Arterial blood oxygen desaturation in infants and children during upper gastrointestinal endoscopy

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

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Comparison of performance and safety of endoscopic retrograde cholangiopancreatography across pediatric age groups

BACKGROUND AND STUDY AIM

Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be overall effective and safe in children, but its performance characteristics and safety profile have not been specifically evaluated according to age. We aim to compare the indications, findings, interventions, and safety outcomes of ERCP across pediatric age groups.

METHODS

A retrospective cross-sectional study of pediatric patients (ages 17 or below) who underwent ERCP between October 1998 and April 2011 at a tertiary-care academic center. Data on indications, findings, technical success, and adverse events of ERCP were collected and compared according to age groups (0-6, 7-12, or 13-17 years).

RESULTS

There were 289 procedures performed in 154 children (mean age, 11.5 years). The number of patients undergoing ERCP increased with age; teenagers constituted the largest group (52.6%) and had the most procedures (49.8%). Children aged 0-6 years had an equal distribution of biliary and pancreatic cases; children aged 7-12 years had predominantly pancreatic indications. Most procedures in teenagers were for biliary indications. Overall, the technical success rates of ERCPs were similar across age groups (P=0.661). Seventeen adverse events (5.9% of procedures) were identified: post-procedure pancreatitis (12 cases; 4.2%), hypoxia (3; 1.0%), and hemorrhage (2; 0.7%). The youngest group had more adverse events (12.0%, compared to 6.3 and 2.1% in other groups; P=0.049), mostly due to mild pancreatitis.

CONCLUSION

ERCP is generally safe in the pediatric population, although the risk of mild post-procedure pancreatitis may be higher among the youngest children.

Procedural sedation analgesia

The number of noninvasive and minimally invasive procedures performed outside of the operating room has grown exponentially over the last several decades.Sedation, analgesia, or both may be needed for many of these interventional or diagnostic procedures. Individualized care is important when determining if a patient requires procedural sedation analgesia (PSA). The patient might need an anti-anxiety drug, pain medicine, immobilization, simple reassurance, or a combination of these interventions. The goals of PSA in four different multidisciplinary practices namely; emergency, dentistry, radiology and gastrointestinal endoscopy are discussed in this review article. Some procedures are painful, others painless. Therefore, goals of PSA vary widely. Sedation management can range from minimal sedation, to the extent of minimal anesthesia. Procedural sedation in emergency department (ED) usually requires combinations of multiple agents to reach desired effects of analgesia plus anxiolysis. However, in dental practice, moderate sedation analgesia (known to the dentists as conscious sedation) is usually what is required. It is usually most effective with the combined use of local anesthesia. The mainstay of success for painless imaging is absolute immobility. Immobility can be achieved by deep sedation or minimal anesthesia. On the other hand, moderate sedation, deep sedation, minimal anesthesia and conventional general anesthesia can be all utilized for management of gastrointestinal endoscopy.

Use of oral midazolam in pediatric upper gastrointestinal endoscopy

BACKGROUND

The purpose of this prospective, randomized study was to compare the safety and efficacy of oral versus i.v. midazolam in providing sedation for pediatric upper gastrointestinal (GI) endoscopy.

METHODS

Sixty-one children (age <16 years) scheduled for upper GI endoscopy were studied. Patients were randomly assigned to receive oral or i.v. midazolam. Measurements were made and compared for vital signs, level of sedation, pre- and post-procedure comfort, anxiety during endoscopy, ease of separation from parents, ease and duration of procedure, and recovery time.

RESULTS

Patients were aged 1-16 years (mean 7.5 + or - 3.42 years); 30 patients received oral medication, and 31 received i.v. medication. There were no statistically significant differences in age or gender between groups. There were no significant differences in level of sedation, ease of separation from parents, ease of ability to monitor the patient during the procedure, heart rate, systolic arterial pressure, or respiratory rate. Oxygen saturation was significantly lower in the i.v. group than the oral group 10 and 30 min after removal of the endoscope, and recovery time was longer in the oral than the i.v. group.

