Key points

Introduction

The role of endoscopy in the diagnosis and treatment of digestive diseases of childhood has grown steadily over the past 40 years. In turn, the need to identify best practices for sedating children undergoing GI procedures has intensified. Generally speaking, the provision of sedation for endoscopy is considered necessary if children are to remain safe, comfortable, and cooperative. Nevertheless, no single sedative or combined sedation regimen has yet been established as ideal for pediatric GI procedures.

Over the past 10 years, a considerable change in the landscape of sedation practices has occurred, with more and more pediatric endoscopy performed in the presence of anesthesiology providers. Although a 2005 survey of members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition suggested wide practice variation in types of sedation at that time, more recent data suggest that anesthesiologist-administered sedation, specifically with propofol, is becoming the more common experience. In turn, it is becoming imperative that anesthesiologists gain knowledge about various pediatric endoscopic procedures as well as evolving evidence for best sedation practices. At the same time, it remains incumbent on endoscopists who perform procedures in children to be knowledgeable about sedation as well as to maintain familiarity with its various educational curricula and guidelines.

Generally speaking, most procedural sedation for pediatric endoscopy involves intravenous (IV) medications and ideally maintains a child’s ability to breathe spontaneously with intact protective airway reflexes. Procedural sedation for pediatric endoscopy may be administered by an anesthesiologist or by an endoscopist in the absence of an anesthesiologist. When an anesthesiologist is involved, it may be acceptable to aim for deep levels of sedation that may verge into general anesthesia. In the absence of an anesthesiologist, it is important that endoscopists are familiar with regimens effective at achieving moderate sedation and know how to rescue patients should the level of sedation become deeper than expected.

Given that many children undergoing stressful and uncomfortable procedures may be agitated, it is becoming more common to plan for deep levels of sedation for pediatric patients undergoing diagnostic endoscopy. Another primary option for endoscopic sedation in children is general anesthesia with inhalational anesthetics, often in combination with IV agents. Broadly speaking, sedation plans that call for general anesthesia with endotracheal intubation are not necessary for routine pediatric endoscopic procedures. Instead, protocols that seek to achieve general anesthetic sedation levels necessitating endotracheal intubation can be reserved for therapeutic cases as well as endoscopy in very young or medically complex patients.

One important factor driving changes in sedation practices for pediatric endoscopy may be the need to identify means of improving efficiency. In addition, there is increasing pressure to reduce costs. To this end, using anesthesiologists, especially in operating room settings, for brief procedures that do not require patients to be fully immobile may involve excessive use of health care resources. Although only 10% of respondents in 2005 reported using general anesthesia for all procedures, a full third reported mostly performing procedures with general anesthesia in hospital operating rooms. Another third of respondents reported performing more than three-quarters of their procedures with anesthesiologist-administered propofol in a dedicated endoscopy facility, outside of main operating rooms. Today, the performance of pediatric endoscopy outside of the main operating room has become standard practice.

Patient safety should and does remain paramount. In this regard, it has become clear that the use of procedural sedation to achieve all levels of consciousness (moderate, deep, and general anesthesia) represents the most common risk factor for endoscopy complications. Complications due to sedation, regardless of who has administered it, have been consistently documented to occur more commonly during pediatric endoscopy than technical complications related to procedures, such as bleeding or perforation. As such, the intersection between performance of GI procedures in children, efficiency, costs, patient safety, and sedation has remained a topic of great interest among pediatric gastroenterologists for the past 4 decades. It is also gaining interest in the world of anesthesiologists, who are increasingly recognizing that best approaches for sedating children for pediatric endoscopy may be quite different from those of other pediatric procedures as well as from sedation of adults for GI procedures.

In short, all endoscopists, whether or not they work with anesthesiologists, should understand the myriad implications of sedation choices inherent to performing GI procedures in children. Those endoscopists who work with anesthesiologists, including pediatric gastroenterologists who do this exclusively, should also have a working knowledge of approaches that anesthesiologists may use to achieve procedural sedation. Box 1 lists several patient risk factors for complications during procedural sedation and anesthesia that should be discussed by endoscopists working with anesthesiologists to perform sedated endoscopy in children.

This article reviews a broad clinical experience with traditional and newer sedatives for pediatric GI endoscopy, with a focus on benefits, limitations, and pitfalls of various regimens. Both traditional and innovative sedative regimens are discussed as well as opportunities for minimizing patient risk while optimizing procedural efficiency. The importance of engaging in a dialogue with pediatric anesthesiologists, who are increasingly called on to gain familiarity with best practices for sedating children to undergo pediatric endoscopy, is also emphasized.

