Sedation for Pediatric Endoscopy

Pediatric patients are less cooperative than adult patients when they undergo endoscopy, and their parents also experience more anxiety with regard to the procedure. Furthermore, the satisfaction of the patients and their parents has recently emphasized. Even though the sedation in pediatric patients is one of the most important factors of endoscopy, there are not many hospitals that use standardized guidelines such as those published by the American Academy of Pediatrics (AAP) and American Society of Anesthesiologists (ASA). This article discusses the details of sedation for pediatric endoscopy, including the purposes of sedation, levels of sedation, medical history of the patients, physical examination, preparation before the procedure, selection of medication, patient monitoring, patient recovery, and discharge decision based on the above-mentioned guidelines.

The following purposes of sedation are addressed by the AAP [1]. (1) Guarantee the patient's safety and welfare; (2) reduce physical pain; (3) minimize anxiety and maximize the potential for amnesia; (4) control patient's movement for the safe procedure; (5) discharge the patient safely. The level of sedation, monitoring, type of sedative agents, and their dosage are determined based on the patient's status, age, purpose, type of procedure, and opinion of the patient or their caregivers/parents.

There have been various terminologies to describe the levels of sedation. The AAP and ASA classify it into four categories which are minimal sedation, moderate sedation, deep sedation, and general anesthesia [1, 2]. During minimal sedation, cognitive function and coordination may be impaired, and patients respond normally to verbal commands. During moderate sedation, patients respond purposefully to verbal commands whereas their consciousness is depressed. During deep sedation, patients have also depressed level of consciousness whereas they respond purposefully to repeated or painful stimulation. During general anesthesia, patients are not arousable, even by painful stimulation. Ventilatory and cardiovascular functions are usually maintained during minimal or moderate sedation. But ventilatory function may be impaired during deep sedation, and often impaired during general anesthesia. During general anesthesia, cardiovascular function may be impaired.

In esophagogastroduodenoscopy (EGD), gagging and poor cooperation can be problem. The use of a local spray or oral medication before the insertion of the intravenous line prevents gagging and increases the cooperation of patients for EGD, which leads to the improvement of tolerance and satisfaction in pediatric patients [3, 4]. In colonoscopy, the visceral pain associated with looping should be avoided.

The effect of sedation appears differently depending on the age of the pediatric patients [5, 6]. Infants who are younger than 6 months of age may have little anxiety and may be easily affected by the sedation. However, patients, who are 6 months of age or older, have already developed stranger anxiety and they may require their parents to remain next to them during the induction. For school-age children, it is surprisingly difficult to sedate them as they have developed concrete thinking. As a result, it is recommended to carefully discuss what to expect during the procedure in order to decrease their anxiety level. Adolescents may be cooperative before the procedure, but they may also exhibit disinhibition and strong anxiety with initial doses of sedatives.

A thorough assessment of the patient's physical condition should be conducted regarding the suitability for sedation before the endoscopy. Physicians are recommended to use the ASA classification of the patient's physical status in order to determine the appropriate level of sedation (Table 1) [1, 7]. For example, patients without underlying disease fall under the ASA class 1, while those with controlled asthma fall under the ASA class 2. The asthma patients with clear signs of wheezing fall under the ASA class 3, and those with status asthmaticus fall under the ASA class 4. The patients who have severe myocardiopathy and are candidates for heart transplant are classified into the ASA class 5.

Table 1
American Society of Anesthesiologists (ASA) Classification of Patient's Physical Status

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Moreover, the airway of the patients should be assessed before the endoscopy. The use of a grading system, such as the modified Mallampati score, is helpful in the assessment of risk factors pertaining to airway difficulty (Table 2) [8].

Table 2
Modified Mallampati Score for Airway Assessment

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The pediatric patients, who are candidates for elective endoscopy, should follow the preoperative fasting guideline before undergoing general anesthesia (Table 3) [2]. A routine and necessary medication is allowed to be taken with a little amount of water. For emergent endoscopy, the risk of non-fasting and necessity of the procedure should be considered altogether.

Table 3
Appropriate Intake of Food and Liquids before Elective Sedation

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The medications that are commonly used for the sedation of pediatric patients are summarized in Table 4 [6, 9, 10].

Table 4
Recommendations for Dosages of Drugs Commonly Used for Intravenous Sedation for Pediatric Gastrointestinal Procedures

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In the past, cyanosis was observed with naked eyes to monitor the patient's breathing. Recently, the pulse oximetry has become a widely used device, and it has contributed greatly to the reduction of endoscopy complication rate. The pulse oximetry, however, has limitations. It shows lots of artifact, which prompts the staff to frequently check both the pulse oximetry and the patients. Furthermore, because oximetry presents oxygenation, not ventilation, it takes a longer time to become desaturated after the ventilation has been stopped [34]. As a result, a capnography device is recommended in order to detect the end-expiratory carbon dioxide level. The level of carbon dioxide from the mouth and nose is collected through the catheter of the capnography device and it is converted into a real-time graph. Using capnography in the pediatric endoscopy setting may reveal the occurrence of abnormal ventilation with unexpected higher rates during the procedures done on children [35].

In order to monitor the cardiovascular system of the patients, blood pressure measurement and electrocardiography can be used. Blood pressure measurement is recommended every 5 minutes after the initial measurement at the beginning of the procedure, while electrocardiography is recommended to be used for all deep sedation or moderate sedation in patients with significant cardiovascular diseases [2].

The patients should stay in the recovery room of the hospital equipped with oxygen administration, airway management, appropriate monitoring, and emergency treatment until they are suitable for discharge. Physicians can use the ASA guideline [2] (Table 5) or scaling system, such as the Modified Aldrete score (Table 6) [36]. The modified Aldrete score of at least 9 out of 10 means patient readiness for discharge [37].

Table 5
Guideline for Discharge after Sedation

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Table 6
The Modified Aldrete Scoring System

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Sedation during endoscopy is now considered to be more important; however, successful sedation is hard to achieve in pediatric patients. For a successful and safe sedation, physicians and all staff members should be sufficiently trained and educated, following the standardized guideline from preparation of sedation to discharge.