Colonoscopy under general anesthesia in children

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopists and Endoscopists in Training: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric endoscopy requires reliable performance of procedures by competent individual providers who consistently uphold all standards determined to assure optimal patient outcomes. Establishing consensus expectations for ongoing monitoring and assessment of individual pediatric endoscopists is a method for confirming the highest possible quality of care for such procedures worldwide. We aim to provide guidance to define and measure quality of endoscopic care for children.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopists. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 6 standards that all providers who perform pediatric endoscopy should uphold and 2 standards for pediatric endoscopists in training, with 7 corresponding indicators that can be used to identify high-quality endoscopists. Additionally, these can inform continuous quality improvement at the provider level. Minimum targets for defining high-quality pediatric ileocolonoscopy were set for 2 key indicators: cecal intubation rate (≥90%) and terminal ileal intubation rate (≥85%).

DISCUSSION

It is recommended that all individual providers performing or training to perform pediatric endoscopy initiate and engage with these international endoscopist-related standards and indicators developed by PEnQuIN.

Procedural anesthesia and sedation for children undergoing diagnostic and medical procedures - A review of postprocedural pain, nausea, and vomiting by questionnaire-based survey

BACKGROUND

Sedation and anesthesia are widely used to relieve pain and ensure cooperation during elective diagnostic and medical procedures in the pediatric population. However, there is currently limited evidence about the recovery trajectory following deep sedation or general anesthesia for such procedures in children.

AIMS

The primary aim was to describe the severity and duration of pain, nausea, and vomiting after common diagnostic and medical procedures. Secondary outcomes include return to baseline functioning and incidence of medical re-presentation.

METHODS

Recruitment was achieved postprocedurally by telephone interview with parents or legal guardians of patients who underwent botox injection, bronchoscopy, either or both a colonoscopy or upper gastrointestinal endoscopy, or MRI scan. Daily pain scores, nausea and vomiting, administration of at-home analgesia, and any adverse events requiring medical attention were obtained. Children were followed until pain completely resolved and baseline activity resumed.

RESULTS

A total of 307 patients were included (50 botox injection, bronchoscopy and MRI; 48 colonoscopy, 58 upper gastrointestinal endoscopy, 51 colonoscopy plus upper gastrointestinal endoscopy). Parental-rated pain scores peaked on day of procedure across all groups and decreased over time, with most children resuming normal activity within 1 day postprocedure. Pain was mostly mild and resolved quickly in botox injection (10% moderate to severe and 22% mild), bronchoscopy (8% and 10%, respectively), and MRI (2% mild) patients. Combined upper gastrointestinal endoscopy and colonoscopy was associated with greatest pain severity (29% moderate to severe and 20% mild). Highest rates of nausea and/or vomiting were observed in colonoscopy (23%), upper gastrointestinal endoscopy (28%), and combined procedure groups (20%). At-home simple analgesia was administered in 21% of patients. Unplanned medical re-presentations were infrequent across all groups.

CONCLUSION

This study demonstrates that the recovery trajectory following procedural sedation and anesthesia is short, with minimal requirement for additional medical attention. These findings will aid in alleviating parental anxiety and encourage utilization of regular simple analgesia.

Additional Intestinal Mucosal Biopsy Sampling for Research Is Safe During Pediatric Endoscopic Procedures

Advancing the understanding of inflammatory bowel disease (IBD) pathogenesis has been facilitated by mechanistic studies that require human intestinal tissue. Enrolling pediatric subjects into these studies improves our knowledge of IBD in this underserved population. Given the additional research protections granted to children, institutional review boards (IRBs) must weigh the benefit of obtaining research biopsies against perceived risks. Although obtaining clinical biopsies from children is generally considered safe, there are only limited data on the safety of obtaining research biopsies in children.^1-6.

Training and Assessment in Pediatric Endoscopy

A key aspect of pediatric gastroenterology practice is the ability to perform endoscopy procedures safely, effectively, and efficiently. Similar to adult endoscopy, performance of pediatric endoscopy requires the acquisition of related technical, cognitive, and integrative competencies to effectively diagnose and manage gastrointestinal disorders in children. However, the distinctive requirements of pediatric patients and their families and the differential spectrum of disease highlight the need for a pediatric-specific training curriculum and assessment framework to ensure endoscopic procedures are performed safely and successfully in children. This review outlines the current state of evidence as it pertains to pediatric endoscopy training and assessment.