CONCLUSIONS

Oral administration of midazolam is a safe and effective method of sedation that significantly reduces anxiety and improves overall tolerance for children undergoing esophagogastroduodenoscopy.

Flexible upper videoendoscopy through a modified endoscopy mask in infants and young children

Esophagogastroduodenoscopy (EGD) is considered an essential diagnostic and therapeutic procedure in the pediatric population. Although generally safe, EGD has the potential for airway complications. We routinely use general anesthesia to carry out EGD in patients younger than 10 years. In the past, these patients received oxygen either through a nasal cannula or were intubated; both modalities have drawbacks and may be associated with complications. Here we report our experience using a modified endoscopy mask, devised primarily for bronchoscopy, for upper endoscopy in children under general anesthesia.

RESULTS

Two hundred forty children (122 boys and 118 girls) participated in the study. Age range was 7 to 135 months (mean 60.7 +/- 34.4 months). All patients maintained a stable hemodynamic status throughout the procedure. Ventilation was satisfactory in 230 patients. It was difficult in 9 patients, and external airway maneuvers had to be applied. Ventilation was impossible in only 1 patient (10 months old), and endotracheal intubation was performed. There were no procedure-related complications.

CONCLUSION

The modified endoscopy mask is efficient and safe and should be recommended for routine use for upper endoscopy under general anesthesia in children older than 6 months.

Paediatric endoscopy performed by adult-service gastroenterologists

BACKGROUND

Children often travel from district hospitals to teaching centres for endoscopic procedures by paediatric gastroenterologists. A 10-year district hospital experience of 'adult-service' gastroenterologists endoscoping children is reported with the aim of quantifying the workload, indications, sedation/anaesthesia practices, findings and safety of paediatric endoscopy performed by adult-service gastroenterologists.

METHODS

Data on endoscopic procedures in patients younger than 16 years of age between 1997 and 2006 were obtained from hospital case-notes and computerized endoscopy/histology databases and were analysed.

RESULTS

A total of 174 procedures (118 gastroscopies, 41 colonoscopies and 15 flexible sigmoidoscopies) were performed in 162 children. The median (interquartile range) age was 11.5 (5-14) years. Sixty-nine percent of patients were referred by paediatricians and 31% by general practitioners /other adult specialties. Children referred as outpatients waited a total of 50 (23.5-95) days from referral to procedure. Inpatient children waited 3 (1-4) days for their procedure. General anaesthesia was used in 89% (63 of 71) endoscopic procedures in children aged below 11 years and 100% of 47 procedures in children aged below 6 years. In contrast, 96% (99 of 103) procedures in children aged 11 years or older were done in the endoscopy unit with intravenous or no sedation. Organic disease was identified from 90 (52%) procedures. The most common diagnoses were coeliac disease (41), inflammatory bowel disease (26), gastro-oesophageal reflux (six) and foreign body removal (seven). No endoscopic complications occurred.

CONCLUSION

General gastroenterologists supported by paediatricians can provide endoscopic services for children safely and promptly in their local hospital. This is appropriate for the management of common gastrointestinal problems affecting children.

Safety of intravenous midazolam and fentanyl for pediatric GI endoscopy: prospective study of 1578 endoscopies

BACKGROUND

Data on safety of intravenous sedation in pediatric GI endoscopy are sparse.

OBJECTIVE

To evaluate safety of intravenous sedation for GI endoscopy.

DESIGN/SETTING

Single-center prospective series of outpatient GI endoscopies performed from February 2003 to February 2004 at The Children's Hospital of Philadelphia. The recorded information included demographic, medication, and adverse event data.

PATIENTS

A total of 1226 patients were studied.

MAIN OUTCOME MEASUREMENTS

Description of adverse events relating to intravenous sedation.

