Association of enteral chloral hydrate with benzodiazepine exposure and delirium after pediatric cardiac surgery: A retrospective before-and-after cohort study

Objectives To evaluate the association between the addition of enteral chloral hydrate to a postoperative sedation protocol and benzodiazepine exposure, sedation quality, withdrawal, delirium, and short-term clinical outcomes in children undergoing congenital heart surgery. Design Single-center retrospective before-and-after cohort study. Setting Pediatric cardiac intensive care unit of a tertiary referral center. Participants Eighty-six children who underwent congenital heart surgery with cardiopulmonary bypass, required postoperative mechanical ventilation for more than 24 hours, and received sedation for at least 24 hours. Interventions Patients were treated according to the institutional postoperative sedation protocol before (July 2021–June 2023) and after (August 2023–July 2025) implementation of enteral chloral hydrate as an adjunctive sedative. Measurements and Main Results The primary endpoint was cumulative midazolam exposure during the pediatric cardiac intensive care unit stay. Secondary endpoints included sedative and analgesic requirements, sedation and pain scores, withdrawal, delirium, and clinical outcomes. Compared with the pre-protocol group, the chloral hydrate group had significantly lower cumulative midazolam exposure (10.2 vs. 13.2 mg/kg, p=0.010) and peak midazolam infusion rates (0.15 vs. 0.20 mg/kg/h, p<0.001), and a lower observed frequency of delirium (14.6% vs. 37.8%, p=0.015). No significant between-group differences were observed in sedation quality, pain scores, withdrawal, duration of mechanical ventilation, length of stay in the pediatric cardiac intensive care unit or hospital, or mortality. Conclusions Addition of enteral chloral hydrate to a postoperative sedation protocol was associated with reduced benzodiazepine exposure and a lower observed frequency of delirium without statistically significant differences in sedation quality or short-term clinical outcomes. Prospective multicenter studies are warranted to confirm these findings.