By Sue Kost, MD
A recent thread on the Society for Pediatric Sedation Listserve piqued my curiosity—that being the continued use of chloral hydrate (CH) for procedural sedation. Readers may have assumed, like me, that CH was extinct. Numerous adverse events linked to CH, including deaths, were reported in the 1990’s and early 2000’s, and chloral hydrate has not been available commercially in the US or UK since 2012. But through compounding pharmacies, the drug and the problems associated with it continue to exist!
Nordt, et al., reported a series of chloral hydrate overdoses in 2014, including the death of a 4-yo, within a 4-month time frame (1). According to listserve participants (and personal communication), the pharmacies of several large academic children’s hospitals, including the Children’s Hospital of Philadelphia and Texas Children’s Hospital, continue to provide compounded chloral hydrate for sedation. The CH compounding “recipe” is available on-line from Nationwide Children’s Hospital (2). Proponents of its use tend to be specialists within these facilities who use CH because of tradition and familiarity, such as audiology (ABRs), pulmonology (infant PFTs), and cardiology (echocardiograms). Cardiologists at Children’s Hospital of Wisconsin recently published a comparison of old and new (compounded) CH formulations, and found a shorter duration of action and a higher sedation failure rate with the new formulation (3). Boston Children’s Hospital has recently phased out use of CH for echocardiograms due to increasing rates of failed sedation.
As a group of pediatric sedation providers that pride ourselves on safe, effective sedation practices, I believe that we should work to educate the FDA, compounding pharmacists, and the “hold-out” clinicians in our facilities that CH should be replaced by better alternatives. And we should be designing and carrying out the studies to define these better alternatives. Kudos to our members Drs. Reynolds and Rogers, et al., for getting this ball rolling with their CH versus IN dexmedetomidine study (4). The SPS’s Pediatric Sedation Research Consortium could provide an ideal data repository for a large-scale study to put the final nail in the chloral hydrate coffin. Let’s do it!
- Nordt SP, Rangan C., et al. Pediatric Chloral Hydrate Poisonings and Death Following Outpatient Procedural Sedation. J Med Toxicol. 2014 Jun; 10(2): 219–222.
- Hill GD, Walbergh DB, and Frommelt PC. Efficacy of Reconstituted Oral Chloral Hydrate from Crystals for Echo Sedation. J Am Soc Echocardiogr. 2016 Apr; 29(4): 337–340.
- Reynold J, Rogers A, et al. A prospective, randomized, double-blind trial of intranasal dexmedetomidine and oral chloral hydrate for sedated auditory brainstem response (ABR) testing. Paediatr Anaesth. 2016 Mar;26(3):286-93.