Midazolam-ketamine combination for moderate sedation in upper GI endoscopy

Efficacy and safety of intravenous thiamylal in sedation for colonoscopy in children

Objectives

Since a standard sedation protocol for pediatric colonoscopy (CS) has not been established, evidence on optimal sedative agents is needed. This study aimed to evaluate the efficacy and safety of thiamylal in sedation for pediatric CS compared to midazolam.

Methods

Children from 7 to 16 years of age who underwent CS under sedation with intravenous thiamylal or midazolam at our hospital between June 2010 and March 2024 were included in this retrospective observational study. The primary outcome was the efficacy (success rate of CS without mid-awakening) of the drugs. Meanwhile, the secondary outcomes were the sedation level during CS, procedure time, recovery time, and adverse events related to sedation.

Results

Sixty children were included in the study. The success rate of CS without mid-awakening was significantly higher in the thiamylal group (90.6%) than in the midazolam group (64.3%; p = 0.03). The two groups had no significant differences in median sedation depth, procedure time, or recovery time. Adverse events related to sedation in thiamylal group (22%) and midazolam group (25%) were similar. No severe adverse events were reported.

Conclusions

Intravenous thiamylal provides effective and safe sedation in children requiring CS, with little or no mid-awakening during the procedure.

Intravenous Sedation and Analgesia in a Pediatric Emergency Department: A Retrospective Descriptive Study

Background Painful procedures in the pediatric emergency department often require the use of sedation and analgesia to ensure adequate pain control, a right of children and adolescents. This study aims to describe the procedural sedation and analgesia with intravenous medications performed in a pediatric emergency department. Methods This is a retrospective descriptive study of intravenous sedoanalgesia used in a pediatric emergency department of a level II district hospital in the Lisbon metropolitan area from October 2018 to December 2023. The type of intervention, drugs used, and adverse events were analyzed. Results A total of 615 patients were included in the study; 65.7% (n=404) were male with a median age of 6 years. The most frequently performed procedures were wound suturing (50.9%, n=313) and fracture reduction (36.3%, n=223). The drugs used for sedation and analgesia were ketamine (99.2%, n=610), midazolam (95.8%, n=589), propofol (1.6%, n=10), and morphine (0.5%, n=3). The majority of patients received midazolam and ketamine in association (93.8%, n=577). A total of 50 adverse events (8.1%) were recorded in 42 patients. The most frequent side effects were transient oxygen desaturation (2%, n=12), vomiting (1.5%, n=9), apnea/bradypnea (1%, n=6), and hallucinations (0.8%, n=5). The occurrence of adverse events was not dose-dependent (p >0.05). Respiratory complications resolved without requiring invasive interventions. Children were sedated by a pediatric intensivist in 68.1% (n=419), by a general pediatrician in 26.7% (n=164), and by a pediatric resident in 2% (n=12). Conclusions The results of this study demonstrate that intravenous sedoanalgesia, particularly the combination of ketamine and midazolam, is a safe method for sedation in pediatric patients, with a low rate of adverse events.

The Evolution of Sedation for Pediatric Gastrointestinal Endoscopy

Sedation for pediatric endoscopy has evolved from an endoscopist-administered component of procedures to an almost entirely anesthesiologist-supported endeavor. Nevertheless, there are no ideal endoscopist or anesthesiologist-administered sedation protocols, and wide practice variation exists in both models. Furthermore, sedation for pediatric endoscopy, whether administered by endoscopists or anesthesiologists, remains the highest risk to patient safety. This underscores the importance of both specialties identifying best sedation practices together that can safeguard patients while maximizing procedural efficiency and minimizing costs. In this review, the authors discuss specific levels of sedation for endoscopy and the risks and benefits of various regimens.

The Effect of Preoperative Combined with Intravenous Lidocaine and Ketamine vs. Intravenous Ketamine on Pediatric Patients Undergoing Upper Gastrointestinal Endoscopy

Background

Ketamine is widely used in pediatric sedation. New studies have recommended combination therapy to reduce the side effects of ketamine.

Objectives

This study investigated the effect of adding intravenous (IV) lidocaine to ketamine on hemodynamic parameters, endoscopist satisfaction, and recovery time of children undergoing gastrointestinal endoscopy.

