Cervical Vestibular-Evoked Myogenic Potentials in Sedated Toddlers

Abstract Introduction Cervical vestibular-evoked myogenic potentials (cVEMPs) are difficult to test in toddlers who cannot follow instructions or stay calm. Objective Due to the growing need for vestibular testing in very young children as a part of a delayed walking assessment battery, this study aimed to provide a solution to this problem by recording the cVEMPs in toddlers during sedation. Method The cVEMPs measures were assessed in 30 toddlers aged 12 to 36 months with normal motormilestones. They were sedated with chloral hydrate. Then, the head was retracted ~ 30° backward with a pillow under the shoulders, and turned 45° contralateral to the side of stimulation to put the sternocleidomastoid (SCM)muscle in a state of tension. Results The P13 and N23 waves of the cVEMPs were recordable in all sedated toddlers. The cVEMPs measures resulted in the following: P13 latency of 17.5 ± 1.41 milliseconds, N23 latency of 25.58 ± 2.02 milliseconds, and peak-topeak amplitude of 15.39 ± 3.45 μV. One-sample t-test revealed statistically significant longer latencies and smaller amplitude of the toddlers' cVEMPs relative to the normative data for adults. Conclusions The difficulty of cVEMPs testing in toddlers can be overcome by sedating them and attaining a position that contracts the SCM muscle. However, the toddlers' recordings revealed delayed latencies and smaller amplitudes than those of adults.

Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists.

BACKGROUND: Chloral hydrate is a sedative that has been used for magnetic resonance imaging (MRI). OBJECTIVE: To evaluate the use, effectiveness and safety of chloral hydrate administered by radiologists for the sedation of children who require MRI procedures. MATERIALS AND METHODS: We retrospectively reviewed the clinical charts for all patients ages 0 - 10 years old who underwent sedation with chloral hydrate for MRI from January 2000 to December 2010. Demographic factors, dose information, indication for MRI, therapeutic failures and adverse reactions to the drug were reviewed. RESULTS: One thousand, seven hundred and three children (946 males, 757 females) with a median age of 2.5 years (range: 4 days - 9.91 years) received chloral hydrate. Moderate to deep sedation was achieved in 1,618/1,703 (95%) of the patients, 35/1,703 (2.1%) of the patients failed to achieve moderate to deep sedation, and 47/1,703 (2.8%) of the patients woke up during MRI examination. Adverse reactions were present in 31/1,703 (1.8%) of the patients. Three severe adverse reactions occurred (0.18%). A single dose of chloral hydrate (40-60 mg/kg) was administered to 1,477/1,703 patients (86.7%). An additional dose of chloral hydrate (10-20 mg/kg), given 15 min after the first dose or when the patient woke up during the MRI examination, was required in 226/1,703 patients (13.3%). The likelihood of requiring an additional dose in children older than 2 years was 2.2 times the likelihood compared to children younger than 2 years (OR = 2.2 [95%CI: 1.6-3.0]). The use of a reduced dose (<50 mg/kg) was not associated with a higher therapeutic failure rate (OR = 1.04 [95%CI 0.57-1.89]). CONCLUSION: Chloral hydrate is an appropriate sedation option for pediatric patients in MRI services when strict patient selection criteria are met. The use of a reduced dose does not affect the effectiveness of sedation. The lack of data regarding the presence of transient oxygen desaturation, the time to induce sedation and the exact duration of sedation are limitations of this study.

Post-discharge adverse events following pediatric sedation with high doses of oral medication.

OBJECTIVE: To compare the occurrence of post-discharge adverse events in children having received a high dose of either chloral hydrate (CH) or midazolam (MZ) during outpatient dental treatment. STUDY DESIGN: A repeated-measures study design was carried out with 42 children treated at a sedation center. The sample comprised 103 dental sedation sessions among 22 male and 20 female patients, 1-8 years old, receiving either MZ (1.0-1.5 mg/kg) or CH (70.0-100.0 mg/kg). During treatment, a single observer recorded intraoperative adverse events. Twenty-four hours later, the observer called the child's main caregiver seeking information on further adverse events. Data analysis involved descriptive and bivariate statistics and the general estimating equation for repeated measures. RESULTS: The most common intraoperative and post-discharge adverse events were hallucination (3.9%) and excessive sleep (41.9%), respectively. The chance of the occurrence of an adverse event following oral pediatric sedation was lesser among the children who received MZ than those who received CH (OR: 0.09; 95% CI: 0.01-0.88). CONCLUSIONS: High doses of CH were associated with post-discharge adverse events in children having undergone pediatric dental sedation, whereas high doses of MZ were not associated with these events in pediatric patients.

