Safety of intravenous midazolam and fentanyl for pediatric GI endoscopy: prospective study of 1578 endoscopies

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.

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.

Evaluation of the sedative effect of sublingual lorazepam versus placebo in patients underwent endoscopy: a double-blind, randomized controlled clinical trial

Background

Digestive endoscopy (DE) is uncomfortable for most patients. Lorazepam is a potent benzodiazepine with anxiolytic and sedative effects.

Objective

This study aims to determine the sedative effect of sublingual lorazepam versus placebo as a premedication in patients who underwent DE.

Design

This is a mono-center, double-blind, and randomized controlled trial.

Methods

A lorazepam sublingual tablet was made by researchers and physical tests were done on it, then the double-blind placebo-controlled trial was done to investigate the efficacy of 2 mg sublingually administered lorazepam as a premedication for endoscopy. Lorazepam or a placebo tablet was administered sublingually 30 min before the endoscopy. The patients, nurses, and physicians were blinded to the patient group. The depth of sedation was evaluated according to the American Society of Anesthesiology.

Results

In all, 116 patients were randomly assigned to take either lorazepam (n = 58) or a placebo (n = 58). The results of physical properties tests were acceptable according to United States Pharmacopeia. There were no statistical differences between groups regarding age and gender. In the lorazepam group, 75.8% of patients showed mild sedation, and 24.2% of patients showed no sedation. All of the patients in the placebo had no sedation (p = 0.001). Time of procedure (p < 0.001), intraoperative O2 saturation (p < 0.001), intraoperative heart rate (p < 0.001), and intraoperative blood pressure (p < 0.001) were significantly lower in the lorazepam group. No significant or dangerous side effects were observed except a bit of giddiness and dizziness.

Conclusion

The results of this study showed that prescription of sublingual lorazepam 25-30 min before endoscopy provided mild sedation.

Registration

IRCT201611039014N130 (05/11/2016); https://en.irct.ir/trial/9568.

Post-Discharge Effects and Parents' Opinions of Intranasal Fentanyl with Oral Midazolam Sedation in Pediatric Dental Patients: A Cross-Sectional Study

The aim of this study was to evaluate the post-discharge effects of oral midazolam with intranasal fentanyl sedation in pediatric patients who had dental treatment and to evaluate parents' preference regarding sedation visits.

METHODS

A total of 32 uncooperative healthy pediatric patients aged 3-6 years old who met the inclusion criteria were included. In the first visit, one group received oral midazolam (0.7 mg/kg) with intranasal fentanyl (1 μg/kg) sedation (M/F) and the other group received oral midazolam with intranasal placebo (M), and in the second visit each group received the other type of sedation in a cross-over type. In this cross-sectional study, a post-discharge phone-call questionnaire was carried out 24 h after both sedation visits with the parents to evaluate the children's behavior, function, balance, eating pattern, sleeping pattern, vomiting incidents, and any possible side effects, as well as parents' satisfaction and preference. The Wilcoxon signed-rank test was used to analyze the categorical variables, and the Chi-square test was performed to analyze the parents' preference.

RESULT

A total of 32 parents responded to the phone-call questionnaire after 64 sedation visits. All of them were mothers. There was no statistically significant difference between the two groups with respect to recovery to normal function and balance, behavior, incidents of fever, vomiting, sleep disturbance, oversleeping, and adverse behavioral changes (p > 0.05). Children required a significantly longer amount of time until the first meal after M/F sedation (p = 0.04). No significant difference was found between parents' preferences regarding the sedation visits (p > 0.05).

CONCLUSION

Intranasal fentanyl added to oral midazolam sedation could have an effect on post-discharge adverse behavioral changes, prolonged sleeping, and prolonged recovery time. Children sedated with midazolam/fentanyl required a longer amount of time until the first meal. Vomiting and fever occurred similarly in both sedation regimens with a low incidence. There was no difference in parents' preferences regarding the two sedation regimens.

Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy

Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined. Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events. Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices. Results: 258 healthy children [2-21 years (median 15, (Q1-Q3 = 10-17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time. Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.

Non-anesthetist-administered moderate sedation with midazolam and fentanyl for outpatient MRI-aided hybrid intracavitary and interstitial brachytherapy in cervix cancer: a single-institution experience

Purpose

The aim of the study was to determine the feasibility of interstitial brachytherapy under non-anesthetist-administered moderate sedation, to identify factors influencing the insertion, and the total procedural time.

