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Efficacy and safety of chloral hydrate sedation in infants for pulmonary function tests
Eficácia e segurança do hidrato de cloral na sedação de lactentes para testes de função pulmonar
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Nogueira, Dirceu Solé" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Gustavo Falbo" "apellidos" => "Wandalsen" "email" => array:2 [ 0 => "gfwandalsen@uol.com.br" 1 => "gfwandalsen@unifesp.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernanda de Cordoba" "apellidos" => "Lanza" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Márcia Cristina Pires" "apellidos" => "Nogueira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Dirceu" "apellidos" => "Solé" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidade Nove de Julho, São Paulo, SP, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Eficácia e segurança do hidrato de cloral na sedação de lactentes para testes de função pulmonar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chloral hydrate (CH) is a hypnotic sedative drug widely used in recent decades to sedate children. Although its exact mechanism of action remains uncertain, the CH is metabolized to trichloroethanol, the active metabolite responsible for the hypnotic effects. The half-life of this metabolite is 8–12h in preschoolers, but can be up to four times longer in newborns and preterm infants.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">CH is the sedative of choice for pulmonary function tests in infants and has been used in several laboratories for more than 25 years.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,3</span></a> It is the drug of choice due to several factors. It is administered orally, does not require venipuncture and induces adequate sedation degree and duration for pulmonary function assessment procedures to be carried out.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Additionally, the available reference equations for pulmonary function parameters were obtained after sedation with CH and use of other sedatives could hinder comparisons and induce biases.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> In a recent survey carried out at 148 pulmonary function laboratories in infants worldwide, 79% of them used CH as a sedative for exams.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The use of CH for sedation in young children, however, is not a consensus and severe adverse events, including deaths, have been reported.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2,5</span></a> Recently, the Brazilian National Health Surveillance Agency (ANVISA) has banned the sale of CH in the country for lack of evidence of its efficacy and safety. The aim of this article is to describe the experience of the pulmonary function laboratory in infants treated at the Discipline of Allergy, Clinical Immunology and Rheumatology of the Department of Pediatrics of Escola Paulista de Medicina (Unifesp) regarding the use of CH in necessary sedation for pulmonary function tests.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is a retrospective case series, which evaluated all sedation attempts for pulmonary function tests in infants between June 2007 and August 2014. The pulmonary function tests were carried out in infants weighing ≥4kg and no history of respiratory infection in the previous two weeks. On the day of the pulmonary function test, the infants that came to the service had fasted for at least 3h and received an oral dose of chloral hydrate after clinical evaluation. All tests were performed with the infant in the supine position with slight neck extension and tests were carried out with continuous heart rate and oxygen saturation monitoring. A physician and a physical therapist trained in emergency care were present in all examinations and resuscitation equipment was available during all tests.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lung volumes and forced expiratory flow were measured using specific equipment (Infant Pulmonary Lab, Collins-nSpire, USA), according to existing recommendations.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">6,7</span></a> In brief, lung volume was measured during the infants’ spontaneous breathing movements; then, the airway was occluded for a few seconds, at some moments during breathing. Forced expiratory flows were obtained using the rapid thoracoabdominal compression technique with high lung volumes. Flow-volume curves were obtained by compression of an inflatable jacket placed around the infant's chest and abdomen after inspiration with positive pressure (30cm/H<span class="elsevierStyleInf">2</span>O). Chest and abdomen compression was maintained until the end of expiration was visually identified or for a maximum period of four seconds. Several curves were obtained with increasing thoracoabdominal compression pressure, until there was no increase in forced flow and volume values.