Chloral hydrate to study auditory brainstem response.

UNLABELLED: Chloral Hydrate (CH) is a sedative and hypnotic drug used in pediatric procedures owing to the low depressive effect it has on the respiratory and cardiac systems. AIM: To assess the efficacy of the drug in performing ABR and to systematize its use. MATERIALS AND METHODS: A prospective cross-sectional study with 41 children without history of heart or lung disease. The initial dose of CH at 10% was 50 mg/Kg, with a boost dose of 6 mg/Kg administered 30 minutes later in cases in which there was no sedation. Drug effectiveness was established by sleep induction by 1 hour after the administration of the initial dose. Sleep occurrence was correlated with doses (50 mg or 56 mg/Kg), age, weight and gender. RESULTS: All the 41 children who participated in the study took 50 mg/kg of the agent and 23 of them slept within 30 minutes, 2 had respiratory complications, 16 had the 6 mg/Kg boost dose and 13 fell asleep after 30 minutes. The 56 mg/kg dose presented a statistically significant effect on sleep induction (p<0.05) when compared to the 50mg/kg dose. CONCLUSION: CH produced a satisfactory effect with 50 mg/Kg dose plus 6 mg/kg up to one hour after administration. Complications can occur regardless of the dose used.

Hidrato de cloral para captação dos Potenciais Elétricos Auditivos / Chloral Hydrate to Study Auditory Brainstem Response

O Hidrato de cloral é um sedativo usado em procedimentos pediátricos devido à pouca depressão respiratória e cardíaca. OBJETIVO: Avaliar a eficácia da droga para a captação do PEATE e sistematizar o seu emprego. MATERIAL E MÉTODO: Estudo prospectivo transversal com 41 crianças. A dose inicial de HC 10 por cento foi de 50mg/kg com reforço de 6 mg/kg administrado após 30 minutos nos casos onde não houve sedação. A efetividade da droga foi determinada pela indução do sono até 1 hora após a administração da dose inicial. A ocorrência de sono foi correlacionada com as doses (50mg ou 56mg/kg), a idade, o peso e o sexo. RESULTADOS: As 41 crianças que participaram do estudo tomaram 50mg/kg e 23 dormiram em 30 minutos, 2 apresentaram depressão respiratória; 16 crianças tomaram reforço de 6mg/kg e 13 dormiram em mais 30 minutos. A dose total de 56mg/kg apresentou um efeito estatisticamente significante na indução do sono (p<0,05) em comparação com a dose de 50mg/kg. CONCLUSÃO: O HC é uma droga com um bom efeito satisfatório com a dose de 50mg/kg seguida de mais 6mg/kg em até uma hora após a administração. Complicações podem ocorrer, independente da dose usada. ClinicalTrials.gov Identifier: NCT 00949780.

Chloral Hydrate (CH) is a sedative and hypnotic drug used in pediatric procedures owing to the low depressive effect it has on the respiratory and cardiac systems. AIM: To assess the efficacy of the drug in performing ABR and to systematize its use. MATERIALS AND METHODS: A prospective cross-sectional study with 41 children without history of heart or lung disease. The initial dose of CH at 10 percent was 50mg/Kg, with a boost dose of 6mg/Kg administered 30 minutes later in cases in which there was no sedation. Drug effectiveness was established by sleep induction by 1 hour after the administration of the initial dose. Sleep occurrence was correlated with doses (50mg or 56mg/Kg), age, weight and gender. RESULTS: All the 41 children who participated in the study took 50mg/kgof the agent and 23 of them slept within 30 minutes, 2 had respiratory complications, 16 had the 6mg/Kg boost dose and 13 fell asleep after 30 minutes. The 56 mg/kg dose presented a statistically significant effect on sleep induction (p<0.05) when compared to the 50mg/kg dose. CONCLUSION: CH produced a satisfactory effect with 50 mg/Kg dose plus 6mg/kg up to one hour after administration. Complications can occur regardless of the dose used.