RESULTS

A total of 2635 endoscopies were performed, of which 1717 were outpatient procedures with the patient under intravenous sedation. Sedation data were available on 1578 procedures (92%, M/F 674/552): 758 esophagogastroduodenoscopies (EGD) alone, 116 colonoscopies (COL) alone, and 352 combined EGD and COL. The median dose of fentanyl was 2.77 microg/kg (SD 0.97, range 0-6.73), and of midazolam was 0.11 mg/kg (SD 0.06, range 0-0.39). The mean recovery time was 118 minutes (SD 47.3, range 31-375). Ten patients (0.8%) failed intravenous sedation. Serious adverse events (apnea) were noted in 2 patients (0.2%). Mild or moderate adverse events included desaturation below 92% for less than 20 seconds (100 patients, 9%), vomiting (64 patients, 5%), agitation (15 patients, 1%), desaturation below 92% for greater than 20 seconds (12 patients, 0.7%), and rash (8 patients, 0.7%). No cardiopulmonary resuscitation or sedation reversal was necessary. No patients required hospitalization. Patients younger than 6 years were more likely to develop respiratory adverse event (P < .01).

CONCLUSIONS

Intravenous sedation with midazolam and fentanyl is safe for pediatric GI endoscopy. Serious adverse events are rare and no patient required hospitalization.

Unsedated upper endoscopy in children

BACKGROUND

EGD is essential to the investigation and treatment of GI disorders in children. Although safe, EGD has the potential for complications, in particular cardiopulmonary abnormalities associated with intravenous sedation. EGD is often performed in adults without sedation. Unsedated EGD is occasionally performed in children but has not been subjected to study. This study assessed the safety, efficacy, and feasibility of unsedated EGD in children.

METHODS

Selected, highly motivated children requiring EGD were offered the choice of sedation or no sedation for the procedure. Children recorded scores for pain (face scale) and anxiety (vertical visual analogue scale) before and after EGD. In addition, the times required to prepare the patient, perform the EGD, and recover the patient were recorded.

RESULTS

There was no difference in age, gender, or pre-EGD pain scores between children selecting sedation or no sedation. However, children selecting sedation had significantly higher pre-EGD anxiety scores than those who chose no sedation. Successful completion of EGD was similar for sedated (96.3%) and unsedated (95.2%) children. Post-EGD scores for anxiety were significantly decreased in those receiving sedation and unchanged in children who received no sedation. There was no significant change in post-EGD pain score in either group. Nearly 80% of children undergoing unsedated EGD would elect to forego sedation if EGD was needed again. Total procedure time was significantly longer in sedated versus unsedated children, reflecting longer preparation and recovery.

CONCLUSIONS

Unsedated EGD can be performed safely and successfully in children with good patient tolerance. There was a significant decrease in total procedure time for children who have unsedated EGD. Unsedated EGD should be considered a viable option for motivated children.

Experience with an anesthesiologist interventional model for endoscopy in a pediatric hospital

BACKGROUND

Endoscopy is now a routine part of the work-up for many patients with gastrointestinal symptoms. Adults tolerate these procedures well, with either no sedation or a relatively light level. In contrast, children often require deep sedation or a general anesthetic to successfully perform these procedures. Therefore, pediatric endoscopies may require more time, personnel, and monitoring equipment to provide optimal conditions for the patient. The goals of this retrospective case series were to describe the anesthesia times and recovery duration of the different procedures, the types and amounts of medications commonly used, and the types and rates of complications experienced.

METHODS

Patients (2,306) who underwent endoscopy in the Arkansas Children's Hospital endoscopy suite during a 4-year period were identified. A random sample of 720 charts was reviewed retrospectively.

RESULTS

Patients ranged in age from younger than 1 year to 29 years. Patients most often had abdominal pain or multiple gastrointestinal symptoms. Sixty-eight percent of patients underwent esophagogastroduodenoscopies; 30% colonoscopy or a combination of the two. Ninety-five percent of patients received a propofol-based anesthetic. Midazolam, fentanyl, and alfentanil were frequently used as supplemental agents. Complications occurred infrequently and were airway related. All complications were easily treated, with no adverse sequelae.

