Chloral hydrate

chloral hydrate

(klor' al hye' drate)

Aquachloral Supprettes, PMS-Chloral Hydrate (CAN), Somnote

Pregnancy Category C

Controlled Substance C-IV

Drug class

Sedative-hypnotic (nonbarbiturate)

Therapeutic actions

Mechanism by which CNS is affected is not known; hypnotic dosage produces mild cerebral depression and quiet, deep sleep; does not depress REM sleep, produces less hangover than most barbiturates and benzodiazepines.

Indications

·        Nocturnal sedation

·        Preoperative sedation to lessen anxiety and induce sleep without depressing respiration or cough reflex

·        Adjunct to opiates and analgesics in postoperative care and control of pain

Contraindications and cautions

·        Contraindicated with hypersensitivity to chloral derivatives; allergy to tartrazine (in 324-mg and 648-mg suppositories marketed as Aquachloral Supprettes); severe cardiac disease, gastritis; hepatic or renal impairment; lactation.

·        Use cautiously with acute intermittent porphyria (may precipitate attacks).

Available forms

Capsules—500 mg; syrup—250, 500 mg/5 mL; suppositories—324, 500, 648 mg

Dosages

ADULTS

Single doses or daily dosage should not exceed 2 g.

·        Hypnotic: 500 mg–1 g PO or rectally 15–30 min before bedtime or 30 min before surgery. It is not usually considered safe practice to give oral medication to patients who are NPO for anesthesia or surgery.

·        Sedative: 250 mg PO or rectally tid after meals.

PEDIATRIC PATIENTS

·        Hypnotic: 50 mg/kg/day PO up to 1 g per single dose; may be given in divided doses.

·        Sedative: 25 mg/kg/day PO up to 500 mg per single dose; may be given in divided doses.

Pharmacokinetics

Route	Onset	Peak	Duration
Oral, PR	30–60 min	1–3 hr	4–8 hr

Metabolism: Hepatic; T_1/2: 7–10 hr

Distribution: Crosses placenta; enters breast milk

Excretion: Bile, urine

Adverse effects

·        CNS: Somnambulism, disorientation, incoherence, paranoid behavior, excitement, delirium, drowsiness, staggering gait, ataxia, light-headedness, vertigo, nightmares, malaise, mental confusion, headache, hallucinations

·        Dermatologic: Skin irritation; allergic rashes including hives, erythema, eczematoid dermatitis, urticaria

·        GI: Gastric irritation, nausea, vomiting, gastric necrosis (following intoxicating doses), flatulence, diarrhea, unpleasant taste

·        Hematologic: Leukopenia, eosinophilia

·        Other: Physical, psychological dependence; tolerance; withdrawal reaction

Interactions

Drug-drug

·        Additive CNS depression with alcohol, other CNS depressants

·        Mutual inhibition of metabolism with alcohol

·        Complex effects on oral (warfarin) anticoagulants given with chloral hydrate; monitor prothrombin levels and adjust warfarin dosage whenever chloral hydrate is instituted or withdrawn from drug regimen

Drug-lab test

·        Interference with the copper sulfate test for glycosuria, fluorometric tests for urine catecholamines, and urinary 17-hydroxycorticosteroid determinations (when using the Reddy, Jenkins, and Thorn procedure)

Nursing considerations

Assessment

·        History: Hypersensitivity to chloral derivatives, allergy to tartrazine, severe cardiac disease, gastritis, hepatic or renal impairment, acute intermittent porphyria, lactation

·        Physical: Skin color, lesions; orientation, affect, reflexes; P, BP, perfusion; bowel sounds, normal output, liver evaluation; LFTs, renal function tests, CBC and differential, stool guaiac test

Interventions

·        Give capsules with a full glass of liquid; ensure that patient swallows capsules whole; give syrup in half glass of water, fruit juice, or ginger ale.

·        Supervise dose and amount of drug prescribed for patients who are addiction prone or alcoholic; give least amount feasible to patients who are depressed or suicidal.

·        Withdraw gradually over 2 wk if patient has been maintained on high doses for weeks or months; if patient has built up high tolerance, withdrawal should occur in a hospital, using supportive therapy similar to that for barbiturate withdrawal; fatal withdrawal reactions have occurred.

·        Reevaluate patients with prolonged insomnia; therapy for the underlying cause (eg, pain, depression) is preferable to prolonged use of sedative–hypnotic drugs.

Teaching points

·        Take this drug exactly as prescribed: Swallow capsules whole with a full glass of liquid (take syrup in half glass of water, fruit juice, or ginger ale).

·        Do not discontinue the drug abruptly. Consult your health care provider if you wish to discontinue the drug.

·        Avoid alcohol, sleep-inducing, or over-the-counter drugs; these could cause dangerous effects.

·        You may experience these side effects: Drowsiness, dizziness, light-headedness (avoid driving or performing tasks requiring alertness); GI upset (eat frequent small meals); sleep-walking, nightmares, confusion (use caution: close doors, keep medications out of reach so inadvertent overdose does not occur while confused).

·        Report rash, coffee ground vomitus, black or tarry stools, severe GI upset, fever, sore throat.

Adverse effects in Italic are most common; those in Bold are life-threatening.