Evidence of safety of chloral hydrate for prolonged sedation in PICU in a tertiary teaching hospital in southern Brazil.

OBJECTIVE: To evaluate the utilization of chloral hydrate (CH) for sedation in pediatric intensive care and the incidence of adverse drug reactions. METHODS: This was a cohort study including patients with prescription of chloral hydrate hospitalized in the pediatric intensive care unit (PICU) of a university-affiliated, general, tertiary teaching hospital. Data were collected from a spreadsheet for daily monitoring, and clinical events registered in the patient records were analyzed to evaluate the causality of suspected adverse drug reactions (ADR), applying the Naranjo algorithm. RESULTS: Three hundred forty-three patients who had been prescribed CH were studied. Ages ranged from 0 to 18 years, and 63% were male. The most frequent cause for PICU admission was bronchiolitis (77.6%), and 58.6% required mechanical ventilation. In 92.7% of cases, CH was indicated to control agitation and in 7.3% for procedural sedation. The median time of CH use was 6 days. The incidence of suspected ADR was 22.7% ± 2.3. Oxygen desaturation was the most frequent adverse event (64.6%), followed by hypotension. Specific treatment was required in 60.9% of the events. Chloral hydrate as cause for suspected ADR was classified as probable in 39 events (35.5%) and as possible in 70 (63.6%), and no event was classified as definite. In the multivariate analysis, only mechanical ventilation was predictive of ADR to CH. CONCLUSIONS: The study described the clinical practice of sedation with CH in the PICU setting of a tertiary teaching hospital in southern Brazil. Data suggest that CH is an alternative for prolonged sedation in PICU

Serotonin syndrome following sibutramine poisoning in a child, with sequential quantification of sibutramine and its primary and secondary amine metabolites in plasma.

OBJECTIVE: To report a case of serotonin syndrome (SS) after sibutramine overdose in a child. CASE REPORT: A 4-year-old girl was admitted 25 h after accidentally ingesting approximately 27 pills of sibutramine (15 mg, approximately 23 mg/kg). The child developed clinical features suggestive of SS, including diaphoresis, tachycardia, hypertension, agitation, insomnia, incoordination, hypertonia (lower limbs >> upper limbs), and hallucinations. Serum creatine phosphokinase levels reached a peak on day 3 (2,577 U/L, reference value <145), suggesting mild rhabdomyolysis. No relevant changes were detected in other laboratory examinations or in the electrocardiogram throughout the period of hospitalization. The quantification of sibutramine and the active metabolites, M1 (mono-desmethyl sibutramine) and M2 (di-desmethyl sibutramine), by liquid chromatography/electrospray ionization tandem mass spectrometry in six sequential samples collected from 25 to 147 h post-ingestion revealed a nonlinear decrease in the log-scale plasma concentrations. Treatment was only supportive and involved prolonged sedation to control the agitation, sleeplessness, and hypertension; no cyproheptadine was used. The patient was discharged on day 6 and follow-up revealed no sequelae. CONCLUSION: To our knowledge, this is the first report of SS after sibutramine overdose in a child, with sequential monitoring of the plasma levels of the drug and its two active metabolites. The growing consumption of weight reducing pills may increase the risk of unintentional acute toxic exposures in children.

Sedative effect of oral diazepam and chloral hydrate in the dental treatment of children.

PURPOSE: The purpose was to evaluate two sedation protocols during dental sessions in anxious children. MATERIALS AND METHODS: It was a randomized and double-blind study, with each individual being his/her own control within each protocol. Furthermore, the two protocols were compared. Twenty children (36 to 84 months old) who exhibited "definitely negative" behavior according to the Frankl scale were assigned to receive oral chloral hydrate (40 mg/kg) (Group I) or Diazepam (5 mg) (Group II). Behavior during local anesthesia, application of rubber dam, cavity preparation, restorative procedures was evaluated, considering the degree of sleep, body movement, crying and overall behavior. Vital signs were assessed at three different times. The Wilcoxon, Mann-Whitney, Exact Fisher's and Spearman correlation tests were used to analyze the data. RESULTS: Group I presented higher scores for sleep during the CH session than placebo session during rubber dam application (P = 0.0431) and restoration (P = 0.0431). In Group II there was no statistically significant difference (p > 0.05). There were no statistically significant differences between sessions and groups in the evaluation of body movement, crying and vital signs. Overall behavior in the placebo session was better than in the CH session during local anesthesia, but there was no difference between the two drug regimens. There was influence of age during anesthesia and cavity preparation in Group I and during rubber dam application in Group II. It was concluded that oral diazepam and chloral hydrate had no influence on the behavior management for dental treatment with the studied sample.