CONCLUSIONS

This model of anesthesiologist-provided sedation/anesthesia for gastrointestinal endoscopy procedures has been extremely successful in the Arkansas Children's Hospital and has served to heighten awareness of many issues surrounding sedation and anesthesia outside of the operating room, while ensuring a high level of care is provided.

Anesthesia and sedation in the endoscopy suite? (influences and options)

Advances in technology and pharmacology have enabled gastrointestinal endoscopists to expand the diagnostic and therapeutic capabilities of the specialty. Research into the impact of the endoscopy environment on patient stress, acknowledgement of the various patient coping styles, development and deployment of procedural preparative programs and information streamlining have been shown to be of value in decreasing anxiety and reducing sedative requirements. Being aware of procedure-related stressors, and factors associated with complications, allows us to tailor our sedation or anesthesia plan to the individual patient.

Oxygen saturation during esophagogastroduodenoscopy in children: general anesthesia versus intravenous sedation

BACKGROUND

Hypoxia may occur in children undergoing upper digestive endoscopy under sedation. The purpose of this study was to compare the occurrence of desaturation during intravenous sedation with that which occurs during general anesthesia.

METHODS

Thirty-six patients between 3 months and 6 years old underwent a diagnostic esophagogastroduodenoscopy under sedation (n = 18) or general anesthesia (n = 18). Oxygen pulse oximetry, heart rate, and mean arterial pressure were monitored throughout the procedure. At the end of the procedure, the operator gave the value of the endoscopy satisfaction score on a scale of I (very good conditions) to IV (impossible procedure).

RESULTS

The minimum oxygen pulse oximetry value was significantly lower in the sedation group compared with that in the general anesthesia group (89 +/- 5 vs. 97 +/- 1; p < 0.001). In the general anesthesia group, the oxygen pulse oximetry level declined to less than 95% in only one child; but in the sedation group, it declined to less than 95% in 16 patients (5.5% vs. 89%). Nine patients had a profound desaturation in sedation group (oxygen pulse oximetry < 90%); no patients in the general anesthesia group had desaturation (50% vs. 0%). In the general anesthesia group, heart rate and mean arterial pressure remained stable during the whole procedure, whereas in the sedation group, heart rate and mean arterial pressure increased significantly during the procedure. The endoscopy satisfaction score was I in all 18 patients in the general anesthesia group, whereas in the sedation group, it was I in only 2 patients, II in 8 patients, and III in 10 patients.

CONCLUSIONS

These results confirm that hypoxia during upper digestive endoscopy in patients under sedation is a frequent occurrence in children. When compared with sedation, general anesthesia is a safer technique that prevents hypoxia and allows the gastroenterologist to perform the endoscopy under better conditions.

Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: a twelve-year review

BACKGROUND

Over the past decade, many pediatric endoscopists have replaced general anesthesia with conscious sedation. Sedation is commonly used to minimize discomfort.

METHODS

To evaluate the safety and efficacy of conscious sedation we reviewed 2711 reports of lower and upper gastrointestinal endoscopic examinations performed in 2026 patients between July 1981 and December 1992.

RESULTS

Intravenous sedation was accomplished using meperidine and diazepam (914 examinations, 35%) or meperidine and midazolam (1427 examinations, 55%). Single agents were used for 83 examinations (3%), and 96 examinations (3.5%) were performed with the patient under general anesthesia. In the lower endoscopy group sedated intravenously (n = 713), the cecum was reached in 82% of examinations. The procedure could not be completed in 17 cases in which patients were uncooperative despite sedation. In the upper endoscopy group sedated intravenously (N = 1653), all but 91 endoscopies were completed to the descending duodenum. Esophagoscopy had been planned in 76% of these procedures. Minor complications occurred in 7 patients (0.3%). This included two episodes of significant oxygen desaturation that responded to oxygen administration and narcotic reversal. A major complication occurred in 1 patient (0.04%) who had a gastric perforation during esophageal dilation over a defective guide wire. There were no deaths, episodes of cardiorespiratory arrest, or pulmonary aspirations in our series. The combined major and minor complication rate was 0.3%.

