Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada.
4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
Crit Care. 2017 Nov 26;21(1):290. doi: 10.1186/s13054-017-1879-7.
We aimed to test a novel method of delivery of chloral hydrate (CH) sedation in ventilated critically ill young children.
Children < 12 years old, within 72 hours of admission, who were ventilated, receiving enteral tube-feeds, with intermittent CH ordered were enrolled after signed consent. Patients received a CH loading-dose of 10 mg/kg enterally, then a syringe-pump enteral infusion at 5 mg/kg/hour, increasing to a maximum of 9 mg/kg/hour. Cases were compared to historical controls matched for age group and Pediatric Risk of Mortality score (PRISM) category, using Fisher's exact test and the t test. The primary outcome was feasibility, defined as the use of an enteral CH continuous infusion without discontinuation attributable to a pre-specified potential harm.
There were 21 patients enrolled, at age 11.4 (12.1) months, with bronchiolitis in 10 (48%), a mean Pediatric Logistic Organ Dysfunction (PELOD) score of 6.2 (5.2), and having received enteral CH continuous infusion for 4.5 (2.2) days. Infusion of CH was feasible in 20/21 (95%; 95% CI 76-99%) patients, with one (5%) adverse event of duodenal ulcer perforation on day 3 in a patient with croup receiving regular ibuprofen and dexamethasone. The CH infusion dose (mg/kg/h) on day 2 (n = 20) was 8.9 (IQR 5.9, 9), and on day 4 (n = 11) was 8.8 (IQR 7, 9). Days to titration of adequate sedation (defined as ≤ 3 PRN doses/shift) was 1 (IQR 0.5, 2.5), and hours to awakening for extubation was 5 (IQR 2, 9). Cases (versus controls) had less positive fluid balance at 48 h (-2 (45) vs. 26 (46) ml/kg, p = 0.051), and a decrease in number of PRN sedation doses from 12 h pre to 12 hours post starting CH (4.7 (3.3) to 2.6 (2.8), p = 0.009 versus 2.9 (3.9) to 3.4 (5), p = 0.74). There were no statistically significant differences between cases and controls in inotrope scores, signs or treatment of withdrawal, or PICU days.
Delivering CH by continuous enteral infusion is feasible, effective, and may be associated with less positive fluid balance. Whether there is a risk of duodenal perforation requires further study.
我们旨在测试一种在机械通气的重症婴幼儿中给予水合氯醛（CH）镇静的新方法。
入组年龄<12 岁、入院后 72 小时内、接受机械通气、间歇性给予 CH 医嘱、并经书面知情同意的患儿。患儿给予 10mg/kg 的 CH 负荷剂量，然后通过注射器泵以 5mg/kg/小时的速度进行肠内输注，最大剂量可达 9mg/kg/小时。通过 Fisher 确切检验和 t 检验，将病例与年龄组和儿科危重病评分（PRISM）分类相匹配的历史对照进行比较。主要结局是使用性，定义为在没有因潜在危害而需要停止使用的情况下，使用 CH 肠内持续输注。
共纳入 21 例患儿，年龄为 11.4（12.1）个月，其中 10 例（48%）为毛细支气管炎，平均小儿 logistic 器官功能障碍评分（PELOD）为 6.2（5.2），且已接受 CH 肠内持续输注 4.5（2.2）天。21 例（95%；95%CI 76-99%）患儿中，20 例（95%）CH 输注是可行的，其中 1 例（5%）患儿在机械通气期间接受常规布洛芬和地塞米松治疗后，第 3 天发生十二指肠溃疡穿孔。第 2 天（n=20）和第 4 天（n=11）的 CH 输注剂量（mg/kg/h）分别为 8.9（IQR 5.9，9）和 8.8（IQR 7，9）。达到充分镇静滴定的时间（定义为每 shift 镇静剂量≤3 次）为 1（IQR 0.5，2.5），拔管前唤醒时间为 5（IQR 2，9）。病例组（与对照组相比）在 48 小时时的正液体平衡更少（-2（45）比 26（46）ml/kg，p=0.051），且从开始给予 CH 前 12 小时到 12 小时后，需要镇静的 PRN 剂量减少（4.7（3.3）比 2.6（2.8），p=0.009；与 2.9（3.9）比 3.4（5）相比，p=0.74）。病例组与对照组之间的血管活性药物评分、撤药迹象或治疗、或 ICU 住院天数均无统计学差异。
通过连续肠内输注给予 CH 是可行、有效，并且可能与更少的正液体平衡相关。是否存在十二指肠穿孔的风险需要进一步研究。