Assessment of competence in pediatric gastrointestinal endoscopy

Gastrointestinal endoscopy is an invaluable tool for the diagnosis and treatment of upper and lower gastrointestinal diseases in children. Pediatric and adult endoscopy differ in several respects including differences in procedural indications, sedation practices, pre-procedure preparation, equipment, and the importance of routine tissue sampling and terminal ileum intubation. In the same way that performance of endoscopy in children requires pediatric-specific training, assessment of pediatric endoscopists requires an approach that is tailored to pediatric practice and the use of assessment methods and measures that have been developed and validated specifically within the pediatric context.

Schmerzbehandlung

Zwar lassen sich die meisten abdominalen Schmerzen lokalisieren, allerdings ist der Ort des stärksten Schmerzes nicht unbedingt identisch mit dem Ort der Schmerzentstehung. Dennoch empfiehlt sich zur Schmerzlokalisation ein systematisches Vorgehen, das – je nach klinischer Erfahrung des Untersuchers und der Akutheit des Geschehens – selbstverständlich auch abgekürzt werden kann: Zunächst wird davon ausgegangen, dass Schmerzlokalisation und Ort der Schmerzentstehung identisch sind. Es sind entsprechende gezielte Untersuchungsmaßnahmen einzuleiten (klinische Untersuchung, klinisch-chemische Diagnostik, Bildgebung). Ab dem Schulalter kann die angegebene Schmerzqualität wertvolle Hinweise auf die Schmerzursache geben. Ergeben sich keine Hinweise auf die zugrunde liegende (lokale) Schmerzursache, wird der Blick mehr auf diejenigen inneren Organe gerichtet, die über die Head- Zonen mit dem Ort der Schmerzlokalisation korrespondieren. Wird man auch hier nicht fündig, muss an eine Läsion im Verlauf der Afferenz gedacht werden. Übrig bleiben schließlich idiopathische Schmerzen, bei denen der Schmerz selbst die Krankheit darstellt und keine zu behandelnden Ursachen aufzufinden sind (Migräne, funktionelle Bauchschmerzen etc.). Davon abzugrenzen sind noch definierte kinderpsychiatrische Krankheiten, die mit Schmerzen einhergehen können.

[Inhaled anesthesia through a device for noninvasive continuous positive airway pressure ventilation for upper digestive endoscopy in pediatric patients]

OBJECTIVE

The demand for sedation for pediatric diagnostic procedures performed outside operating rooms has increased considerably, but the ideal method to choose has been the subject of debate. The aim of this study was to assess the efficacy of using a device for continuous positive airway pressure, connected to a Mapleson D circuit and a nasopharyngeal tube as the interface, in order to ventilate and administer sevoflurane for upper digestive tract endoscopy in children.

MATERIAL AND METHODS

Prospective cohort study of children undergoing upper digestive tract endoscopy. We recorded epidemiologic variables, heart rate, mean arterial pressure, arterial oxygen saturation and procedure-related adverse events before, during and 10 minutes after the procedure. Time spent in the recovery room was also recorded. The endoscopist asked the patients about their level of satisfaction and whether they had noticed any irritating smell or gas smell.

RESULTS

Data was collected on 29 patients (17 boys, 12 girls) with a mean (SD) age of 4.2 (3.9) years. The mean duration of endoscopy was 15 (7) minutes. Arterial oxygen saturation below 92% during the procedure did not occur and the endoscopic exploration was completed satisfactorily with this technique in 28 patients (96%). All were discharged from the recovery room within 30 minutes. The endoscopist reported that the technique was considered satisfactory in all cases, although 2 children noted an anesthetic "gas" smell.

CONCLUSIONS

A modified Mapleson D circuit and nasopharyngeal tube can be used effectively as an interface for noninvasive ventilation and administration of sevoflurane during upper digestive endoscopy in pediatric patients.

Colonoscopy in Hong Kong Chinese children

AIM: To investigate the safety and diagnostic yield of colonoscopy in Chinese children in whom the procedure is not often done.

METHODS: We conducted a retrospective review of all colonoscopies in consecutive children who underwent their first diagnostic colonoscopy from Jan 2003 to 2008.

RESULTS: Seventy-nine children (48 boys, 31 girls; mean age 9.2 ± 4.2 years) were identified and reviewed with a total of 82 colonoscopies performed. Successful caecal and ileal intubation rates were 97.6% and 75.6% respectively. Forty patients (50.6%) had a positive diagnosis made in colonoscopy and that included colonic polyps (23), Crohn’s disease (12), ulcerative colitis (1), and miscellaneous causes (4). 80% of polyps were in the rectosigmoid colon. All but one were juvenile hamartomatous polyps. The exception was an adenomatous polyp. The mean ages for children with inflammatory bowel disease (IBD) and polyps were 11.3 and 4.3 years respectively. There was no procedure-related complication.

CONCLUSION: Colonoscopy is a safe procedure in our Chinese children. The increasing diagnosis of IBD in recent decades may reflect a rising incidence of the disease in our children.

Randomised controlled trial of paediatric magnetic positioning device assisted colonoscopy: a pilot and feasibility study

BACKGROUND AND AIMS

Complete colonoscopy is critical for the evaluation of many paediatric gastrointestinal diseases. The aim of the study was to investigate the feasibility of magnetic positioning device for paediatric colonoscopy and to compare completion rate and procedure time with and without the device.

METHODS

Prospective randomised controlled trial of standard colonoscopy compared to magnetic positioning device assisted colonoscopy in children and adolescents ages 7-20 years was performed.

RESULTS

Analysis showed that the proportion of successfully completed colonoscopies were 19/20 (95%) in the MP arm versus 17/18 (94.4%) in the SC arm, p=NS. The median time to complete colonoscopy to the cecum was 16.5 min (range 6-52 min) in the MP arm and 12 min (range 6-33 min) in the SC arm, p=NS.

CONCLUSIONS

Our preliminary data suggest that the use of magnetic positioning device for colonoscopy is feasible in paediatric patients. These data suggest that the use of magnetic positioning device may not be of benefit for experienced endoscopists who achieved very high colonoscopy completion rates without the MP device. Further studies are needed to determine its role in paediatric colonoscopy since this device may be of more benefit for physicians in training.

Determination of the pharmacodynamic interaction of propofol and dexmedetomidine during esophagogastroduodenoscopy in children

OBJECTIVES

Propofol is a sedative-hypnotic drug commonly used to anesthetize children undergoing esophagogastroduodenoscopy (EGD). Dexmedetomidine is a highly selective alpha-2 adrenergic receptor agonist that has been utilized in combination with propofol to provide anesthesia. There is currently no information regarding the effect of intravenous dexmedetomidine on the propofol plasma concentration-response relationship during EGD in children. This study aimed to investigate the pharmacodynamic interaction of propofol and dexmedetomidine when used in combination for children undergoing EGD.

METHODS

A total of 24 children undergoing EGD, ages 3-10 years, were enrolled in this study. Twelve children received dexmedetomidine 1 microg x kg(-1) given over 10 min as well as a continuous infusion of propofol delivered by a computer-assisted target-controlled infusion (TCI) system with target plasma concentrations ranging from 2.8 to 4.0 microg x ml(-1) (DEX group). Another group of 12 children undergoing EGD also received propofol administered by TCI targeting comparable plasma concentrations without dexmedetomidine (control group). We used logistic regression to predict plasma propofol concentrations at which 50% of the patients exhibited minimal response to stimuli (EC50 for anesthesia).

RESULTS

The EC50 +/- SE values in the control and DEX groups were 3.7 +/- 0.4 microg x ml(-1) and 3.5 +/- 0.2 microg x ml(-1), respectively. There was no significant shift in the propofol concentration-response curve in the presence of dexmedetomidine.

CONCLUSION

The EC50 of propofol required to produce adequate anesthesia for EGD in children was unaffected by a concomitant infusion of dexmedetomidine 1 microg x kg(-1) given over 10 min.

Colonic manometry catheter placement with primary fluoroscopic guidance

The purpose of this paper is to describe our experience with a new technique of colonic manometry catheter placement using fluoroscopic guidance. Between 2000 and 2004, 44 colonic manometry catheters were placed with primary fluoroscopic guidance in 38 patients (25 males; median age, 7 years; range, 0.4-31 years) with severe defecation disorders. Fourteen colonoscopic placements were reviewed to compare the different procedures. Manometry catheters were inserted through the rectum (16 patients), cecostomy (9), ileostomy (2), and colostomy (17). Placements through diverted colons were successful in 24 of 28 (86%). Insertion through the rectum was successful in 10 of 16 (63%) fluoroscopic-guided placements vs. 12 of 14 (86%) colonoscopic placements (P=0.23). Significantly longer fluoroscopic exposure was required for fluoroscopic compared to colonoscopic placement (P=0.004). In conclusion, placement of colonic manometry catheters with primary fluoroscopic guidance is feasible in children. An important disadvantage of the fluoroscopic methodology is the prolonged fluoroscopic exposure time.

