Chloral Hydrate
                                ===============

 - ? carcinogen - "As far as the "carcinogenicity" of chloral hydrate, the AAP
   published a statement in 1993 in Pediatrics that addressed this concern.
   There are two studies that implicate chloral hydrate as a carcinogen in
   mice, but there are also animal studies that implicate benzodiazepines and
   barbiturates as carcinogens in animals.  The AAP concluded that the
   available information on the carcogenicity of chloral hydrate does not
   provide a basis for sufficient concern to warrant the selection of an
   alternative sedative rather than chloral hydrate.  They also stated that
   sufficient data are not available for children to establish any of the
   available sedatives as superior with respect to either efficacy or
   safety."
 - "Chloral hydrate was the most common medication used for sedation for
   non-painful procedures in a survey of pediatric residency programs
   published in Clin Peds in 1992.  There are numerous studies (usually
   unblinded, noncomparative case series) that document the use of chloral
   hydrate to facilitate everything from CT and MRI to echocardiography,
   dental cleaning, lumbar puncture, EEG and laceration repair.  These studies
   find the drug to be 80-95% "effective."  It is most commonly given in the
   range of 25-80 mg/kg, with a maximum dose of 1 gram orally.  The package
   insert recommends 25-50 mg/kg.  When I have used it, I have settled on a
   dose of 100 mg/kg minus 100 mg (2 grams max) during the day, a little less
   than that at night. It can also has been reported in combination with other
   drugs orally, though I haven't used it that way. A few examples from the
   radiologic literature: CH 30 mg/kg plus diazepam 0.2 mg/kg (max 2000 mg, 10
   mg respectively); CH 30 mg/kg plus diphenhydramine 1.5 mg/kg (max 2000 mg,
   75 mg respectively); CH 50-75 mg/kg plus thioridazine 2-4 mg/kg (max 2500
   mg, 100 mg respectively); CH 50-75 mg/kg plus hydroxyzine 0.8 mg/kg (max
   2000 mg, 20 mg respectively.)"
 - "The time it takes for children to fall asleep with CH is variable, but
   averages around 30 minutes.  The effective duration is also highly variable
   from 30 minutes to over four hours.  (One published study that followed up
   patients after sedation with CH, parents (n=24) were asked to report when
   their children had "returned to their normal pattern of behavior."  The
   median time was 21 hours, range 90 minutes to 90 hours....this isn't too
   surprising, given that the half life of trichloroethanol, the active
   metabolite, is listed in Goodman and Gilman as highly variable, from 4-12
   hours!)  In my experience, the efficacy of CH as a sedative can be
   difficult to predict (at the low doses, 25-50 mg/kg, I've had poor luck
   with it), and I've had to hold some kids for a long time (hours) when I am
   successful at the higher doses."
 - Chloral hydrate's bitter taste can make it problematic to administer...it
   is also fairly irritating to mucous membranes....and a fair number of kids
   will vomit up the medication, especially if it isn't diluted.  Another
   common side effect is paradoxical excitement (this can happen with Versed
   also, but the worst example I've ever seen of this  phenomenon was with
   chloral hydrate...a shreiking, uncontrollable child I had to eventually use
   ketamine on....) Although the respiratory depression from this medication
   is "minimal," there have been case reports of deaths from chloral hydrate
   given in therapeutic doses to apparently healthy children at home prior to
   radiological and dental procedures and after being sent home in car seats
   after radiologic procedures.  The mechanism in these cases was most likely
   the inability to unobstruct the airway.....  I think these incidents
   underscore the importance of adhering to the American Academy of Pediatrics
   (AAP) published requirements of administering sedatives under supervision
   and of observing patients postsedation to an established endpoint mental
   status."
   --Eric McDonald, MD
   Emergency Medicine Department
   Naval Medical Center, San Diego
 - Isolated reports of bad reactions:
   [Cardiac arrhythmia in a child after the usual dose of chloral hydrate
   [letter] Pediatr Cardiol  1996 Nov-Dec;17(6):419-20.]
   [Chloral hydrate: a dangerous sedative for overdose patients?
   Pediatr Emerg Care  1994 Dec;10(6):349-50.]
   [Seizures caused by chloral hydrate sedative doses [letter]
   J Pediatr  1997 Nov;131(5):787-8.]