Material and methods

A total of 47 insertions with hybrid intracavitary and interstitial applicators were performed in 23 patients from March 2017 to March 2020. Moderate sedation was achieved with intravenous midazolam and fentanyl administered by non-anesthetist. Insertion time and procedural time was recorded. Univariate and multivariate analysis were performed to evaluate the impact of different factors on insertion and procedural time.

Results

A total of 238 needles (range, 2-8 per insertion) were implanted, with an average insertion depth of 30 mm (range, 20-40 mm). The mean doses for midazolam and fentanyl were 3 mg (standard deviation [SD] = 1) and 53.3 mcg (SD = 23.9) per insertion, respectively. The median insertion time was 30 minutes (interquartile range [IQR] = 22-40), and the median total procedural time was 4.3 hours (IQR = 3.6-5.2). First time insertion, insertions performed before 2019, and higher midazolam dose were associated with significantly longer insertion time, whereas longer insertion time, MRI-based planning, and insertions performed before 2019 were associated with significantly longer total procedural time.

Conclusions

Outpatient interstitial brachytherapy with non-anesthetist-administered sedation is achievable and well-tolerated. This method may significantly lessen the burden on hospital resources and has the potential to be cost-effective.

Oral Lorazepam is not Superior to Placebo for Lowering Stress in Children Before Digestive Endoscopy: A Double-Blind, Randomized, Controlled Trial

BACKGROUND

Digestive endoscopies must be performed within a safe and comfortable environment. We have previously shown that the quality of intravenous sedation is influenced by preoperative stress.

AIM

Our primary objective was to compare the effects of oral lorazepam and placebo on the salivary cortisol response of children undergoing a digestive endoscopy. Secondary objectives were the assessment of procedural pain and comfort as well as the occurrence of adverse events.

METHODS

Participants were randomized and received either lorazepam, placebo, or no premedication. Saliva was collected upon arrival at the hospital and 1 h following randomization. The sedation protocol included midazolam and fentanyl ± ketamine. Procedural pain was evaluated with the Nurse Assessed Patient Comfort Score (NAPCOMS). Patients completed a postoperative questionnaire. The primary outcome was defined as the proportion of children having a cortisol decrease ≥ 15 nmol/L.

RESULTS

101 participants (54 females) were included. The rate of children having a cortisol decrease ≥ 15 nmol/L was 27.3%, 35.3%, and 19.4% for lorazepam, placebo, and no premedication, respectively (p = 0.356). The median (IQR) NAPCOMS pain score was 3.0 (0-6) for lorazepam, 4.4 (0-6) for placebo, and 3.4 (3-4) for no premedication (p = 0.428). With lorazepam, 75.9% of children reported experiencing a comfortable procedure, compared with 41.9% taking placebo and 34.5% with no premedication (p = 0.013). Transient tachycardia was the most frequent intraoperative adverse event, particularly with lorazepam (62.5%, p = 0.029).

CONCLUSIONS

Oral lorazepam had no effect on patients' preoperative stress, as measured by salivary cortisol, but was associated with a higher rate of comfortable procedures.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, Identifier NCT03180632.

Administration order of midazolam/fentanyl for moderate dental sedation

Background

The purpose of this study is to investigate the effects of administration order when a sedative drug (midazolam) and an opioid analgesic drug (fentanyl) is applied for moderate intravenous (IV) sedation in dentistry.

Methods

A retrospective chart review was conducted in one dental clinic during its transition from a midazolam-first to a fentanyl-first protocol for dental procedures requiring moderate IV sedation. Physiological parameters, drug administration times, patient recovery times, drug dosages, and patient recall and satisfaction were investigated for differences.

Results

A total of 76 charts (40 midazolam-first and 36 fentanyl-first administrations), were used in the analysis. Administering midazolam first resulted in an average 4.38 min (52%) decrease in administration times (P < 0.001), and a decrease in procedural recollection immediately following the procedure (P = 0.03), and 24 to 48 hours later (P = 0.009). Administering fentanyl first required an average of 2.43 mg (29%) less midazolam (P < 0.001). No significant differences were found for change in vital signs, minimum oxygen saturation levels, recovery times, and patient satisfaction (P > 0.05). Oxygen saturation levels did not drop below 90% for either group; however, 5 cases in the fentanyl-first group fell to between 90% and 92%, compared with 0 cases in the midazolam-first group.

Conclusions

The administration order of fentanyl and midazolam may have different effects on patients and the sedation procedure. Findings from this study should be used to facilitate discussion among dental practitioners and to guide additional research investigating this topic.

Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers

Understanding the pharmacologic options for pediatric sedation outside the operating room will allow practitioners to formulate an ideal anesthetic plan, allaying anxiety and achieving optimal immobilization while ensuring rapid and efficient recovery. The authors identified relevant medical literature by searching PubMed, MEDLINE, Embase, Scopus, Web of Science, and Google Scholar databases for English language publications covering a period from 1984 to 2017. Search terms included pediatric anesthesia, pediatric sedation, non-operating room sedation, sedation safety, and pharmacology. As a narrative review of common sedation/anesthesia options, the authors elected to focus on studies, reviews, and case reports that show clinical relevance to modern day sedation/anesthesia practice. A variety of pharmacologic agents are available for sedation/anesthesia in pediatrics, including midazolam, fentanyl, ketamine, dexmedetomidine, etomidate, and propofol. Dosing ranges reported are a combination of what is discussed in the reviewed literature and text books along with personal recommendations based on our own practice. Several reports reveal that ketofol (a combination of ketamine and propofol) is quite popular for short, painful procedures. Fospropofol is a newer-generation propofol that may confer advantages over regular propofol. Remimazolam combines the pharmacologic effects of remifentanil and midazolam. A variety of etomidate derivatives such as methoxycarbonyl-etomidate, carboetomidate, methoxycarbonyl-carboetomidate, and cyclopropyl-methoxycarbonyl metomidate are in development stages. The use of nitrous oxide as a mild sedative, analgesic, and amnestic agent is gaining popularity, especially in the ambulatory setting. Utilizing a dedicated and experienced team to provide sedation enhances safety. Furthermore, limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans.

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.

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.

Comparison of the effects of ketamine and fentanyl-midazolam-medetomidine for sedation of rhesus macaques (Macaca mulatta)

Background

This study assessed the effects of sedation using a combination of fentanyl, midazolam and medetomidine in comparison to ketamine. Rhesus Macaques (Macaca mulatta), (n = 16, 5 males and 3 females randomly allocated to each treatment group) received either ketamine (KET) (10 mg.kg⁻¹) or fentanyl-midazolam-medetomidine (FMM) (10 μg/kg⁻¹; 0.5 mg.kg⁻¹; 20 μg.kg⁻¹) both IM. Oxygen (100 %) was provided by mask and heart rate, blood pressure, respiratory rate, EtCO₂ and depth of sedation were assessed every 5 min for 20 min. After the last time point, FMM monkeys were reversed with atipamezole-naloxone (0.2 mg.kg⁻¹; 10 μg.kg⁻¹). Recovery was scored using clinical scoring scheme. Differences in physiological parameters and quality of sedation were compared using Area Under the Curve (AUC) method and either Mann-Witney or t-student tests.

Results

Heart rate (beats/min) (Ket = 119 ± 18; FMM = 89 ± 17; p = 0.0066), systolic blood pressure (mmHg) (Ket = 109 ± 10; FMM = 97 ± 10; p = 0.0313), and respiratory rate (breaths/min) (Ket = 39 ± 9; FMM = 29 ± 10; p = 0.0416) were significantly lower in the FMM group. End-tidal CO₂ (mmHg) did not differ between the groups (KET = 33 ± 8; FMM = 42 ± 11; p = 0.0462)_. Although some depression of physiological parameters was seen with FMM, the variables all remained within the normal ranges in both groups. Onset of a sufficient degree of sedation for safe handling was more rapid with ketamine (KET = 2.9 ± 1.4 min; FMM = 7.9 ± 1.2 min; p = 0.0009), but FMM recovery was faster (KET = 21.4 ± 13.4 min; FMM = 9.1 ± 3.6 min; p = 0.0379) and of better quality (KET = 1.3 ± 0.9; FMM = 7.4 ± 1.9; p = 0.0009) most probably because of the effectiveness of the reversal agents used.

Conclusion

FMM provides an easily reversible immobilization with a rapid and good recovery quality and may prove a useful alternative to ketamine.

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.

Prevalence of Chronic Gastritis or Helicobacter pylori Infection in Adolescent Sleeve Gastrectomy Patients Does Not Correlate with Symptoms or Surgical Outcomes

BACKGROUND

In adults undergoing gastric bypass surgery, it is routine practice to perform pre-operative testing for Helicobacter pylori infection. Evidence suggests that infection impairs anastomotic healing and contributes to complications. There currently are no data for adolescents undergoing bariatric procedures. Despite few patients with pre-operative symptoms, we noted occasional patients with H. pylori detected after sleeve gastrectomy. We reviewed our experience with our adolescent sleeve gastrectomy cohort to determine the prevalence of H. pylori infection, its predictive factors, and association with outcomes. We hypothesized that H. pylori infection would be associated with pre-operative symptoms, but not surgical outcomes.

