Intro Who should read this document Page2 Key practice points. Prior to receiving chloral Administration. Explanation of terms

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Georgina Dawson
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1 Chloral hydrate use for infants receiving CPAP Classification: Policy Lead Author: Ruth Clay Additional author(s): Liz Willis Authors Division: Children s directorate Unique ID: DDCPan08(14) Issue number: 2 Expiry Date: February 2018 Contents Section Page Intro Who should read this document Page2 Key practice points Page2 Background Page2 Policy Page3 Red flags Page3a Prior to receiving chloral Page3b Administration Standards Explanation of terms Document control information (Published as separate document) Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page 1 of 5

2 Who should read this document? PANDA unit clinicians & nurses Adult ED clinicians & nurses Anaesthetic staff & ODP s who are involved in the care of children Key Practice Points Sucrose solution should be tried first- please refer to the Use of sucrose in neonates and babies guideline. Chloral hydrate dose is: 10-15mg/kg via oral-gastric or nasal-gastric tube. This is lower than the BNFc dose. Once the infant has received chloral hydrate they will require one-on-one observation until the are transferred. Background This policy sets out the dosage and care required by a child who is on CPAP and requires sedation to improve CPAP effectiveness. Continuous positive airways pressure (CPAP) is used in children who require additional respiratory support, but do not require intubation & ventilation. CPAP is commonly used in resus in the emergency department and may also be used on the PANDA unit. When CPAP is commenced infants may become unsettled as they are initially kept nil by mouth due to the respiratory distress. Chloral hydrate can be used as a mild sedative for infants who become unsettled on CPAP to reduce the distress to the infant. Chloral hydrate is a hypnotic commonly used in children for sedation for procedures. It accumulates on prolonged use and there is also a risk of habituation. This policy does not address the use of CPAP or the treatment of bronchiolitis. Page 2 of 5

3 Policy Person responsible for the sedated child Any infant who is being sedated whilst on CPAP should be under the care of a consultant paediatrician, emergency consultant. In conjunction, an anaesthetist may be present. They will be allocated a nurse who will be responsible for their nursing care. Red Flags Any child with red flags must be discussed with NWTS prior to receiving Chloral hydrate Abnormal airway, this is to include very large tonsils or anatomical abnormalities. History of sleep apnoea Raised intracranial pressure Symptomatic heart disease Bowel obstruction Unstable epilepsy Depressed conscious level. Significant underlying neurological disease Abdominal distension and risk of pulmonary aspiration Severe metabolic, liver or renal disease A known allergy or any previous adverse reaction Informed refusal by parent Safety aspects Response to sedation varies from infant to infant and may be unpredictable, there is therefore a risk of apnoea. To maintain the safety of the child it is essential that: All staff involved are skilled in resuscitation Oxygen and suction and appropriate administration devices are available at the bed side All staff are familiar with equipment on the ward All staff understand the emergency procedures and are able to access medical assistance immediately. Prior to receiving chloral The following observations should be made by a trained children s nurse. o Heart rate, respiratory rate, blood pressure and oxygen saturations Estimated or actual weight should be recorded. Sucrose solution should be tried first. This may settle the infant and negate the need for chloral hydrate. An OG (oral gastric) or NG tube should be passed & stomach emptied. It should be passed in line with the trust NG tube insertion policy. The chloral hydrate may be given via the OG/NG tube once position has been confirmed. Page 3 of 5

4 Administration The chloral should be administered via the OG or NG tube Supply: Chloral hydrate 100mg/ml solution Dose: 10-15mg/kg maximum. Interval: 6 hourly Care of the child following administration of sedation Only qualified nursing staff who have received training in paediatric basic life support skills should care for a sedated child. Continual monitoring of heart rate, oxygen saturations and respiratory rate should occur. Vital signs should be recorded every 15 minutes for the first hour and in line with the PEWS score policy after this. The nurse caring for the child should be able to recognise adverse effects of sedation such as impaired respiratory effort and know how to respond. Transferring the child within the department The child must be fully monitored- (saturations, chest leads, respiratory rate, BP). A trained member of staff skilled in paediatric basic life support and the usage of CPAP must accompany the child at all times. Oxygen, suction and equipment to resuscitate an infant must accompany the child. Standards Sucrose is tried first unless contraindicated- please refer to the Use of sucrose in neonates and babies guideline. An oralgastric or nasogastric tube is inserted in line with the trust nasogastric insertion policy The infant receives one-to-one care at all times Explanation of terms CPAP: Continuous positive airways pressure NG: nasogastric OG: oralgastric Page 4 of 5

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Intro Who should read this document 2 Key Messages 2 Background 2

Intro Who should read this document 2 Key Messages 2 Background 2 Classification: Policy Lead Author: Nathan Griffiths, Consultant Nurse Paediatric Emergency Medicine Additional author(s): N/A Authors Division: Salford Healthcare Unique ID: DDCPan04(14) Issue number: