II. Precaution

  1. Avoid Chloral Hydrate use due to risks and better alternatives
    1. IM or IV Route
      1. Ketamine
    2. Oral or Intranasal Route
      1. Midazolam
  2. Chloral Hydrate has an unpredictable time course of Sedation
    1. See Pharmacokinetics below
    2. Erratic absorption (especially with patient Fasting)
    3. Recurrent Sedation following awakening (related to the metabolite trichloroethanol's long duration of activity)
  3. If used despite disadvantages, Exercise vigilence
    1. Limit to short term Sedation only
    2. Avoid repetitive dosing
    3. Procedural Sedation risks respiratory and cardiovascular depression
    4. Monitoring is critical
      1. See Procedural Sedation and Analgesia
      2. Case reports of pediatric deaths associated with outpatient use

III. Indications

  1. Pediatric Procedural Sedation
    1. Common use among pediatric dentists
    2. Alternative sedatives are far preferred (see above)

IV. Mechanism

  1. Sedation only (offers no Analgesic effect)
  2. Older oral Sedation agent similar to Ethanol with GABA-receptor mediated effects
  3. Chlorinated hydrocarbon with similar risks in Overdose (see below)
  4. Rapidly metabolized to the active form, trichloroethanol
    1. Trichloroethanol has a long duration of action
    2. Trichloroethanol is responsible for the recurrent Sedation following awakening

V. Dosing

  1. Dosing: 50-75 mg/kg/dose PO or PR
  2. Maximum: 1000 mg

VI. Pharmacokinetics

  1. Onset and duration are unpredictable and prolonged if Fasting (decreased and erratic absorption)
  2. Onset: 30 minutes
  3. Peak: 30 to 60 minutes
  4. Duration: 4 to 6 hours

VII. Adverse Effects

  1. Nausea or Vomiting
  2. Headache
  3. Dizziness
  4. Fever
  5. Paradoxic excitation or agitation
  6. Possible carcinogenicity
    1. Aneuploidy
    2. Hepatic tumors

VIII. Management: Toxicity or Overdose

  1. Mechanism
    1. Chloral Hydrate has similar toxic effects to hydrocarbon Overdose
    2. Chloral Hydrate sensitizes the Myocardium to Catecholamines
  2. Presentation
    1. Respiratory Depression
    2. Myocardial toxicity and arrhythmia (especially Ventricular Tachycardia)
  3. Antidote: Ventricular Tachycardia WITH a pulse
    1. Beta Blocker (Esmolol is preferred)
    2. Avoid Epinephrine or other Catecholamines (unless pulseless)

IX. References

  1. Nordt and Swadron in Majoewsky (2013) EM:Rap 13(5): 6
  2. Litman (2010) Anesth Analg 110(3): 739-46 [PubMed]

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Ontology: Chloral Hydrate (C0008161)

Definition (NCI) A synthetic monohydrate of chloral with sedative, hypnotic, and anticonvulsive properties. Chloral hydrate is converted to the active compound trichloroethanol by hepatic alcohol dehydrogenase. The agent interacts with various neurotransmitter-operated ion channels, thereby enhancing gamma-aminobutyric acid (GABA)-A receptor mediated chloride currents and inhibiting amino acid receptor-activated ion currents. In addition, chloral hydrate enhances the agonistic effects of glycine receptors, inhibits AMPA-induced calcium influx in cortical neurons, and facilitates 5-HT 3 receptor-mediated currents in ganglionic neurons. Overall, this results in a depressive effect on the central nervous system.
Definition (CSP) hypnotic and sedative used in the treatment of insomnia; the safety margin is too narrow for chloral hydrate to be used as a general anesthetic in humans, but it is commonly used for that purpose in animal experiments; chemical formula CCL3CH(OH)2.
Definition (MSH) A hypnotic and sedative used in the treatment of INSOMNIA.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D002697
SnomedCT 321089003, 273948005, 28748001
LNC LP16316-9, MTHU007756
English Hydrate, Chloral, chloral hydrate, 1,1-Ethanediol, 2,2,2-trichloro-, Chloral hydrate product, sedatives chloral hydrate, chloral hydrate (medication), Chloral Hydrate [Chemical/Ingredient], CHLORAL HYDRATE, Chloral hydrate product (product), Chloral hydrate, Hydrated chloral, Trichloroacetaldehyde monohydrate, Chloral hydrate (product), Chloral hydrate (substance), Chloral hydrate product (substance), Chloral Hydrate
Swedish Kloralhydrat
Czech chloralhydrát
Finnish Kloraalihydraatti
French 2,2,2-Trichloroéthane-1,1-diol, Hydrate de chloral, Chloral hydraté, 2,2,2-Trichloro-éthane-1,1-diol
Russian KHLORALGIDRAT, ХЛОРАЛГИДРАТ
Japanese 抱水クロラール
Croatian KLORALHIDRAT
Polish Chloralhydrat
Spanish hidrato de cloral, producto, hidrato de cloral, producto (producto), coral hidratado, hidrato de cloral (producto), hidrato de cloral (sustancia), hidrato de cloral, producto (sustancia), hidrato de cloral, monohidrato de tricloroacetaldehído, Hidrato de Cloral
German Chloralhydrat
Italian Idrato di clorale
Portuguese Hidrato de Cloral