Patient-reported symptoms after pediatric outpatient colonoscopy or flexible sigmoidoscopy under general anesthesia

OBJECTIVES

Endoscopic examination of the colon is indicated in children with diarrhea, hematochezia and suspected inflammatory bowel disease. The aim of this study was to determine the rate of patient-reported symptoms after colonoscopy and flexible sigmoidoscopy under general anesthesia in children.

PATIENTS AND METHODS

This prospective study included patients 18 years of age and younger who underwent colonoscopy or flexible sigmoidoscopy during a 1-year period. At least 30 days after the endoscopy, an interview was conducted regarding symptoms after colonoscopy or flexible sigmoidoscopy.

RESULTS

Eighty-eight children were eligible, and 68 (77%) were available for follow-up. Ten (15%) reported symptoms after their endoscopy. The most common symptoms reported were diarrhea, excessive gas and sore throat. The frequency of reported symptoms was similar between colonoscopy and flexible sigmoidoscopy. The frequency of symptoms was not affected by intubation of terminal ileum, polypectomy or the number of prior colonoscopies or flexible sigmoidoscopies.

CONCLUSIONS

Outpatient colonoscopy and flexible sigmoidoscopy under general anesthesia are well tolerated by children. A minority of children reports mild symptoms that spontaneously resolve.

Inflammatory bowel disease in children and adolescents: recommendations for diagnosis--the Porto criteria

Ulcerative colitis and Crohn disease may present before the age of 20 years in 25% to 30% of all patients with inflammatory bowel disease. Reported incidence figures vary considerably depending on the collection of data. Multicenter, multinational collaboration is needed when studying pediatric inflammatory bowel disease. The essential first step is uniformity in the work-up and criteria used for diagnosis. The Porto diagnostic criteria presented here provide the tool that is needed. These criteria are the result of consensus reached by the ESPGHAN inflammatory bowel disease working group. Diagnosis of Crohn disease, ulcerative colitis and indeterminate colitis is based on clinical signs and symptoms, endoscopy and histology and radiology. Every child suspected of inflammatory bowel disease should undergo a complete diagnostic program consisting of colonoscopy with ileal intubation, upper gastrointestinal endoscopy and (in all cases except in definite ulcerative colitis) radiologic contrast imaging of the small bowel. Multiple biopsies from all segments of the gastrointestinal tract are needed for a complete histologic evaluation. A diagnosis of indeterminate colitis cannot be made unless a full diagnostic program has been performed.

Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy

BACKGROUND

This study tested the hypothesis that, for colonoscopy, analgesia/sedation with remifentanil and propofol might be more effective compared with anesthesia by intravenous administration of midazolam, fentanyl, and propofol.

METHODS

In a prospective, randomized trial, 100 adult patients received either conscious analgesia/sedation (Sedation group) or total intravenous anesthesia (TIVA group). Analgesia/sedation was achieved by infusion of remifentanil (0.20 to 0.25 microg/kg/min) and propofol in titrated doses. TIVA was induced by intravenous administration of fentanyl (2 microg/kg), midazolam (0.05 mg/kg) and propofol (dosage titrated). Cardiorespiratory parameters and bispectral index were monitored and recorded. The quality of the analgesia was assessed with a Numerical Pain Rating Scale (NRS); recovery level and return of psychomotor efficiency were evaluated with, respectively, the Aldrete scale and a Modified Post Anesthesia Discharge Scoring (MPADS) system.

RESULTS

Both groups of 50 patients were comparable with respect to demographic data, initial parameters, and duration of colonoscopy. All patients in the TIVA group found the colonoscopy painless (NRS score 0). In the Sedation group, the average pain intensity score was 0.4 (0.8). There was a marked difference between the Sedation and TIVA groups with respect to the time from the end of the procedure until the maximum MPADS score was reached: respectively, -6.9 (4.0) versus 25.7 (8.4) minutes (p < 0.001). In the TIVA group, changes in mean arterial pressure and heart rate and signs of respiratory depression were significant (p < 0.05).

CONCLUSIONS

Combined administration of remifentanil and propofol for colonoscopy provides sufficient analgesia, satisfactory hemodynamic stability, minor respiratory depression, and rapid recovery, and allows patients to be discharged approximately 15 minutes after the procedure.