Comparison of three conscious sedation regimens for pediatric dental patients.

The aim of this study was to compare the clinical success of three conscious sedation regimens for pediatric dental patients. A clinical trial was performed wherein dental treatment was administered to pediatric patients ASA I and II under conscious sedation.. Fifty-four children were divided into three groups of 18 patients each, randomly assigned Group A received hydroxyzine (2 mg/kg 2 h before treatment and a subsequent dose of 1 mg/kg 20 min before treatment) orally; group B received 0.50 mg/kg midazolam mixed with 1.5 mg/kg hydroxyzine 20 min before treatment orally; group C received chloral hydrate, 50 mg/kg mixed with 1.5 mg/kg hydroxyzine 20 min before treatment orally. The Ohio State Behavioral Rating Scale (OSBRS) showed statistically significant differences between groups B and C with respect to group A. The regimens of midazolam or chloral hydrate mixed with hydroxyzine represent excellent choices for conscious sedation regimens for pediatric dental patients.

A randomized double-blinded trial of chloral hydrate with or without hydroxyzine versus placebo for pediatric dental sedation.

Chloral hydrate and hydroxyzine are a drug combination frequently used by practitioners to sedate pediatric dental patients, but their effectiveness has not been compared to a negative control group in humans. The aim of this crossover, double-blinded study was to evaluate the effect of these drugs compared to a placebo, administered to young children for dental treatment. Thirty-five dental sedation sessions were carried out on 12 uncooperative ASA I children aged less than 5 years old. In each session patients were randomly assigned to groups P (placebo), CH (chloral hydrate 75 mg/kg) and CHH (chloral hydrate 50 mg/kg plus hydroxyzine 2.0 mg/kg). Vital signs and behavioral variables were evaluated every 15 min. Comparisons were statistically analyzed using Friedman and Wilcoxon tests. P, CH and CHH had no differences concerning vital signs, except for breathing rate. All vital signs were in the normal range. CH and CHH promoted more sleep in the first 30 min of treatment. Overall behavior was better in CH and CHH than in P. CH, CHH and P were effective in 62.5%, 61.5% and 11.1% of the cases, respectively. Chloral hydrate was safe and relatively effective, causing more satisfactory behavioral and physiological outcomes than a placebo.

A randomized double-blinded trial of chloral hydrate with or without hydroxyzine versus placebo for pediatric dental sedation

Chloral hydrate and hydroxyzine are a drug combination frequently used by practitioners to sedate pediatric dental patients, but their effectiveness has not been compared to a negative control group in humans. The aim of this crossover, double-blinded study was to evaluate the effect of these drugs compared to a placebo, administered to young children for dental treatment. Thirty-five dental sedation sessions were carried out on 12 uncooperative ASA I children aged less than 5 years old. In each session patients were randomly assigned to groups P (placebo), CH (chloral hydrate 75 mg/kg) and CHH (chloral hydrate 50 mg/kg plus hydroxyzine 2.0 mg/kg). Vital signs and behavioral variables were evaluated every 15 min. Comparisons were statistically analyzed using Friedman and Wilcoxon tests. P, CH and CHH had no differences concerning vital signs, except for breathing rate. All vital signs were in the normal range. CH and CHH promoted more sleep in the first 30 min of treatment. Overall behavior was better in CH and CHH than in P. CH, CHH and P were effective in 62.5 percent, 61.5 percent and 11.1 percent of the cases, respectively. Chloral hydrate was safe and relatively effective, causing more satisfactory behavioral and physiological outcomes than a placebo.