Methods

This triple-blind, randomized, controlled clinical trial was conducted in Isfahan, Iran (2021). One hundred twenty children between the ages of 1 and 6 were enrolled. Patients were divided into 2 groups. The intervention group received 1.0 mg/kg of IV lidocaine and 1.0 mg/kg of IV ketamine, and the placebo group received 1.0 mg/kg of IV ketamine and placebo 2 minutes before entering the endoscopic room. Patients in both groups were sedated with 1.0 mg/kg of propofol, 0.1 mg/kg of midazolam, and 2.0 ug/kg of fentanyl for the procedure. The pulse rate, mean arterial pressure (MAP), respiratory rate, and oxygen saturation were recorded 1 minute before injection and every 5 minutes afterward.

Results

The mean (SD) ages of the intervention and control groups were 3.4 (1.5) and 3.4 (1.7), respectively. The mean difference in hemodynamic parameters between the 2 groups was insignificant during the investigation (P > 0.05). Furthermore, no significant differences were found regarding endoscopist satisfaction scores and length of recovery room stay (P > 0.05).

Conclusions

Adding low-dose IV lidocaine to ketamine for pediatric sedation does not significantly affect the hemodynamic status, endoscopist satisfaction, and recovery time.

Comparison of the Sedative Effect of Ketamine, Magnesium Sulfate, and Propofol in Patients Undergoing Upper Gastrointestinal Endoscopy: Double-Blinded Randomized Clinical Trial

BACKGROUND

Endoscopy provides valuable diagnostic information and intervention therapies for gastroenterologists. Therefore, various drugs have been used to induce sedation in patients undergoing endoscopy, whereas none have been considered preferred by endoscopists. In the current study, we decided to use the combination of magnesium sulfate, ketamine, and their synergistic effects for creating partial analgesia to increase the satisfaction of endoscopists and patients.

METHODS

This study is a Double-Blind Randomized Clinical Trial that investigates the sedative effect of ketamine, magnesium sulfate, and propofol in endoscopy. Patients were selected from individuals over 12 years old and with American Society of Anesthesia (ASA) physical status I or II. The study was performed on 210 patients classified as ASA (I have no underlying disease) or II (with underlying controlled disease). The whole group was relieved of pain through sedation according to Ramsay criteria, satisfaction with the operation, duration, recovery, nausea and vomiting, hypotension, and decreased oxygen saturation were compared.

RESULTS

A total of 155 patients were enrolled in our study, including 51 patients (midazolam and propofol), 55 patients (midazolam and ketamine), and 49 patients (midazolam and ketamine and magnesium). The results showed that preoperative heart rate, intraoperative systolic blood pressure, intraoperative diastolic blood pressure, postoperative heart rate, postoperative systolic blood pressure, and postoperative heart rate were significantly different between the groups.

CONCLUSION

The satisfaction of the endoscopic was achieved to a great extent, mainly in the group receiving midazolam and propofol and in the group receiving midazolam and ketamine. In most cases, the satisfaction of the endoscopic was acceptable, and the low satisfaction of the endoscopic was more in the group receiving midazolam. Ketamine and magnesium were observed. The two compounds midazolam-ketamine, and midazolam-propofol, have a more favorable effect than the combination of midazolam, ketamine, and magnesium.

Efficacy and safety of low dose oral ketamine for controlling pain and distress during intravenous cannulation in children: a double-blind, randomized, placebo-controlled trial

Background

Ketamine is widely used in infants and young children for procedural sedation and anesthesia. The aim of this study was to evaluate the efficacy and safety of low dose oral ketamine to control pain and distress in children during intravenous (IV) cannulation.

Methods

This is a prospective, randomized, double-blind study, including children aged between 3 and 6 years requiring a non-emergent IV-line placement. Children were randomly assigned to two groups, treated either with oral ketamine or a placebo. All patients were monitored for vital signs. Pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wong-Baker Faces Pain Rating Scale (WBFS) scales and sedation using a 5-point sedation score. The facility of IV-line placement was measured by a 3-point scale. Adverse effects were recorded after 1 and 24 hours.