CONCLUSIONS

Intravenous conscious sedation is safe and effective in children undergoing endoscopic examination of the gastrointestinal tract. Selected patients will require general anesthesia.

Modifications of Oxygen Saturation During Transesophageal Echocardiography

The present study was designed: (1) to establish the effects of transesophageal echocardiography (TEE) on arterial oxygen saturation (SAO(2)%); (2) to verify the possible clinical consequences of this phenomenon; and (3) to study the possibility of predicting modifications of SAO(2)% by clinical or hemodynamic variables or by specific factors related to the TEE procedure. We prospectively studied 116 unselected patients, aged 61 +/- 12 years, who underwent diagnostic TEE for various clinical indications. Thirty-seven patients had mitral valve disease, 19 aortic valve disease, 14 combined mitroaortic disease, 8 congenital heart disease, and 38 other cardiovascular diseases. Eight patients were affected by chronic obstructive pulmonary disease. Ninety-seven patients were sedated by 4 +/- 2 mg of diazepam IV SAO(2)% (5-min average) (Ohmeda Biox 3700 pulse oxymeter finger probe), heart rate (HR), and blood pressure (BP) were considered during baseline transthoracic examination, after pharmacological sedation but before the introduction of the probe, and finally during TEE. Neither clinical complications nor major arrhythmias were observed. Baseline SAO(2)%, HR and BP were, respectively, 93.6 +/- 3.3%, 76 +/- 14 beats/min, and 129 +/- 20/75 +/- 10 mmHg. Pharmacological sedation did not modify SAO(2)%, HR, and BP (P > 0.1). During TEE a small but significant reduction in SAO(2)% by an average of 1.2 +/- 3.2% was observed (P < 0.005), as well as a small and significant increase in HR by an average of 3 +/- 10 beats/min (P < 0.01). BP did not change significantly (P > 0.1 for both systolic and diastolic). The changes of SAO(2)% and HR were not interrelated and were not related to the duration of the procedure and to any of the clinical and hemodynamic variables taken into consideration. TEE can induce a small but significant drop in SAO(2)% and a small increase in HR even without any clinical relevance. No clinical or hemodynamic variable or specific factors related to the TEE procedure were related to these changes.

Neonatal and infantile upper gastrointestinal endoscopy using a new small diameter fibreoptic gastroscope

Using a new prototype (Olympus XPGIF 5.2/ N30) gastroscope, upper gastrointestinal endoscopy was safely performed under sedation on 99 infants (weights 0.9 to 10.1 kg). No complications occurred. Macroscopic and microscopic abnormalities were found in 60%, including abnormal duodenal biopsies in 47% of cases with protracted diarrhoea. Duodenal biopsy material was, however, of suboptimal standard for histologic assessment in 25% of the cases. In 52% of those under 3.5 kg diagnoses were made that would not have otherwise been possible and, in 75% of those in the Intensive Care Unit, abnormalities were found. The use of this new endoscope represents a significant advance in clinical practice.

Sedation for the pediatric patient. A review

Safe sedation of a pediatric patient requires a thorough knowledge of the pharmacokinetics and pharmacodynamics of the drugs used to sedate the patient and the skills necessary to deal effectively with potential adverse events as a result of the sedation. The Sedation Guidelines of the American Academy of Pediatrics are reviewed. Emphasis is placed on monitoring and appropriate selection of drugs.