A associação hidrato de cloral- hidroxizina tem sido utilizada na clínica odontológica para sedar crianças, mas sua efetividade ainda não foi comparada a um controle negativo em humanos. O objetivo deste estudo prospectivo foi avaliar o efeito dessas drogas, comparadas a um placebo, em crianças submetidas a tratamento odontológico. Trinta e cinco sessões de sedação foram realizadas em 12 crianças menores de 5 anos, não cooperativas, ASA classe I. Em cada sessão os pacientes foram aleatoriamente alocados para os grupos P (placebo), CH (hidrato de cloral 75 mg/kg) e CHH (hidrato de cloral 50 mg/kg mais hidroxizina 2,0 mg/kg). Sinais vitais e comportamento foram avaliados a cada 15 min, e comparados pelos testes de Friedman e Wilcoxon. Os grupos não apresentaram diferenças quanto às variáveis fisiológicas, exceto a freqüência respiratória. Todos sinais vitais registrados estiveram dentro de faixa aceitável. CH e CHH promoveram mais sono nos primeiros 30 min de tratamento. O comportamento geral foi melhor em CH e CHH do que em P. CH, CHH e P foram efetivos em 62,5 por cento, 61,5 por cento e 11,1 por cento dos casos, respectivamente. O hidrato de cloral foi seguro e relativamente efetivo, levando a resultados fisiológicos e comportamentais melhores que o placebo.

Seguridad del manejo estomatológico de pacientes pediátricos bajo sedación consciente en la clínica de odontopediatría / Safe management for dental procedures in children under concient sedative analgesia the odontopediatric clinic. Odontologic specialties unit

El objetivo fundamental del presente estudio es disminuir las indicaciones de anestesia general en los niños que se someten a rehabilitación dental. Se presenta una serie de 20 niños con edad comprendida entre 1.5 y 3 años, que se sometieron únicamente a sedación con hidroxizina a 20 mg por kg de peso e hidrato de cloral a 70 mg por kg de peso, por vía oral o por sonda nasogástrica. Se encontró una clara respuesta favorable en cuanto a la conducta observada por parte de los niños, que eliminó la actitud inconveniente clasificada como conducta Frankl II o III y permitió al cirujano efectuar la rehabilitación bucal. Asimismo se encontró una elevación del umbral al dolor, la preservación de reflejos protectores y amnesia postoperatoria en cuanto al evento quirúrgico.

Uso de hidrato de cloral nas audiometrias de tronco encefálico / Cloral hydrate use in brainsteam response audiometry

A audiometria do tronco encefálico deve ser realizada em ambiente silencioso, aconchegante e com pouca luminosidade. O relaxamento do paciente é indispensável, pois as contraçoes musculares interferem na morfologia das ondas dificultando a análise do exame. Em crianças, o relaxamento pode ser conseguido com o sono natural oou com sedativos. Relatamos a nossa experiência com o uso de hidrato de cloral a 20 por cento, como sedativo, em mil pacientes pediátricos submetidos à audiometria de tronco encefálico.

Safety and efficacy of chloral hydrate sedation in children undergoing echocardiography.

The purpose of this prospective study was to determine the safety and efficacy of chloral hydrate sedation in children with known or suspected congenital heart disease. The study population included 405 children with a median age of 13 months (3 weeks to 14 years). Cyanotic heart disease was present in 64 of the children. The median dosage of chloral hydrate given was 77 mg/kg, with a range of 25 to 125 mg/kg. Sedation was achieved in 397 (98%) of the children. The complete study time averaged 2.2 hours (range, 1.6 to 5.2 hours). The time to achieve sedation was 30 minutes or less in 82%, more than 30 but less than 60 minutes in 12%, and more than 60 minutes in 4%; 2% failed to achieve sedation. Children aged 3 years or younger were more likely to be successfully sedated with chloral hydrate (p = 0.003). The type of heart disease did not affect the success of sedation. No child had a clinically significant change in heart rate or blood pressure during sedation; however, oxygen saturation decreased in 24 (6%) of 397 children successfully sedated. Decreases in oxygen saturation occurred more commonly in children with trisomy 21 (7/13) than in children without genetic syndromes (17/384). Vomiting occurred in 23 (6%) of the 405 study subjects, usually immediately after drug administration. Chloral hydrate is a safe and effective agent for sedation of children with known or suspected congenital heart disease who are undergoing echocardiography in the outpatient cardiology clinic.

