Chloral Hydrate Safely Sedates Children for Eye Exams

October 17, 2013

By Lorraine L. Janeczko

NEW YORK (Reuters Health) Oct 17 - Chloral hydrate (CH) may be a good alternative to general anesthesia in children who can't cooperate with detailed eye exams, according to a new study.

"We have performed sedations for over 15 years at SickKids Hospital (aka The Hospital for Sick Children) in Toronto and are happy to have the benefits and successes of the procedures confirmed by these findings," said lead author Dr. Stephanie West, also of the Southampton General Hospital in Southampton, Hampshire, UK, in an email to Reuters Health.

Dr. West and her co-authors say the retrospective analysis was "the largest study on the safety and effectiveness of sedation in pediatric ophthalmology in a nurse-led outpatient sedation unit."

The cohort consisted of all children who underwent sedation over about five years in one UK facility, in a total of 1,509 recorded procedures. They received 80 mg/kg of oral CH, with half-dose increases as needed.

As reported online September 17 in the British Journal of Ophthalmology, the average patient age was 23.86 months, and the average weight was 11.76 kg.

More children were American Society of Anesthesiologists status II than I (58.5% vs 41.5%, p=0.0001).

Overall, 96.7% were successfully sedated, with 4.8% requiring an additional dose. The average sedation lasted 53.4 min and an average of 1.7 procedures were performed, most commonly a detailed eye exam (93.5%) and an electroretinogram (45.1%).

Adverse events included paradoxical reaction (1.33%), oxygen desaturation (0.99%), and vomiting (0.53%), with no serious complications or hospital admissions.

Weight over 15 kg and needing an additional dose were significant risk factors for failure (OR=2.49 and 8.69, respectively) and adverse events (OR=2.1 and 3.97, respectively), the authors said. Neither gender nor American Society of Anesthesiologists Physical Status score significantly affected outcomes.

"The option of performing sedated eye exams in the clinic can free operating room time for other surgeries that require full general anesthesia and can ultimately reduce patient wait times," said Dr. West in an email.

"When adequate facilities are available, sedations are important to consider, and ultimately the individual doctor can discuss this option with the patient's family," she added.

Dr. Robert T. Wilder, associate professor of anesthesiology at Mayo Clinic in Rochester, MN, said in an email, "This study shows that appropriately using a medication or technique with which you are familiar may allow improved success and safety. It is not necessary to always use the newest medication."

"Chloral hydrate is a very old drug with a long track record of relative safety in pediatric patients. This study shows that it may still have a place in pediatric sedation. The safety of the technique is enhanced by having a sedation nurse in constant attendance," he added.

"Other medications are available which may do an equally good job of sedating patients when used correctly. I have not prescribed chloral hydrate for at least two decades because, as an anesthesiologist, I have multiple alternative medications. The downsides to chloral hydrate are its relatively slow onset and its unpredictable length of action," he said.

But his colleague Dr. Randall Flick, associate professor of anesthesiology and pediatrics and director of inpatient operations and quality at Mayo Clinic Children's Center, also in Rochester, advised in an email, "It is important not to over-interpret the results of small studies like this."

"The authors' conclusions regarding safety are not justified, despite having no significant adverse events. Serious adverse events are very rare in anesthesia, with death occurring at a rate of one in more than 100,000, and in this type of practice, major adverse events would occur at a much lower frequency. Although this may seem like a large study, it is severely underpowered to establish safety," he added.

"This should not be the standard of care. The standard of care has little or nothing to do with the drug and much more to do with the provider, setting, and ability to rescue," he said.


Br J Ophthalmol 2013.


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