Results

A total of 79 and 81 children were entered in the ketamine and placebo groups, respectively. The heart and respiratory rates increased significantly in the placebo group. The median CHEOPS 4 (95% confidence interval [CI]: 3, 4, P < 0.001) and WBFS 6 (95% CI: 4, 6, P < 0.001) scores decreased statistically in the ketamine group. IV-line placement was 50% easier in the ketamine group (95% CI: 37%, 63%, P < 0.001). No serious adverse effects were observed in all cases.

Conclusions

Low dose oral ketamine effectively decreased the pain and distress during IV cannulation in children without any significant adverse reactions.

Procedural Sedation for Pediatric Upper Gastrointestinal Endoscopy in Korea

BACKGROUND

Sedative upper endoscopy is similar in pediatrics and adults, but it is characteristically more likely to lead to respiratory failure. Although recommended guidelines for pediatric procedural sedation are available within South Korea and internationally, Korean pediatric endoscopists use different drugs, either alone or in combination, in practice. Efforts are being made to minimize the risk of sedation while avoiding procedural challenges. The purpose of this study was to collect and analyze data on the sedation methods used by Korean pediatric endoscopists to help physicians perform pediatric sedative upper endoscopy (PSUE).

METHODS

The PSUE procedures performed in 15 Korean pediatric gastrointestinal endoscopic units within a year were analyzed. Drugs used for sedation were grouped according to the method of use, and the depth of sedation was evaluated based on the Ramsay scores. The procedures and their complications were also assessed.

RESULTS

In total, 734 patients who underwent PSUE were included. Sedation and monitoring were performed by an anesthesiologist at one of the institutions. The sedative procedures were performed by a pediatric endoscopist at the other 14 institutions. Regarding the number of assistants present during the procedures, 36.6% of procedures had one assistant, 38.8% had 2 assistants, and 24.5% had 3 assistants. The average age of the patients was 11.6 years old. Of the patients, 19.8% had underlying diseases, 10.0% were taking medications such as epilepsy drugs, and 1.0% had snoring or sleep apnea history. The average duration of the procedures was 5.2 minutes. The subjects were divided into 5 groups as follows: 1) midazolam + propofol + ketamine (M + P + K): n = 18, average dose of 0.03 + 2.4 + 0.5 mg/kg; 2) M + P: n = 206, average dose of 0.06 + 2.1 mg/kg; 3) M + K: n = 267, average dose of 0.09 + 0.69 mg/kg; 4) continuous P infusion for 20 minutes: n = 15, average dose of 6.6 mg/kg; 5) M: n = 228, average dose of 0.11 mg/kg. The average Ramsay score for the five groups was 3.7, with significant differences between the groups (P < 0.001). Regarding the adverse effects, desaturation and increased oxygen supply were most prevalent in the M + K group. Decreases and increases in blood pressure were most prevalent in the M + P + K group, and bag-mask ventilation was most used in the M + K group. There were no reported incidents of intubation or cardiopulmonary resuscitation. A decrease in oxygen saturation was observed in 37 of 734 patients, and it significantly increased in young patients (P = 0.001) and when ketamine was used (P = 0.014). Oxygen saturation was also correlated with dosage (P = 0.037). The use of ketamine (P < 0.001) and propofol (P < 0.001) were identified as factors affecting the Ramsay score in the logistic regression analysis.

CONCLUSION

Although the drug use by Korean pediatric endoscopists followed the recommended guidelines to an extent, it was apparent that they combined the drugs or reduced the doses depending on the patient characteristics to reduce the likelihood of respiratory failure. Inducing deep sedation facilitates comfort during the procedure, but it also leads to a higher risk of complications.

A comparison of ketamine-midazolam combination and propofol-fentanyl combination on procedure comfort and recovery process in pediatric colonoscopy procedures

Objective

To compare the efficacy and safety of midazolam-ketamine combination versus fentanyl-propofol combination in pediatric diagnostic colonoscopy.

Methods

This is a retrospective study of 68 children undergoing diagnostic gastroenterology with midazolam-ketamine combination (Group-K) or with fentanyl-propofol combination (Group-P) in the pediatric gastroentology department at a Turkish tertiary hospital between January 2015 and June 2017. An intravenous midazolam was administered one minute before ketamine administration in Group K. Intravenous fentanyl was given to Group P, followed by intravenous propofol.