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To evaluate the safety and efficacy of CH in this study, anthropometric data, test indication, CH dose employed (per kg of bodyweight) and sedation outcome were recorded, as well as successful sedation and pulmonary function assessment. In cases of clinical complications, the nature of these complications and required procedures were recorded.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All tests were performed after obtaining written consent from parents and/or guardians and after approval of the Institutional Review Board of Universidade Federal de São Paulo (Unifesp).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 277 infants were assessed (165 males), with a median age of 51.5 weeks (range 14–182). The indications for the tests were: prematurity and/or low birth weight in 74 (27%), recurrent wheezing and/or lung disease in 156 (56%), sickle-cell anemia in 13 (5%) and others in 34 (12%) infants.</p><p id="par0045" class="elsevierStylePara elsevierViewall">CH dose ranged from 50 to 80mg/kg (orally), with a median of 70mg/kg. This dose usually induces sleep quickly (in approximately 20min) and maintains it for approximately 50min. Of the attempted assessments, it was not possible to perform the pulmonary function test in 32 (12%) cases: 18 (6.5%) due to problems in sedation (9 infants did not sleep and 9 awakened too soon), 10 (4%) due to clinical problems and 4 (1%) due to technical difficulties. Clinical problems that prevented the assessment from being performed were cough (2 infants); respiratory distress (1); vomiting (3); presence of airway secretions (1); decrease in peripheral oxygen saturation (SpO<span class="elsevierStyleInf">2</span>) (1); bradycardia (1) and upper airway obstruction (1).</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the 245 pulmonary function tests performed, clinical events were observed during the examination in eight infants (3%). Thus, of the 277 sedation attempts, 18 (6.5%) infants showed some type of clinical complication after CH administration. The observed adverse events are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The actions required in these cases were upper airway aspiration, cervical repositioning and oxygen supplementation. The child that had bradycardia was a preterm infant, born at 27 weeks of gestation weighing 770g, and a chronological age of 11 months at the time of the examination. After sedation with 75mg/kg of CH, the heart rate decreased for about 15min, not lower than 65bpm, being responsive to tactile stimulation.</p><p id="par0060" class="elsevierStylePara elsevierViewall">All adverse events observed during the 277 sedation attempts were transient, with spontaneous improvement after the end of CH action. There were no cases that required ventilation and resuscitation maneuvers, use of injectable medications or hospitalization.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">CH-induced sedation is considered of moderate intensity and, therefore, it is recommended that it be performed under the supervision of physicians and health professionals trained in life support, with available resuscitation equipment and infant monitoring.</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is known that the CH can reduce upper airway muscle tone and increase the chance of collapse in infants with some degree of upper airway obstruction, such as those with pharyngeal and palatine tonsil hypertrophy, obstructive sleep apnea and craniofacial abnormalities.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> For this reason, such conditions contraindicate pulmonary function test performance in our laboratory. Similarly, examinations are not carried out in infants with heart disease due to the potential cardiac depression and induction of conduction disorders caused by CH, which causes arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Some comments about our data are important. Overall, our findings reinforce data from other services and demonstrate the safety and efficacy of CH as a sedative to be used for procedures in infants.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">8–10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The CH dose used by us (50–80mg/kg) was similar to that employed by other investigators<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> and sedation failure was observed in only 6.5% of the attempts. Higher doses of the sedative and/or repeated doses could reduce the number of failures, but are associated with increased risk of adverse events.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> West et al. evaluated the efficacy and safety of CH in infants and preschoolers for ophthalmic procedures.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> Using a dose of 80mg/kg of CH, they observed inadequate sedation in 7.2% of children. An additional dose of up to 40mg/kg was administered in cases of failure, with sedation failure being reduced to 3.3%.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In our service, we observed an incidence of 6.5% of adverse events. The observed adverse events and their frequency were similar to those described by other authors, that is: paradoxical reactions (1.3%); decrease in SpO<span class="elsevierStyleInf">2</span> (1%); vomiting (0.5%) and bradycardia (0.1%).