Introduction

The role of endoscopy in the diagnosis and treatment of digestive diseases of childhood has grown steadily over the past 40 years. In turn, the need to identify best practices for sedating children undergoing GI procedures has intensified. Generally speaking, the provision of sedation for endoscopy is considered necessary if children are to remain safe, comfortable, and cooperative. Nevertheless, no single sedative or combined sedation regimen has yet been established as ideal for pediatric GI procedures.

Over the past 10 years, a considerable change in the landscape of sedation practices has occurred, with more and more pediatric endoscopy performed in the presence of anesthesiology providers. Although a 2005 survey of members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition suggested wide practice variation in types of sedation at that time, more recent data suggest that anesthesiologist-administered sedation, specifically with propofol, is becoming the more common experience. In turn, it is becoming imperative that anesthesiologists gain knowledge about various pediatric endoscopic procedures as well as evolving evidence for best sedation practices. At the same time, it remains incumbent on endoscopists who perform procedures in children to be knowledgeable about sedation as well as to maintain familiarity with its various educational curricula and guidelines.

Generally speaking, most procedural sedation for pediatric endoscopy involves intravenous (IV) medications and ideally maintains a child’s ability to breathe spontaneously with intact protective airway reflexes. Procedural sedation for pediatric endoscopy may be administered by an anesthesiologist or by an endoscopist in the absence of an anesthesiologist. When an anesthesiologist is involved, it may be acceptable to aim for deep levels of sedation that may verge into general anesthesia. In the absence of an anesthesiologist, it is important that endoscopists are familiar with regimens effective at achieving moderate sedation and know how to rescue patients should the level of sedation become deeper than expected.

Given that many children undergoing stressful and uncomfortable procedures may be agitated, it is becoming more common to plan for deep levels of sedation for pediatric patients undergoing diagnostic endoscopy. Another primary option for endoscopic sedation in children is general anesthesia with inhalational anesthetics, often in combination with IV agents. Broadly speaking, sedation plans that call for general anesthesia with endotracheal intubation are not necessary for routine pediatric endoscopic procedures. Instead, protocols that seek to achieve general anesthetic sedation levels necessitating endotracheal intubation can be reserved for therapeutic cases as well as endoscopy in very young or medically complex patients.

One important factor driving changes in sedation practices for pediatric endoscopy may be the need to identify means of improving efficiency. In addition, there is increasing pressure to reduce costs. To this end, using anesthesiologists, especially in operating room settings, for brief procedures that do not require patients to be fully immobile may involve excessive use of health care resources. Although only 10% of respondents in 2005 reported using general anesthesia for all procedures, a full third reported mostly performing procedures with general anesthesia in hospital operating rooms. Another third of respondents reported performing more than three-quarters of their procedures with anesthesiologist-administered propofol in a dedicated endoscopy facility, outside of main operating rooms. Today, the performance of pediatric endoscopy outside of the main operating room has become standard practice.

Patient safety should and does remain paramount. In this regard, it has become clear that the use of procedural sedation to achieve all levels of consciousness (moderate, deep, and general anesthesia) represents the most common risk factor for endoscopy complications. Complications due to sedation, regardless of who has administered it, have been consistently documented to occur more commonly during pediatric endoscopy than technical complications related to procedures, such as bleeding or perforation. As such, the intersection between performance of GI procedures in children, efficiency, costs, patient safety, and sedation has remained a topic of great interest among pediatric gastroenterologists for the past 4 decades. It is also gaining interest in the world of anesthesiologists, who are increasingly recognizing that best approaches for sedating children for pediatric endoscopy may be quite different from those of other pediatric procedures as well as from sedation of adults for GI procedures.

In short, all endoscopists, whether or not they work with anesthesiologists, should understand the myriad implications of sedation choices inherent to performing GI procedures in children. Those endoscopists who work with anesthesiologists, including pediatric gastroenterologists who do this exclusively, should also have a working knowledge of approaches that anesthesiologists may use to achieve procedural sedation. Box 1 lists several patient risk factors for complications during procedural sedation and anesthesia that should be discussed by endoscopists working with anesthesiologists to perform sedated endoscopy in children.

This article reviews a broad clinical experience with traditional and newer sedatives for pediatric GI endoscopy, with a focus on benefits, limitations, and pitfalls of various regimens. Both traditional and innovative sedative regimens are discussed as well as opportunities for minimizing patient risk while optimizing procedural efficiency. The importance of engaging in a dialogue with pediatric anesthesiologists, who are increasingly called on to gain familiarity with best practices for sedating children to undergo pediatric endoscopy, is also emphasized.