Results

There were statistically no significant differences between the groups as for age, gender, weight, duration of colonoscopy and complications observed during procedure. Ramsay sedation score was significantly higher in Group K. Recovery time and the rate of complications during the recovery of Group-K (23 patients, 65.7%) was significantly higher than that of Group P (8 patients, 24.2%) (p= 0.001).

Conclusions

Colonoscopy procedures can be quite comfortable in children when using the midazolam-ketamine combination. However, adverse effects related to ketamine were observed during recovery.

Comparison of Ketamine and Propofol-Based Regimens for Deep Sedation in Children Undergoing Esophagogastroduodenoscopy

We retrospectively reviewed the charts of 180 children sedated for esophagogastroduodenoscopy (EGD) with ketamine or propofol-based regimens at our institution. Pre-EGD diagnoses and American Society of Anesthesiology physical status were similar in all subjects. Onset of action and recovery time for both regimens were not statistically significant (p > 0.05). Mean onset of sedation for all patients was 3.85 ± 3.04 minutes, mean Aldrete score was 6.31 ± 0.61, and mean recovery time was 51.85 ± 31.78 minutes (p > 0.05). Sedation-related adverse events observed include apnea, hypoxemia, bradycardia, hypotension, laryngospasm, skin rash, and wheezing. Deep sedation for pediatric EGD is safe if patients are carefully screened and properly monitored.

Dexamethasone Reduces Postoperative Nausea in Pediatric Upper Endoscopy With Deep Sedation: A Randomized Controlled Trial

OBJECTIVES

We aimed to evaluate the effect of a single dose of preoperative dexamethasone on postoperative nausea and vomiting (PONV), a frequent complication and a major cause of delayed recovery in pediatric upper gastrointestinal endoscopy (UGIE) under sedation.

METHODS

In this double-blind randomized controlled study, 98 children aged 2 to 14, with American Society of Anesthesiologists status I to II, and undergoing elective UGIE with deep sedation were included and randomly assigned to 2 groups. Preoperatively, after anesthesia induction with sodium thiopental and maintenance with sevoflurane, patients in the intervention (n = 49) and control (n = 49) groups, respectively received 0.1 mg/kg i.v. dexamethasone and 2 cm i.v. 0.9% saline. Postoperatively, PONV incidence was measured as the primary outcome.

RESULTS

PONV incidence was significantly less in dexamethasone group (8.2%) compared to the control group (26.5%) (difference = 18.3%, 95% confidence interval: 3.4%-33%, P = 0.016). For secondary outcomes, between-group differences were not statistically significant: incidence of bronchospasm or laryngospasm (both 4.1%, P = 1); emergence delirium assessed with Pediatric Anesthesia Emergence Delirium scale (5.9 ± 3.4 vs 5.7 ± 3.2, P = 0.751); Modified Aldrete score at 0 minutes (9.4 ± 0.8 vs 9.3 ± 0.9, P = 0.909) and at 5 minutes (9.5 ± 0.7 vs 9.4 ± 0.9, P = 0.527); and recovery time (21.1 ± 6.6 vs 23.4 ± 8.6 minutes, P = 0.130).

CONCLUSIONS

A single preoperative dose of i.v. dexamethasone reduces PONV in children undergoing elective UGIE with deep sedation, but has no significant effect on the patient recovery time or the incidence of postoperative bronchospasm or laryngospasm and emergence delirium.

The pearls of pediatric sedation: polish the old and embrace the new

Over the past decade, as the complexity and breadth of pediatric procedures increases, the actual choices of approved sedatives have remained relatively stagnant. Since the introduction of midazolam, there has not been a sedative approved for pediatric labelling until December 2018. This December, the European approval of ADV6209 (Ozalin) for pediatric usage marked the newest addition to the pediatric sedative armamentarium in over a decade. This review is timely and significant because it will provide a balanced evaluation of the most common sedatives in use today, the most recent sedative to be approved and, most importantly, a critical look at the literature supporting the latest approaches to the most commonly performed procedures.