Hidrato de cloral y midazolam en sedación para electroencefalograma en niños de 1 a 5 años / Chloral hydrate and midazolam in electroencephalography sedation in children of 1 to 5 years of old

Se comparó la efectividad de hidrato de cloral y midazolam como inductores de sueño para electroencefalograma en 59 niños a los que se suministró, previa asignación al azar, por vía rectal, hidrato de cloral (50 mgùkg) (n:32) o midazolam (1 mgùkg) (n:27) y 33 niños de la misma edad y condición que durmieron espontáneamente y no requirieron sedación para realizar los registros. Se logró sueño en todos los niños tratados con hidrato de cloral ante 66,6 por ciento de los que recibieron midazolam (p< 0,01). La latencia hasta el sueño fue 21,8 ñ 17,5 min. con hidrato de cloral y 117,5 + 47,2 min. con midazolam (p< 0,01). No se observaron influencias de edad, sexo, estado del desarrollo psicomotor, tiempo de vigilia previo o intervalo desde la alimentación hasta la sedación. Estos resultados apoyan el uso de hidrato de cloral por vía rectal en niños pequeños que requieren sedación para EEG

Transcutaneous carbon dioxide pressure for monitoring patients with severe croup.

In a prospective investigation of 17 children with severe croup, we analyzed the effect of epinephrine inhalations and mild sedation with chloral hydrate on transcutaneous carbon dioxide pressure (tcPCO2), pulse oximetry measurements, and croup scores. There was a highly significant reduction (p less than 0.001) in the tcPCO2 values and croup scores after inhalation of epinephrine. The changes in the tcPCO2 values correlated with the clinical findings. Mild sedation also significantly improved the croup scores but failed to influence the tcPCO2 values. There was not statistically significant difference in pulse oximetry saturation, fraction of administered oxygen, heart rate, or respiratory rate before and after inhalation of epinephrine or chloral hydrate administration. Monitoring tcPCO2 appears to be a reliable and objective tool for managing patients with upper airway obstruction, whereas croup scores may be misleading.

The induction of aneuploidy in cultured Chinese hamster cells by propionaldehyde and chloral hydrate.

The induction of aneuploidy in cultured Chinese hamster cells by propionaldehyde (PA) and chloral hydrate (CH) has been studied. Chinese hamster embryonic diploid (CHED) cells were grown as a monolayer in cover glasses. Treatments were performed with doses of 5 x 10(-4), 1 x 10(-3) and 2 x 10(-3)% of PA for 3 h and doses of 1 x 10(-3), 2 x 10(-3) and 3 x 10(-3)% of CH for 1.5 h. Treatments with 2 x 10(-3)% of acetaldehyde (AA) for the same PA and CH treatments were used as positive controls. Untreated cultures were used as negative controls. PA induced chromosomal aberrations with the three doses employed although in a lesser degree than the positive control. CH induced chromosomal damage only with the two higher doses. No correlation was found between the amount of chromosomal damage induced and the doses of PA or CH employed. Both compounds increased the frequency of aneuploid cells in relation to untreated controls but not in relation to the positive control. However, neither PA nor CH significantly increased the frequencies of polyploid cells. These results indicate that aldehydes and chlorine-replaced aldehydes are strong inducers of aneuploidy despite some differences between PA or CH and AA regarding cytotoxicity and polyploidy induction.

[Degree of sedation. Incidence of vomiting and time of postoperative sleep with 3 different oral administration schedules of hydroxyzine chlorhydrate and chloral hydrate]. / Incidencia de vómito y tiempo de sueño postoperatorio, con tres diferentes esquemas de administración oral de clorhidrato de hidroxicina e hidrato de cloral.

In this paper a comparison of sedation effectiveness, vomiting incidence and postoperative sleeping time with three sedation schemes: Chloral hydrate exclusively, hidroxicine chlorhydrate the night before and 15 minutes before chloral hydrate administration and hidroxicine chlorhydrate 15 minutes before chloral hydrate. We find that there is no significant differences between these three sedation schemes in sedation, degree of postoperative sleeping time and vomiting incidence, therefore we can expect an effective sedation degree using any of these sedation methods.