Etiopathogenesis of inflammatory bowel disease: the importance of the pediatric perspective

Inflammatory bowel disease (IBD) is now recognized as a common chronic disease affecting children and adolescents. This article will review recent advances made in the fields of genetics, epidemiology, gut ecology, and immunology regarding the etiopathogenesis of IBD, with particular emphasis on the contributions made by pediatric studies. Areas where further study of the pediatric age group would be beneficial will be highlighted.

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.

Ketamine sedation for pediatric gastroenterology procedures

BACKGROUND

Although the dissociative sedative ketamine is used commonly for pediatric procedural sedation in other settings, the safety of this agent in pediatric gastroenterology is not well-studied. A 5-year experience with ketamine sedation for pediatric gastroenterology procedures was reviewed to document the safety profile of this agent and to identify predictors of laryngospasm during esophagogastroduodenoscopy (EGD).

METHODS

The study was a retrospective consecutive case series of children receiving ketamine administered by pediatric gastroenterologists skilled in basic airway management to facilitate pediatric gastrointestinal procedures during a 5-year period. Patient's records were reviewed to determine indication, dosage, adverse effects, drugs, inadequate sedation, and recovery time for each sedation. A multiple logistic regression analysis was performed to identify predictors of laryngospasm during EGD. Outcome measures were descriptive features of sedation, including adverse effects and predictors of laryngospasm during EGD.

RESULTS

During the study period pediatric gastroenterologists administered ketamine 636 times, primarily for EGD (86%) and primarily by the intravenous route (98%). The median loading dose and total dose were 1.00 mg/kg and 1.34 mg/kg, respectively. Inadequate sedation was noted in seven (1.1%) procedures. Adverse effects included transient laryngospasm (8.2%), emesis (4.1%), recovery agitation (2.4%), partial airway obstruction (1.3%), apnea and respiratory depression (0.5%), and excessive salivation (0.3%). There were no adverse outcomes attributable to ketamine. Nearly half (46%) the subjects had severe underlying illness (American Society of Anesthesiologists (ASA] class > or =3). All instances of laryngospasm occurred during EGD (9.5% incidence), and the only independent predictor of laryngospasm in this sample was decreasing age. The incidence of laryngospasm was 13.9% in preschool-aged (< or =6 years) children and was 3.6% in school-aged (>6 years) children (difference 10.3%, 95% confidence intervals 5.5-14.9%). No dose relationship was noted with laryngospasm, and the risk did not increase with underlying illness.

CONCLUSION

Pediatric gastroenterologists skilled in ketamine administration and basic airway management can effectively administer this drug to facilitate gastrointestinal procedures. Transient laryngospasm occurred in 9.5% of children receiving ketamine for EGD, and its incidence was greater in preschool than in school-aged children.

Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy

BACKGROUND

Sevoflurane is an inhaled anesthetic agent with ideal properties for achieving deep sedation during pediatric outpatient gastrointestinal endoscopy. This is a comparison of experience with this gas and other sedation methods used in the authors' hospital.

METHODS

Retrospective chart review and statistical analysis of data from children receiving inhaled sevoflurane administered by an anesthesiologist through laryngeal insufflation, intravenous propofol, or intravenous midazolam-fentanyl-ketamine in any combination to achieve deep sedation for outpatient gastrointestinal endoscopy. Anesthesia was administered in a dedicated procedure room. The intravenous drugs were administered by pediatric intensivists in the intensive care unit. The same endoscopist performed all the procedures.

RESULTS

A total of 248 procedures were reviewed (midazolam-fentanyl-ketamine 67, propofol 114, and sevoflurane 67). All patients were adequately sedated with sevoflurane, and no intravenous access was required. Time (in minutes) to awakening (midazolam-fentanyl-ketamine 47.15, propofol 36.12, sevoflurane 5.70), discharge (midazolam-fentanyl-ketamine 141.99, propofol 91.20, sevoflurane 53.34), and total time, including induction and procedure (midazolam-fentanyl-ketamine 163.97, propofol 119.40, sevoflurane 73.93), were significantly lower for sevoflurane (P < 0.01). The complication rate for sevoflurane (4.5%) was lower (P < 0.05) than for midazolam-fentanyl-ketamine (13.4%) and for propofol (17.5%). Charges for room use and medications were also lower for sevoflurane (P < 0.01). The total charges for sedation (U.S.$) were comparable for sevoflurane (688.10) and propofol (723.08) but were higher for midazolam-fentanyl-ketamine (855.10, P < 0.01).

CONCLUSIONS

Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy is as safe as conventional sedation techniques, potentially less expensive, increases endoscopy unit productivity, and eliminates the inconvenience associated with obtaining intravenous access in children.

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.