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> The report of another large case series, by Avlonitou et al. compiled adverse events after sedation with CH for hearing tests in 1903 children up to 14 years of age (568 children under six months of age).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> In this study, they observed hyperactivity in 8% of cases, vomiting in 11%, mild respiratory discomfort 0.5% and apnea in 0.2% of the cases.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Prematurity and younger age are factors known to be associated with increased risk of adverse events after sedation with CH.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> These two factors were present in the case of the infant who had bradycardia in our laboratory. As observed by us, other authors have reported that cases of bradycardia induced by CH tend to be responsive to physical stimuli, with good evolution.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The safety of CH (80mg/kg) has also been studied in a group of 1095 children (aged between one month and three years) sedated for echocardiograms.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> In this risk group, consisting mostly of patients with heart disease, 10.8% had some adverse event, such as decrease in SpO<span class="elsevierStyleInf">2</span> (5.9%), hypercapnia (6.6%), airway obstruction (1.4%), apnea (0.3%), hypotension (0.4%) and vomiting (0.4%). Of the assessed children, 24% showed a decrease in heart rate ≥20%, but only 1.4% decreased heart rate below the normal range for age.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> Major interventions such as face-mask ventilation and volume expansion were necessary in five cases (<0.5%), with tracheal intubation in one of them.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">A review of adverse event reports associated with sedation in North-American children identified 95 severe cases reported by the end of the 1990s.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Of these, 20 were related to the use of CH, with 13 cases leading to death or permanent neurological damage. Among these more severe cases, CH was administered alone in seven patients and in combination with other drugs in six.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> CH overdose was identified in four cases and nine had pre-existing clinical problems, such as tracheomalacia, tracheostomy, genetic syndromes, congenital heart defects and cerebral palsy.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Despite the existence of these severe adverse event reports, CH has been administered for pulmonary function tests in a large number of studies involving thousands of infants with respiratory problems, with a low incidence of adverse events and no report of death or permanent sequelae.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Several other sedative drug options for infants are available, each showing specific advantages and disadvantages. Midazolam is a short-duration benzodiazepine that is widely used in clinical practice, especially intravenously. In addition to the need for venous access, midazolam can also cause respiratory depression and hypotension.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> The main advantage of midazolam is the availability of an antagonist able to reverse its effects.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> More recently, the intranasal formulation of midazolam has been developed, which is more convenient for outpatient procedures, but with less sedative action. Dexmedetomidine is a selective α2-adrenergic agonist capable of inducing sedation and slight analgesia, used in several diagnostic procedures.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> It is preferably administered intravenously, with a small failure rate, and its most common adverse effects are bradycardia and blood pressure changes.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">13,14</span></a> The effect of dexmedetomidine on the respiratory system is small and, unlike CH, the sedative seems to be safe in children with upper airway obstructive disorders, but studies in young children are still limited.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion, the data obtained in our service are similar to those observed by other authors and demonstrate that CH, at the assessed doses, is a safe and effective drug for infant sedation during short procedures, such as pulmonary function tests. Due to the possibility of severe adverse events, dose recommendations and contraindications to the use of CH should be strictly followed. Sedation with CH should always be carried out by trained staff, under medical supervision and continuous monitoring of infants. Special attention should be given to infants belonging to risk groups, such as preterm infants.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">This study did not receive funding.