Chloral Hydrate

chloral hydrate (klor' al hye' drate) Aquachloral Supprettes, PMS-Chloral Hydrate (CAN) 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

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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

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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

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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 Oral, PR

Onset 30–60 min

Peak 1–3 hr

Duration 4–8 hr

Metabolism: Hepatic; T1/2: 7–10 hr Distribution: Crosses placenta; enters breast milk Excretion: Urine and bile Adverse effects

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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 (possible vasodilation reaction characterized by tachycardia, palpitations, and facial flushing) • Complex effects on oral (coumarin) anticoagulants given with chloral hydrate; monitor prothrombin levels and adjust coumarin 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

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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; liver and kidney function tests, CBC and differential, stool guaiac test

Interventions

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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.

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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

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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 care provider if you wish to discontinue the drug. Avoid alcohol, sleep-inducing, or over-the-counter drugs; these could cause dangerous effects. These side effects may occur: Drowsiness, dizziness, light-headedness (avoid driving or performing tasks requiring alertness); GI upset (eat small, frequent 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.