Haloperidol-Induced Dystonia due to Sedation for Upper Gastrointestinal Endoscopy: A Pediatric Case Report

Dystonia is a movement disorder characterized by sustained muscle tone. Antipsychotic agents sometimes cause acute dystonia that can rapidly worsen within a few hours or days. Because healthy children rarely receive antipsychotic agents, it is unusual to see antipsychotic agent-induced dystonia in pediatric emergency departments. We report a rare case of a 12-year-old healthy boy who presented with acute dystonia after administration of haloperidol for sedation. He was suspected of laryngeal dystonia because stridor and desaturation were present. The symptoms disappeared with the administration of hydroxyzine. Rapid diagnosis was important in this case because laryngeal dystonia is a potential life-threatening complication due to upper airway obstruction. Considering the risk of side effects, doctors who are not accustomed to administering pediatric anesthesia should consult a pediatrician and/or an anesthesiologist prior to administration of anesthetics to pediatric patients.

Sedation in Pediatric Esophagogastroduodenoscopy

Pediatric esophagogastroduodenoscopy (EGD) has become an established diagnostic and therapeutic modality in pediatric gastroenterology. Effective sedation strategies have been adopted to improve patient tolerance during pediatric EGD. For children, safety is a fundamental consideration during this procedure as they are at a higher risk of severe adverse events from procedural sedation compared to adults. Therefore, a detailed risk evaluation is required prior to the procedure, and practitioners should be aware of the benefits and risks associated with sedation regimens during pediatric EGD. In addition, pediatric advanced life support by endoscopists or immediate intervention by anesthesiologists should be available in the event that severe adverse events occur during pediatric EGD.

Investigation of Efficacy of Lidocaine Spray for Sedated Esophagogastroduodenoscopy in Children

PURPOSE

Our aim in this study is to investigate efficacy of topical lidocaine spray for sedated esophagogastroduodenoscopy (EGD) in children.

METHODS

The endoscopy of children aged between 3-18 years who underwent EGD in our endoscopy unit. Intravenous (IV) midazolam and ketamine were used for sedation. Prior to sedation, endoscopy nurse applied topical lidocaine 10% with pump spray at 1 mg/kg dose in group 1, and distilled water via identically scaled pump spray in group 2, in a double blinded fashion.

RESULTS

Sedation was not applied in 24.1% of the cases in topical lidocaine spray group (LS group) and in 5.7% of the cases in distilled water spray group (DS group). Gag reflex was observed in 6.5% of cases in LS group and 33.3% of cases in DS group (p=0.024), increased oral secretion was observed in 9.3% of cases in LS group and 51.7% of cases in DS group (p=0.038), sore throat was observed in 3.7% of cases in LS group and 35.6% of cases in DS group (p=0.019) and the difference was statistically significant.

CONCLUSION

The study showed that topical pharyngeal lidocaine reduces both requirement and amount of IV sedation before EGD in children and sore throat, gag reflex and decreased oral secretion increase.

Efficacy and safety of midazolam and ketamine in paediatric upper endoscopy

BACKGROUND AND STUDY AIM

Upper endoscopy can be successfully carried out in children under deep sedation and anaesthesia. However, the best method of upper endoscopy for children who require gastrointestinal intervention has yet to be defined. The aim of this study is to investigate the efficacy and safety of the sedation induced by intravenous midazolam and ketamine during upper endoscopy in children.

PATIENTS AND METHODS

This study included patients ages 3-18years who had undergone upper endoscopy. All subjects received IV midazolam and ketamine. During the intervention, hypoxia, tachycardia, bradycardia, hypertension, and hypotension were recorded. After the intervention, euphoria, dysphoria, vertigo, visual problems (such as diplopia and nystagmus), and emergencies (such as arrhythmia, convulsion, and hallucination), among other findings, were recorded. Older children who were capable of expressing themselves were questioned to help determine these conditions.

RESULTS

The mean age of the study group was was 11.9±3.42years; 54% of the patients were females, and 46% were males. During the upper endoscopy, hypoxia occurred in 9% of patients, mild hypertension in 14%, hypotension in 5%, tachycardia in 23%, bradycardia in 8%, and flushing-urticaria in 2%. After the upper endoscopy, one of the most common complications was sore throat, which occurred in 24% of patients. Vomiting was observed in 14% of patients, dizziness in 24%, diplopia in 27%, euphoria in 3% (5 patients), dysphoria in 4%, and hallucination in 4%. Of the total patients, 4% required oxygen supply with a face mask.