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres756597" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec758694" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres756598" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec758693" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-29" "fechaAceptado" => "2016-05-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec758694" "palabras" => array:3 [ 0 => "Chloral hydrate" 1 => "Hypnotics and sedatives" 2 => "Infant" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec758693" "palabras" => array:3 [ 0 => "Hidrato de cloral" 1 => "Hipnóticos e sedativos" 2 => "Lactente" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the efficacy and safety of chloral hydrate sedation in infants for pulmonary function tests.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">All sedation attempts for pulmonary function tests in infants carried out between June 2007 and August 2014 were evaluated. Obstructive sleep apnea and heart disease were contraindications to the exams. Anthropometric data, exam indication, used dose, outcomes of sedation and clinical events were recorded and described.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The sedation attempts in 277 infants (165 boys) with a median age of 51.5 weeks of life (14–182 weeks) were evaluated. The main indication for the tests was recurrent wheezing (56%) and the chloral hydrate dose ranged from 50 to 80mg/kg (orally). Eighteen (6.5%) infants had some type of clinical complication, with the most frequent being cough and/or airway secretion (1.8%); respiratory distress (1.4%) and vomiting (1.1%). A preterm infant had bradycardia for approximately 15 minutes, which was responsive to tactile stimulation. All observed adverse effects were transient and there was no need for resuscitation or use of injectable medications.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The data demonstrated that chloral hydrate at the employed doses is a safe and effective medicament for sedation during short procedures in infants, such as pulmonary function tests. Because of the possibility of severe adverse events, recommendations on doses and contraindications should be strictly followed and infants should be monitored by trained staff.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Descrever a eficácia e a segurança do hidrato de cloral na sedação de lactentes para testes de função pulmonar.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram avaliadas retrospectivamente todas as tentativas de sedação para exames de função pulmonar em lactentes feitas entre junho 2007 e agosto 2014. Apneia obstrutiva do sono e cardiopatia foram contraindicações para os exames. Dados antropométricos, indicação do exame, dose empregada, desfechos da sedação e intercorrências clínicas foram registrados e descritos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Avaliaram-se as tentativas de sedação de 277 lactentes (165 meninos) com mediana de 51,5 semanas de vida (14-182). A principal indicação para os testes foi sibilância recorrente (56%) e a dose de hidrato de cloral usada variou entre 50-80mg/kg (via oral). Dezoito (6,5%) lactentes apresentaram algum tipo de intercorrência clínica e foram as mais frequentes: tosse e/ou secreção na via aérea (1,8%); desconforto respiratório alto (1,4%) e vômitos (1,1%). Um lactente prematuro apresentou bradicardia por cerca de 15 minutos, responsiva a estimulação tátil. Todos os efeitos adversos observados foram transitórios e não houve necessidade de manobras de reanimação e uso de medicações injetáveis.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os dados demonstraram que o hidrato de cloral, nas doses empregadas, é um medicamento seguro e eficaz para a sedação de lactentes em procedimentos de curta duração, como os testes de função pulmonar. Devido à possibilidade de eventos adversos graves, as recomendações referentes à dosagem e contraindicações devem ser seguidas de forma rígida e os lactentes devem ser monitorados por equipe treinada.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cough and/or airway secretion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Upper respiratory distress \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Decrease in oxygen saturation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal distension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged hiccups \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bradycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1250758.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Adverse events observed after administration of chloral hydrate in 277 infants.