamic compromise and it did not lead to escalation of baseline respiratory support modality. A small number of patients (11%) experienced emesis that was not associated with adverse outcome.