Anorectal manometry (ARM) is indicated for pediatric patients for a variety of reasons but most often to rule out Hirschsprung's disease. This disease is characterized by the absence of ganglion cells in the affected portion of the colon. These cells are responsible for allowing muscle to relax. With these cells absent, the internal anal sphincter is unable to relax, resulting in constipation. The primary presenting symptom of Hirschsprung's disease is constipation.

Jason was a 3-year-old boy who came to our gastroenterology procedure unit (GPU) for ARM secondary to his ongoing difficulties with constipation. He was accompanied by his mother, who was expecting her second baby at the time. Although ARM is not an uncomfortable test, it requires the patient to remain still for the duration of the examination; in this case, approximately 15 minutes. Because of Jason's age and concern for his ability to cooperate, the physician decided to administer oral sedation. I explained this to Jason's mother, who stated her understanding.

Chloral hydrate, a hypnotic, is frequently used as a sedative in the toddler population. An order for oral chloral hydrate was given, and written consent for sedation was then obtained from his parent by the ordering physician. After the appropriate patient assessment, the oral chloral hydrate was administered. The required patient monitoring began with the assessment of vital signs every 5 minutes. In our GPU, we practice family-centered care and allow parental presence during some procedures. ARM is one such procedure for which we give the parent the option to stay even when the patient is sedated.

After about 10-15 minutes, when the chloral hydrate started to take effect, it became apparent that Jason would not have the desired sedated response to the medication. Instead, he became agitated, crying and thrashing around. He was beginning to display signs of a paradoxical reaction to the chloral hydrate. In my experience administering chloral hydrate to toddlers, I had only seen the desired effect of a sleep-like hypnotic state. This, however, was the first time I had cared for a patient undergoing a paradoxical response.

I feel it is important to share this experience for two reasons: The knowledge that I gained from this experience in caring for a toddler with agitation and rage reaction and my change in practice in preparing a family for the sedation of their child. The focus of my care during this reaction was to maintain patient safety and decrease the level of parental anxiety of the mother witnessing this reaction in her toddler. Jason clearly was not recognizing the comforting words from his mother (and certainly not mine) while under the influence of the chloral hydrate. He screamed and thrashed constantly. He kicked his legs forcefully and was in danger of injuring himself during this prolonged period. This behavior continued uninterrupted for approximately 45 minutes.

I notified the physician and, although challenging in a combative child, continued providing physical assessment of the child and monitoring of his vital signs. Patient safety was a priority at this time, and safety was maintained throughout this episode. But it was increasingly evident, as minutes became quarter hours, that his mother was in need of nursing interventions as well. I realized early on that I had not adequately prepared her for the possibility of this very situation. While describing the use of a sedative, chloral hydrate in particular, I failed to mention the paradoxical reaction that might occur. I had told her that some children "may not get sleepy" from this medication but clearly did not elaborate enough.

Jason's mother stayed with him during the entire time. During our preprocedure time together, she presented as an intelligent, calm, caring person and mother. These qualities helped her keep her composure during this very stressful time for a parent. She held Jason when possible, talked to him in a calm voice, and stayed with him throughout. I had concerns for her safety as well, because she was about 6 months pregnant and holding a thrashing toddler. We talked about how to position him to maximize safety. I held him intermittently to give her some breaks along the way. I also asked whether she would like to go to the waiting area if it was too upsetting to see her child in this state. As it became apparent that Jason was going to have this reaction, I explained to her what was occurring, keeping him safe from injury, and stressing that it will pass. I provided her constant reassurance, and she amazingly kept her emotions in check. At this point, my words could only be comforting to her but not to my patient. In the end, we were able to safely perform Jason's ARM once he calmed. He (and his mother) recovered well from this sedation attempt. His ARM was normal.

Since this episode, I have included the possibility of a paradoxical reaction to sedatives as part of my routine preprocedure teaching of patients and parents. I also allow time for the family to ask questions before administering sedatives. Healthcare professionals cannot predict which child may have a paradoxical response to sedatives. For this reason, it is imperative that the parent be informed and prepared for this possibility.

A few weeks after this experience, I received a thank-you note from Jason's mother. As the years have passed, I have found myself thinking about the lessons I have learned from little Jason, his mother, and this experience. I owe them the "thank you" for making me a better teacher and a more vigilant pediatric gastroenterology nurse.

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