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infant respiratory function testing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Stocks" 1 => "P.D. Sly" 2 => "R.S. Tepper" 3 => "W.J. Morgan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1996" "editorial" => "Wiley-LissInc" "editorialLocalizacion" => "New York" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0080" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmacodynamics of chloral hydrate in former preterm infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K. Allegaert" 1 => "H. Daniels" 2 => "G. Naulaers" 3 => "D. Tibboel" 4 => "H. Devlieger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00431-005-1648-5" "Revista" => array:6 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2005" "volumen" => "164" "paginaInicial" => "403" "paginaFinal" => "407" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15798911" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0085" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chloral hydrate sedation for infant pulmonary function testing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Ren" 1 => "P. Robinson" 2 => "S. Ranganathan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.23012" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2014" "volumen" => "49" "paginaInicial" => "1251" "paginaFinal" => "1252" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24574186" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0090" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Survey of clinical infant lung function testing practices" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.L. Peterson-Carmichael" 1 => "M. Rosenfeld" 2 => "S.B. Ascher" 3 => "C.P. Hornik" 4 => "H.G. Arets" 5 => "S.D. Davis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.22807" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2014" "volumen" => "49" "paginaInicial" => "126" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23765632" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0095" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse sedation events in pediatrics: analysis of medications used for sedation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.J. Coté" 1 => "H.W. Karl" 2 => "D.A. Notterman" 3 => "J.A. Weinberg" 4 => "C. McCloskey" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2000" "volumen" => "106" "paginaInicial" => "633" "paginaFinal" => "644" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11015502" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0100" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ERS/ATS Task Force on Standards for Infant Respiratory Function Testing. European Respiratory Society/American Thoracic Society. Plethysmographic measurements of lung volume and airway resistance. ERS/ATS Task Force on Standards for Infant Respiratory Function Testing. European Respiratory Society/American Thoracic Society" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Stocks" 1 => "S. Godfrey" 2 => "C. Beardmore" 3 => "E. Bar-Yishay" 4 => "R. Castile" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2001" "volumen" => "17" "paginaInicial" => "302" "paginaFinal" => "312" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11334135" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0105" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Statement: raised volume forced expirations in infants: guidelines for current practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "American Thoracic Society" 1 => "European Respiratory Society" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200408-1141ST" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2005" "volumen" => "172" "paginaInicial" => "1463" "paginaFinal" => "1471" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16301301" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0110" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of chloral hydrate as a sedative for auditory brainstem response testing in a pediatric population" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. Avlonitou" 1 => "D.G. Balatsouras" 2 => "E. Margaritis" 3 => "P. Giannakopoulos" 4 => "Douniadakis" 5 => "M. Tsakanikos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijporl.2011.02.010" "Revista" => array:6 [ "tituloSerie" => "Int J Pediatr Otorhinolaryngol" "fecha" => "2011" "volumen" => "75" "paginaInicial" => "760" "paginaFinal" => "763" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21531030" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0115" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilisation of an outpatient sedation unit in pediatric ophthalmology: safety and effectiveness of chloral hydrate in 1509 sedation episodes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.K. West" 1 => "B. Griffiths" 2 => "Y. Shariff" 3 => "D. Stephens" 4 => "K. Mireskandari" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bjophthalmol-2013-303818" "Revista" => array:6 [ "tituloSerie" => "Br J Ophthalmol" "fecha" => "2013" "volumen" => "97" "paginaInicial" => "1437" "paginaFinal" => "1442" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24045857" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0120" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chloral hydrate sedation in term and preterm infants: an analysis of efficacy and complications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.S. Litman" 1 => "K. Soin" 2 => "A. Salam" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0b013e3181ca12a8" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2010" "volumen" => "110" "paginaInicial" => "739" "paginaFinal" => "746" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20032023" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0125" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chloral hydrate sedation for pediatric echocardiography: physiologic responses, adverse events, and risk factors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.C. Heistein" 1 => "C. Ramaciotti" 2 => "W.A. Scott" 3 => "M. Coursey" 4 => "P.W. Sheeran" 5 => "M.S. Lemler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2005-1445" "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2006" "volumen" => "117" "paginaInicial" => "e434" "paginaFinal" => "e441" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16481449" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0130" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sedation and anesthesia for CT: emerging issues for providing high-quality care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.G. Macias" 1 => "C.E. Chumpitazi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Radiol" "fecha" => "2011" "volumen" => "41" "numero" => "Suppl. 2" "paginaInicial" => "S517" "paginaFinal" => "S522" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0135" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dexmedetomidine for infant pulmonary function testing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Callahan" 1 => "S.J. Pinto" 2 => "G. Kurland" 3 => "J.G. Cain" 4 => "E.K. Motoyama" 5 => "D.J. Weiner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.23100" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2015" "volumen" => "50" "paginaInicial" => "150" "paginaFinal" => "154" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25187360" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0140" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sedation for infants and children outside of the operating room" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.D. Tobias" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ACO.0000000000000203" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Anaesthesiol" "fecha" => "2015" "volumen" => "28" "paginaInicial" => "478" "paginaFinal" => "485" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26087264" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23593482/0000003400000004/v1_201611120202/S2359348216300288/v1_201611120202/en/main.assets" "Apartado" => array:4 [ "identificador" => "42248" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23593482/0000003400000004/v1_201611120202/S2359348216300288/v1_201611120202/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2359348216300288?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 52 | 7 | 59 |
| 2024 September | 129 | 6 | 135 |
| 2024 August | 109 | 8 | 117 |
| 2024 July | 136 | 8 | 144 |
| 2024 June | 107 | 4 | 111 |
| 2024 May | 105 | 13 | 118 |
| 2024 April | 119 | 4 | 123 |
| 2024 March | 126 | 3 | 129 |
| 2024 February | 121 | 11 | 132 |
| 2024 January | 148 | 5 | 153 |
| 2023 December | 115 | 16 | 131 |
| 2023 November | 134 | 8 | 142 |
| 2023 October | 114 | 13 | 127 |
| 2023 September | 86 | 8 | 94 |
| 2023 August | 82 | 9 | 91 |
| 2023 July | 67 | 10 | 77 |
| 2023 June | 67 | 8 | 75 |
| 2023 May | 73 | 8 | 81 |
| 2023 April | 81 | 1 | 82 |
| 2023 March | 67 | 1 | 68 |
| 2023 February | 46 | 6 | 52 |
| 2023 January | 32 | 9 | 41 |
| 2022 December | 53 | 6 | 59 |
| 2022 November | 60 | 10 | 70 |
| 2022 October | 50 | 11 | 61 |
| 2022 September | 42 | 13 | 55 |
| 2022 August | 63 | 8 | 71 |
| 2022 July | 50 | 12 | 62 |
| 2022 June | 42 | 12 | 54 |
| 2022 May | 43 | 8 | 51 |
| 2022 April | 36 | 7 | 43 |
| 2022 March | 47 | 4 | 51 |
| 2022 February | 55 | 10 | 65 |
| 2022 January | 46 | 4 | 50 |
| 2021 December | 34 | 8 | 42 |
| 2021 November | 42 | 11 | 53 |
| 2021 October | 60 | 10 | 70 |
| 2021 September | 55 | 13 | 68 |
| 2021 August | 49 | 8 | 57 |
| 2021 July | 18 | 5 | 23 |
| 2021 June | 22 | 5 | 27 |
| 2021 May | 22 | 9 | 31 |
| 2021 April | 21 | 17 | 38 |
| 2021 March | 16 | 14 | 30 |
| 2021 February | 5 | 8 | 13 |
| 2021 January | 8 | 11 | 19 |
| 2020 December | 15 | 7 | 22 |
| 2020 November | 12 | 5 | 17 |
| 2020 October | 11 | 5 | 16 |
| 2020 September | 9 | 8 | 17 |
| 2020 August | 13 | 5 | 18 |
| 2020 July | 10 | 12 | 22 |
| 2020 June | 6 | 6 | 12 |
| 2020 May | 5 | 6 | 11 |
| 2020 April | 11 | 3 | 14 |
| 2020 March | 5 | 3 | 8 |
| 2020 February | 6 | 4 | 10 |
| 2020 January | 7 | 0 | 7 |
| 2019 December | 7 | 8 | 15 |
| 2019 November | 4 | 5 | 9 |
| 2019 October | 12 | 2 | 14 |
| 2019 September | 6 | 6 | 12 |
| 2019 August | 3 | 4 | 7 |
| 2019 July | 4 | 4 | 8 |
| 2019 June | 9 | 6 | 15 |
| 2019 May | 5 | 20 | 25 |
| 2018 September | 1 | 0 | 1 |
| 2018 July | 1 | 1 | 2 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 1 | 0 | 1 |
| 2018 April | 2 | 0 | 2 |
| 2018 March | 2 | 0 | 2 |
| 2018 February | 3 | 0 | 3 |
| 2017 February | 2 | 1 | 3 |
| 2017 January | 23 | 21 | 44 |
| 2016 December | 34 | 16 | 50 |
| 2016 November | 27 | 9 | 36 |
| 2016 October | 5 | 7 | 12 |
| 2016 September | 3 | 3 | 6 |
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