CONCLUSION

The results of our study showed that the use of IV midazolam and ketamine during upper endoscopy in children was safe and effective.

A comparison of sedation with midazolam-ketamine versus propofol-fentanyl during endoscopy in children: a randomized trial

PURPOSE

We aimed to compare the efficacy and safety of midazolam plus ketamine versus fentanyl plus propofol combination administered to children undergoing upper gastrointestinal endoscopy (UGE) and to determine the most appropriate sedation protocol.

MATERIALS AND METHODS

This prospective, randomized, single-blind study included patients between the ages of 4 and 17 years who underwent UGE for diagnostic purposes. Patients were divided randomly into groups A (midazolam-ketamine combination, n=119) and B (fentanyl plus propofol combination, n=119). The effectiveness of the sedation and complications during the procedure and recovery period were recorded.

RESULTS

The processes started without an additional dose of the drug for 118 patients (99.1%) in group A and for 101 patients (84.8%) in group B (P=0.001). The average dose of ketamine administered to the patients in group A was 1.03±0.15 mg/kg and the average dose of propofol administered to the patients in group B was 1.46±0.55 mg/kg. None of the patients stopped the endoscopic procedure in group A, but one patient (0.8%) had to discontinue the endoscopic procedure in group B. 27 patients in group A (22.7%) and 41 patients (34.5%) in group B developed complications during the procedure (P=0.044). The rate of complications during the recovery of group A (110 patients, 92.4%) was significantly higher than that in group B (48 patients, 40.3%) (P=0.001).

CONCLUSION

In children, UGE procedures can be quite comfortable when using the midazolam-ketamine combination. However, adverse effects related to ketamine were observed during recovery.

Sedative and Analgesic Effects of Propofol-Fentanyl Versus Propofol-Ketamine During Endoscopic Retrograde Cholangiopancreatography: A Double-Blind Randomized Clinical Trial

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is a painful procedure that requires analgesia and sedation.

Objectives

In this study, we compared the analgesic and sedative effects of propofol-ketamine versus propofol-fentanyl in patients undergoing ERCP.

Methods

In this clinical trial, 72 patients, aged 30 - 70 years old, who were candidates for ERCP were randomly divided into two groups. Before the start of ERCP, both groups received midazolam 0.5 - 1 mg. The intervention group (PK) received ketamine 0.5 mg/kg, and the control group (PF) received fentanyl 50 - 100 micrograms. All patients received propofol 0.5 mg/kg in a loading dose followed by 75 mcg/kg/minute in an infusion. The patients, the anesthesiologist, and the endoscopist were unaware of the medication regimen. Sedation and analgesia quality (based on a VAS), blood pressure, respiratory rate, heart rate, arterial oxygen saturation, recovery time (based on Aldrete scores), and endoscopist and patient satisfation were recorded.

Results

The sedative effects were equal in the two groups (P > 0.05), but the analgesic effects were higher in the PF group than in the PK group (P < 0.05). The PK group had higher blood pressure levels in the eighth minute. Respiratory rate, heart rate, and arterial oxygen saturation showed no significant differences between the groups (P > 0.05). Endoscopist satisfaction, patient satisfaction, and recovery time showed no significant differences between the two groups (P > 0.05).

Conclusions

The results showed that the sedative effect of propofol-ketamine was equal to the propofol-fentanyl combination during ERCP. To prevent respiratory and hemodynamic complications during ERCP, the propofol-ketamine combination should be used in patients with underlying disease.

Sedation and Monitoring in the Pediatric Patient during Gastrointestinal Endoscopy

Sedation is a fundamental component of pediatric gastrointestinal procedures. The 2 main types of sedation for pediatric endoscopy remain general anesthesia and procedural sedation. Although anesthesiologist-administered sedation protocols are more common, there is no ideal regimen for endoscopy in children. This article discusses specific levels of sedation for endoscopy as well as various regimens that can be used to achieve each. Risks and considerations that may be specific to performing gastrointestinal procedures in children are reviewed. Finally, potential future directions for sedation and monitoring that may change the practice of pediatric gastroenterology and ultimately patient outcomes are examined.

