Section Editor(s): Finkel, Yigael MD, PhD; Molleston, Jean MD; Alonso, Estella MD; Oliva-Hemker, Maria MD
Although gastrointestinal endoscopy is widely accepted as fundamental to the diagnosis and treatment of digestive disorders in children (1), considerable controversy and practice differences persist with respect to the methods and agents used to achieve optimal endoscopic sedation. These discrepancies have spawned a lively debate in the pediatric gastroenterology community. In an effort to craft reasonable sedation guidelines for children undergoing endoscopic evaluation, gastroenterologists need to consider several factors: the anesthetic/analgesic agents used, the approach to drug administration and monitoring (ie, endoscopist- vs anesthesiologist-delivered), and the clinical history and status of the patient. In addition, the final anesthetic decision often depends not only on physician training and experience but also on individual institutional policies. Regrettably, practice differences have had an impact the payment (or nonpayment) for anesthesia services by insurers, who have often sought to limit reimbursement for pediatric sedation. Clearly, children are not “little adults,” and use of safe sedation techniques must be based on many factors, including patient age, diagnosis, clinical condition, anxiety level, willingness to cooperate with the endoscopist, and previous sedation experience. Ultimately, practitioners must be allowed to use the sedation approach that is best indicated for their patient.
Intravenous sedation and analgesia for adult and pediatric patients undergoing gastrointestinal endoscopy procedures represent standard practice in the United States. Definitions of sedation levels have been published by the American Society of Anesthesiologists, and include the following (2):
* Moderate sedation/analgesia (conscious sedation): a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
* Deep sedation/analgesia: a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully to repeated or painful stimulation. The ability to maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
* General anesthesia: a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to maintain independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
Because adults, excluding older adult patients and those with debilitating conditions, generally tolerate upper and lower gastrointestinal endoscopy well, moderate conscious sedation may be used successfully in the majority of cases. Although many children can safely and effectively undergo endoscopy with the use of similar techniques, a large number frequently require a level of anesthesia that ranges from deep sedation (often using a nasal “trumpet” or laryngeal airway) to general anesthesia with endotracheal intubation. Adequate sedation must be used to ensure that patients remain motionless during the procedure and experience minimal levels of distress and discomfort (3,4).
Important physiological differences between pediatric and adult patients may increase the risks of sedation-induced hypoventilation in children (5). In cases of anatomic variations, including obligate nasal breathing in infants younger than 5 months of age, occlusion of the upper airway by the relatively larger tongue and tonsillar/adenoidal hypertrophy (maximum proportions at ages 5–7 years) may increase the likelihood of airway occlusion, especially under intravenous sedation. Considering these diverse factors, pediatric endoscopies, compared with similar procedures in adults, regularly require different anesthetic techniques, increased procedural time, additional personnel, and more intensive monitoring (6). Furthermore, time required to complete preprocedural education and achieve reassurance of an anxious child (and his or her often anxious parents) will typically far exceed that required in the adult endoscopic setting.
In pediatric and adult gastroenterology, significant differences in sedation protocols exist among institutions and even within the same institution (3). In addition to criteria based on patient age, anxiety level, clinical condition, and institutional guidelines, use of a specific anesthetic agent(s) may depend on endoscopist training and preference and the procedure being conducted.
Standard intravenous sedation regimens delivered by pediatric gastroenterologists most often use benzodiazepines (eg, diazepam, midazolam) with or without added narcotic analgesics (eg, meperidine, fentanyl). Retrospective data from a large tertiary children's hospital confirmed the efficacy and safety of this approach; however, the investigators also reported a significant incidence (approximately 20%) of non–life-threatening side effects (7). Indeed, another report, again from a tertiary children's facility, suggests that non–anesthesiologist-administered sedation may fail to achieve the desired level of anesthesia (ranging from conscious to deep sedation) in a significant number of children undergoing a variety of procedures (8). With this approach to conscious sedation, another center reported that 20% of children retained some recall of esophagogastroduodenoscopies, hence heightening the levels of anxiety and aversion to subsequent procedures (9). Not infrequently, higher doses of these agents are required in children who are unable to cooperate to attain the desired sedative effect. Often, when higher doses are administered, deep sedation occurs, which may increase the likelihood of untoward side effects (10,11).
The use of deep sedation and general anesthesia has increased in pediatric patients undergoing endoscopic procedures. In particular, propofol has achieved wide acceptance in many practice sites in the United States and abroad. Interestingly, some centers have begun to use an anaesthesiologist-interventional approach exclusively during pediatric endoscopies that entails solely propofol-induced deep sedation and/or general anesthesia (6,12). Although published reports suggest that propofol may be safely administered by non-anesthesiologists, this mode of drug delivery has been associated with a small but significant risk of potentially severe complications (13). In fact, the American Society of Anesthesiologists and the American Association of Nurse Anesthetists issued a joint communication in April 2004, stating:
“Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these general or surgical procedures. This restriction is concordant with specific language in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.”
Regardless of the mode of sedation, the depth of sedation required during pediatric endoscopy demands that patients be adequately monitored before, during, and after the procedure. Monitoring of pulse oximetry and hemodynamics is essential. Because available data suggest that a significant proportion of children undergoing endoscopy under conscious sedation manifest oxygen desaturation and/or arrhythmias (11), we also advocate routine supplemental oxygen administration and cardiac monitoring. If sedation is not supervised by an anesthesiologist or certified anesthetist, then at least 1 health care provider trained in pediatric advanced life support, in addition to the endoscopist, should be present throughout the procedure.
At this time, we continue to recommend that all plans regarding sedation type and depth for pediatric endoscopy to be made solely by physicians performing the procedures. The determination of which type of sedation to use must also conform to institutional policies, regardless of whether these procedures are conducted in a dedicated endoscopy facility, an ambulatory surgical unit, or a multispecialty pediatric sedation center. In the opening paragraph, we repeated the oft-stated dictum that children are not merely little adults. In the same way, pediatricians are not merely “little internists,” and pediatric gastroenterologists are not “little adult gastroenterologists.” Even considering the similarities with our adult gastrointestinal colleagues with respect to endoscopic indications and techniques, approaches to safe and effective sedation will frequently diverge. The establishment of guidelines for administration of sedation/anesthesia during pediatric gastrointestinal endoscopy should result from a collaborative effort between the pediatric gastroenterology and anesthesiology communities, and must not be determined by the imposition of payor mandates. Future research should focus on developing an evidence-based foundation for best sedation practices. Most important, in the continuing discussion about sedation for pediatric endoscopy, we must consider holding the safety and comfort of our patients paramount.
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