Goals and levels of sedation for pediatric gastrointestinal procedures

The primary purpose of sedation for children undergoing upper and lower endoscopies is to perform procedures safely, with a minimal amount of emotional and physical discomfort. Secondary and often desirable goals of sedation are to affect periprocedural amnesia, maximize procedural efficiency, minimize recovery times, and maintain cost effectiveness. Although some GI procedures may be preferentially performed without sedation, almost all require some sedative regimen to ensure patient cooperation. Historically, gastroenterologists have measured sedation success using several different benchmarks ( Box 2 ). To objectively compare regimens, it may be preferable to use independent observers and standardized scales.

In terms of the levels of sedation that can be achieved, there are 4 that have been defined to stretch along a continuum without clear boundaries: minimal, moderate, deep, and general anesthesia. These levels are defined by a patient’s response to verbal, light tactile, or painful stimuli and are generally also associated with physiologic changes in patient vital signs. Minimal sedation implies the retention of a patient’s ability to respond voluntarily to vocal commands (eg, “take a deep breath” or “turn on your back”) and to maintain a patent airway with protective reflexes. Moderate sedation describes a depth of sedation at which patients are able to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function, protective airway reflexes, and the ability to react to verbal or tactile stimulation. Deep sedation implies a medically controlled state of depressed consciousness from which a patient is not easily aroused but may respond purposefully to painful stimulation. General anesthesia describes the deepest level of sedation where a patient is unconscious, with reduced responses to stimuli and with an airway that may require support.

Optimal levels of sedation may vary depending on the procedure. In upper endoscopy, a major goal of sedation may be to avoid gagging and increase patient cooperation; in colonoscopy, the goal of sedation is often to avoid visceral pain associated with looping. Child anxiety levels may also vary for different procedures and may be mediated by other practice choices. For upper endoscopy, both premedication with topical sprays and premedication with oral sedatives prior to IV line insertion have been shown to independently improve pediatric patient tolerance and satisfaction.

Generally speaking, depth of sedation is directly related to cardiovascular stability; the deeper the level of sedation, the more a patient is considered at risk for cardiopulmonary events ( Fig. 1 ). During all sedated GI procedures, even those conducted with anesthesiologist assistance, pediatric endoscopists must be exquisitely familiar with the fine line between achieving adequate light sedation and creating the potential for a child to become deeply sedated. For instance, deep sedation may develop in lightly sedated patients due to delayed drug absorption or a secondary decrease in painful stimuli common to procedures (eg, after successful navigation of the hepatic flexure during pediatric colonoscopy).

Commonly used terms to describe sedation, their relationship to the continuum of sedation levels, and their relationship to potential adverse events.

Over the past decade, it has become standard to work with an anesthesiologist to achieve deep sedation verging into general anesthesia. To some extent, this is the most reliable level of sedation to plan for in children to assure tolerance of the procedure without signs of distress that may include vocalization and disruptive movements. Many endoscopists who previously may have performed procedures with endoscopist-administered moderate sedation, and who have had experience with children struggling throughout procedures, have recognized the benefits of being assured that a child is deeply sedated for the procedure. In turn, there has been a strong movement toward increased use of anesthesiologist-administered sedation in pediatric endoscopy.

Unsedated procedures

Recently, unsedated transnasal endoscopy has been investigated as a safe and effective means of monitoring the esophageal mucosa of pediatric patients with eosinophilic esophagitis. In such procedures, very-small-diameter (ie, 2.8–4 mm) scopes are used in the office, with a reported high patient satisfaction score. Further studies are needed to determine whether such protocols are generalizable to other centers but hold promise that certain pediatric endoscopic procedures someday may be performed without sedation.

In the meantime, it is true that it remains possible to perform standard upper and lower endoscopic procedures in infants and small children without sedation, especially if they are restrained. The routine use of this method is not recommended and may be considered unethical when there are safe forms of IV sedation or general anesthesia available. In turn, the practice of performing endoscopic procedures in children without sedation seems to be falling out of favor with most contemporary pediatric GI practitioners, especially as greater access to anesthesiologists has become standard in the majority of endoscopy units worldwide.

Patient risk stratification and airway assessment

Sedation for pediatric GI procedures should be tailored to a patient’s physical status, in accordance with guidelines from the American Society of Anesthesiologists ( Table 1 ). Taking into account a patient’s age and developmental status when choosing a sedation regimen may also improve procedural success. Data suggest that the smallest and youngest pediatric patients with the highest American Society of Anesthesiologists classifications are at greatest risk for complications during GI procedures.

Table 1

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