METHODS

All patients undergoing sleeve gastrectomy at our hospital were included. We conducted a chart review to determine pre- or post-operative symptoms of gastroesophageal reflux disease GERD or gastritis, operative complications, and long-term anti-reflux therapy after surgery. Pathology reports were reviewed for evidence of gastritis and H. pylori infection.

RESULTS

78 adolescents had laparoscopic sleeve gastrectomy from January 2010 through July 2014. The prevalence of chronic gastritis was 44.9% (35/78) and 11.4% of those patients had H. pylori (4/35). Only one patient with H. pylori had pre-operative symptoms, and only 25.7% (9/35) of patients with pathology-proven gastritis had symptoms. One staple line leak occurred but this patient did not have H. pylori or gastritis. Mean patient follow-up was 10 (3-26) mos.

CONCLUSIONS

There is a moderate prevalence of gastritis among adolescents undergoing sleeve gastrectomy, but only a small number of these patients had H. pylori infection. Neither the presence of chronic gastritis nor H. pylori infection correlated with symptoms or outcomes. Thus, in the absence of predictive symptomology or adverse outcome in those who are infected, we advocate for continued routine pathologic evaluation without the required need for pre-operative determination unless or until H. pylori infection is associated with adverse surgical outcomes.

A prospective randomized controlled trial of two different sedation sequences for third molar removal in adults

PURPOSE

In oral and maxillofacial outpatient surgery, sedation techniques are an important component in patient management for a wide variety of surgical procedures. Fentanyl and midazolam are commonly used sedatives with different mechanisms of action and specific analgesic or amnestic properties. This study examined whether the order of their administration would affect a patient's pain perception or procedural vital signs.

MATERIALS AND METHODS

After institutional review board approval and written informed consent, a prospective, randomized, parallel-group clinical trial was conducted in patients who planned to undergo removal of at least 2 third molars under intravenous moderate sedation. Patients were randomly assigned to 1 of 2 groups. The fentanyl-first group received fentanyl and then midazolam; the midazolam-first group received midazolam and then fentanyl. Recollection of the intraoperative pain score was assessed 24 hours after surgery using the Wong-Baker FACES pain scale. The Mann-Whitney U test was used to assess for the presence of a statistically significant difference between the 2 groups. Statistically significant differences in procedural vital sign fluctuations were examined using the t test. Patients' satisfaction with the procedure was assessed and intergroup comparisons were made.

RESULTS

Sixty-six patients were enrolled, 1 of whom did not complete the study. Recollected procedural pain scores at 24 hours after surgery were not statistically different between groups. Median scores on the Wong-Baker FACES pain scale for the 2 groups were 2.0 (interquartile range, 3.1) for the fentanyl-first group and 1.5 (interquartile range, 2.5) for the midazolam-first group (P = .333). There was no statistical difference in the change in vital signs from baseline to 2 surgical end points in the 2 groups. In addition, patient satisfaction with the procedure did not statistically differ between the 2 groups.

CONCLUSIONS

In this study, selective sequencing of midazolam or fentanyl during an intravenous moderate-sedation procedure did not result in a measurable difference of recollected procedural pain scores at 24 hours after third molar extraction. The choice of the sedation agents and the order of their administration should be tailored to the patient's needs, type of surgical procedure, and surgeon preference.

Adverse events related to gastrointestinal endoscopic procedures in pediatric patients under anesthesia care and a predictive risk model (AEGEP Study)

BACKGROUND

Multiple studies have analyzed perioperative factors related to adverse events (AEs) in children who require gastrointestinal endoscopic procedures (GEP) in settings where deep sedation is the preferred anesthetic technique over general anesthesia (GA) but not for the opposite case.

METHODS

We reviewed our anesthesia institutional database, seeking children less than 12 years who underwent GEP over a 5-year period. A logistic regression was used to determine significant associations between preoperative conditions, characteristics of the procedure, airway management, anesthetic approaches and the presence of serious and non-serious AEs.

RESULTS

GA was preferred over deep sedation [77.8% vs. 22.2% in 2178 GEP under anesthesia care (n=1742)]. We found 96 AEs reported in 77 patients, including hypoxemia (1.82%), bronchospasm (1.14%) and laryngospasm (0.91%) as the most frequent. There were 2 cases of severe bradycardia related to laryngospasm/hypoxemia and a case of aspiration resulting in unplanned hospitalization, but there were no cases of intra- or postoperative deaths. Final predictive model for perioperative AEs included age <1 year, upper respiratory tract infections (URTI) <1 week prior to the procedure and low weight for the age (LWA) as independent risk factors and ventilation by facial mask as a protector against these events (p<0.05).