Efficacy and Safety of Low Dose Ketamine and Midazolam Combination for Diagnostic Upper Gastrointestinal Endoscopy in Children

PURPOSE

We aimed to analyze the effectiveness and safety of low-dose midazolam and ketamine combination for upper gastrointestinal endoscopy (UGIE) in children.

METHODS

The study included the children (n=425, 10.78±3.81 years) who underwent UGIE for diagnostic purpose during 1 year period. All children were sedated with low dose midazolam (0.1 mg/kg) and ketamine (0.5 mg/kg) intravenously. Effectiveness of the sedation and complications during the procedure and recovery period were recorded.

RESULTS

Endoscopic procedure was successfully completed in 414 patients (97.4%; 95% confidence interval, 95.8-98.9). Mean±standard deviation (SD) duration of procedure was 6.36±1.64 minutes (median, 6.0 minutes; range, 4-12 minutes). Minor complications occurred during the procedure in 39.2% of the patients. The most common complication was increased oral secretion (33.1%). No major complications were observed in any patient. Age and Ramsay sedation scores of patients with complications during the procedure were lower than the others (9.49±4.05 years vs. 11.61±3.43 years, p=0.002 and 2.10±1.46 vs. 4.37±1.16, p=0.001). Mean recovery time was 22 minutes (range, 10-90 minutes; mean±SD, 25±12.32 minutes). Minor complications developed during recovery in 60.1% of the patients. The most common complication was transient double vision (n=127, 30.7%). Emergence reaction was observed in 5 patients (1.2%).

CONCLUSION

The procedure was completed with high level of success without any major complication in our study. Combination of low-dose midazolam and ketamine is a suitable sedation protocol for pediatric endoscopists in UGIE.

Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists

AIM

To present evidence and formulate recommendations for sedation in pediatric gastrointestinal (GI) endoscopy by non-anesthesiologists.

METHODS

The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords "endoscopy, GI", "endoscopy, digestive system" AND "sedation", "conscious sedation", "moderate sedation", "deep sedation" and "hypnotics and sedatives" for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for (upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed.

RESULTS

From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented.

CONCLUSION

General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations.

Sedation for pediatric endoscopy

It is more difficult to achieve cooperation when conducting endoscopy in pediatric patients than adults. As a result, the sedation for a comfortable procedure is more important in pediatric patients. The sedation, however, often involves risks and side effects, and their prediction and prevention should be sought in advance. Physicians should familiarize themselves to the relevant guidelines in order to make appropriate decisions and actions regarding the preparation of the sedation, patient monitoring during endoscopy, patient recovery, and hospital discharge. Furthermore, they have to understand the characteristics of the pediatric patients and different types of endoscopy. The purpose of this article is to discuss the details of sedation in pediatric endoscopy.

Does haloperidol prophylaxis reduce ketamine-induced emergence delirium in children?

OBJECTIVES

Ketamine is a non-barbiturate agent with rapid action onset that induces profound sedation; however, some emergency physicians tend not to use ketamine because of the risk of emergence delirium (ED). This study aimed to evaluate the effectiveness of haloperidol prophylaxis in postoperative ketamine delirium in children.

METHODS

Prospective data relating to any emergence dreams, delirium, hallucinations, agitation, crying, altered perceptions, and necessary interventions were recorded in consecutive cases of ketamine delirium in patients attending Mansoura University Hospital, Egypt, from June 2010 to May 2011.

RESULTS

A total of 537 records were available for analysis. Of those, 267 received prophylactic haloperidol (49.7%). There were significant differences between the two groups regarding post-anaesthetic care unit behaviour. The ketamine-haloperidol groups included more patients who were sleepy, calm (P ≤0.01) and less irritable (P ≤0.01), with a lower incidence of crying (P ≤0.01) and disorientation (P ≤0.01).

CONCLUSION

We found that preoperative administration of haloperidol decreases the incidence of postoperative delirium in a sample of Egyptian children undergoing minor surgery. This is congruent with earlier work conducted in adults. This work carries great hope to decrease and even prevent ED in hospitalised, non-surgical patients.