The effect of supplemental oxygen in sedated and unsedated patients undergoing upper gastrointestinal endoscopy

A total of 212 patients undergoing elective upper gastrointestinal endoscopy were prospectively studied. They were randomly assigned to one of four treatment groups: (I) sedation with no supplemental oxygen; (II) no sedation and no oxygen supplementation; (III) sedation and supplemental oxygen; and (IV) no sedation but supplemental oxygen. Oxygen desaturation occurred in all the groups except group IV and was worsened by sedation. Supplemental oxygen corrected the desaturation in the sedated patients and minimized the associated haemodynamic changes. The duration of the endoscopy procedure was shortest in patients who were sedated and given supplemental oxygen. It can be concluded that during conscious sedation for upper gastro-intestinal endoscopy, supplemental oxygen should be given and continued during the postendoscopy period to prevent oxygen desaturation.

Oxygen desaturation and cardiac arrhythmias in children during esophagogastroduodenoscopy using conscious sedation

To determine whether oxygen desaturation and cardiac arrhythmias occur in children during esophagogastroduodenoscopy with the use of conscious sedation, we prospectively studied 34 consecutive patients between the ages of 2 months and 18 years. Patients with pulmonary, cardiac, and neurologic disorders were defined as high risk and those without were defined as normal. All patients received intravenous sedation with meperidine, diazepam, or midazolam, used alone or in combination. Pulse oximetry, respiratory rate, and lead II electrocardiogram were recorded throughout all episodes of desaturation and tachycardia. Oxygen desaturation to less than 90% occurred in 68% of normal patients and in 58% of high-risk patients during esophagogastroduodenoscopy. Seventy-five percent of the high-risk patients and 82% of the normal patients had an arrhythmia during esophagogastroduodenoscopy usually associated with oxygen desaturation. Sinus tachycardia was the most common arrhythmia, although other arrhythmias were identified. Despite the frequency of oxygen desaturation and cardiac arrhythmias, no adverse outcome was observed in any patient. Most episodes of oxygen desaturation and cardiac arrhythmia resolved spontaneously. Subdivision of patients into high-risk groups by age, sex, weight, or diameter of endoscope used did not allow prediction of oxygen desaturation or cardiac arrhythmia. Our data suggest that conscious sedation in children undergoing esophagogastroduodenoscopy is safe and free of significant adverse clinical problems. However, conscious sedation during esophagogastroduodenoscopy continues to have certain inherent risks. Therefore we strongly advocate the routine use of continuous cardiac rhythm and pulse oximetry monitoring of all children during esophagogastroduodenoscopy performed with the use of conscious sedation.

Pharmacokinetic and pharmacodynamic study of midazolam in children during esophagogastroduodenoscopy

We undertook a prospective study to evaluate the relationship between the onset and degree of sedation and the midazolam plasma concentration in children between 6 and 18 years of age during esophagogastroduodenoscopy. Thirteen boys and seven girls (median age 13.5 years) were studied. Midazolam was injected intravenously for 5 minutes, and the dose was titrated to sedation or a maximum dose of 0.1 mg/kg was given. Plasma midazolam concentration was determined just before and at 5, 10, 15, 30, 45, and 60 minutes after the start of midazolam injection. The patient's level of sedation was evaluated by an assistant at each blood sampling time. Clearance, volume of distribution, and terminal elimination (beta) half-life were estimated from a biexponential fit of the serial plasma midazolam concentrations. Mean beta half-life of midazolam was 47 +/- 26 minutes and mean clearance was 10.0 +/- 5.0 ml/min per kilogram of body weight. Maximum level of sedation occurred at 5 minutes after initiation of the injection and corresponded to a mean peak midazolam serum concentration of 229 +/- 39 micrograms/L. Thereafter, a decline of mean sedation scores paralleled the decrease in midazolam concentration. Mean oxygen saturation remained greater than 94% during the study. We conclude that children metabolize and excrete midazolam more rapidly than adults do and that sedation adequate for endoscopy is safely achieved in the majority of children with a midazolam dose of 0.05 to 0.1 mg/kg and a mean peak midazolam concentration greater than 200 microgram/L.