Objective: The purpose of this prospective study was to determine the frequency of adverse events associated with supplemented and unsupplemented chloral hydrate sedation in a select group of children undergoing CT or MR imaging using the revised American Academy of Pediatrics (AAP) monitoring and management guidelines for pediatric sedation. The AAP guidelines do not recommend drug selection or dosages but define patient selection, discharge criteria, and monitoring standards for sedating children.
Subjects and methods: This prospective study included 410 children 4 years of age or younger who were scheduled for CT and MR imaging as outpatients. Selected children were physical status 1 or 2 as determined by the American Society of Anesthesiologists physical status classification and had no contraindications to sedation per our institutional sedation policy. Children younger than 1 year old received only oral incremental doses of chloral hydrate. Children 1-4 years old received hydroxyzine plus incremental doses of chloral hydrate. Children between 2 and 4 years old who were not satisfactorily sedated 30 min after hydroxyzine plus incremental chloral hydrate were given 2 mg/kg meperidine intramuscularly, with a maximum dose of 50 mg. All children were monitored according to the revised guidelines recommended by the committee on drugs of the AAP. Vital signs and arterial hemoglobin oxygen saturation (SpO2) were monitored continuously by registered nurses trained in pediatric advanced life support from the time of sedative drug administration until the recommended discharge criteria were met.
Results: Mild hypoxia (SpO2, 90-95%) that resolved spontaneously without any therapeutic intervention was seen in 9% of the chloral hydrate group and in 5% of the chloral hydrate-hydroxyzine group. One child in the chloral hydrate group had severe hypoxia (SpO2, 85-89%), and one child in the chloral hydrate-hydroxyzine group had moderate hypoxia (SpO2, < 85%). Both required therapeutic intervention. In both cases, the severity of the underlying medical disease was underestimated at the time of presedation medical screening. The success rate of sedation was 100% for all the children having CT. For those having MR imaging, success was 100% for children 1-4 years old and 97% for children less than 1 year old.
Conclusion: Use of supplemented and unsupplemented chloral hydrate sedation provides effective and safe sedation in children if the AAP guidelines for patient selection, monitoring, and management are followed. Careful medical screening and patient selection by knowledgeable medical personnel is important to exclude patients at high risk for life-threatening hypoxia. Monitoring with AAP guidelines is essential for prompt detection and management of life-threatening hypoxia.