CONCLUSIONS

AEs are infrequent and severe ones are remote in a setting where AG is preferred over deep sedation. Ventilatory AEs are the most frequent and depend on biometrical and comorbid conditions more than anesthetic drugs chosen. Age <1 year, history of URTI in the week prior to the procedure and LWA work as independent risk factors for AEs in these patients.

Midazolam-ketamine combination for moderate sedation in upper GI endoscopy

OBJECTIVES

The aim of the study was to compare the quality of sedation with 3 different sedation regimens in upper gastrointestinal endoscopy (UGIE) in pediatric patients.

METHODS

One hundred fifty consecutive children who underwent UGIE were randomly assigned to 1 of the 3 medication regimens. Patients in group A (n = 49) received placebo. Forty-five minutes after the placebo was given, repeated intravenous (IV) doses of 0.1 mg/kg midazolam were administered titrated to achieve a level of deep sedation. Patients in group B (n = 51) received oral ketamine instead of placebo, and patients in group C (n = 50) received oral fentanyl instead of placebo with the same methodology and sedation endpoint.

RESULTS

The mean dose of midazolam administered in group B patients was remarkably lower compared with that of groups A and C. Patients in group B showed less distress in IV line placement and separation from parents, higher comfort level, more endoscopist satisfaction, and higher sedation depth compared with groups A and C. The recovery time was significantly shorter in group B. All of the 3 regimens were safe. All of the complications were managed successfully.

CONCLUSIONS

Our data suggest that synergistic sedation with oral ketamine and IV midazolam for UGIE in children is a suitable and safe sedation. The higher rate of vomiting in group B in contrast to previous studies must be caused mainly by the oral route of ketamine administration.

Safe and effective procedural sedation for gastrointestinal endoscopy in children

OBJECTIVE

The aim of the study was to assess, by a review of published evidence, the safest and most effective way to provide procedural sedation (PS) in children undergoing gastrointestinal endoscopy (GIE).

METHODS

The databases MEDLINE, Cochrane Library, and Embase were used. Search terms "endoscopy, gastrointestinal" or "endoscopy, digestive system" were combined with "sedation," "conscious sedation," "moderate sedation," "deep sedation," and "hypnotics and sedatives." The final review was restricted to studies reporting specifically on safety (incidences of adverse events) and/or effectiveness (time characteristics, need for supplemental sedation, need for restraint, procedural success, provider satisfaction, and patient comfort) of PS for GIE in children younger than 18 years.

RESULTS

The search yielded 182 references and the final selection included 11 randomized controlled trials (RCTs) and 15 non-RCTs. Six sedation categories were identified: propofol, opioid/benzodiazepine, premedication, ketamine-, sevoflurane-, and midazolam-based. Only a few RCTs have compared different categories. Opioid/benzodiazepine- and propofol-based PS have a similar safety profile and a low incidence of major adverse events. Propofol-based sedation turned out to be the most effective regimen, with effectiveness comparable to general anesthesia. The addition of midazolam, fentanyl, remifentanil, and/or ketamine to propofol may increase the effectiveness without creating more adverse events. Data on midazolam-, ketamine- and sevoflurane-based sedation were generally too limited to draw conclusions.

CONCLUSIONS

Despite a lack of RCTs containing all aspects of effectiveness and safety, the present evidence indicates propofol-based PS to be the best practice for PS in children undergoing GIE. Propofol can be safely administered by specifically trained nonanesthesiologists.

Sedation under JCI standard

The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents. In Korea, the Ministry of Health and Welfare developed new sedation standards for hospital evaluation, which is similar to the JCI standards. This review intends to help with the understanding of the JCI sedation standard and compare it to the Korean sedation standard.

A Pilot Study of Ketamine versus Midazolam/Fentanyl Sedation in Children Undergoing GI Endoscopy

Background. Ketamine sedation has been found superior by physician report to traditional sedation regimens for pediatric endoscopy. Goal. To objectively compare sedation with ketamine versus midazolam/fentanyl for children undergoing gastrointestinal endoscopy. Study. Patients received one of two regimens and were independently monitored using a standardized rating scale. Results. There were 2 episodes of laryngospasm during ketamine sedation. Univariate analyses showed patients sedated with ketamine (n = 17) moved more (median 25% of procedure time versus 8%, P = .03) and required similar low levels of restraint (0.83% versus 0.25%, P = .4) as patients sedated with midazolam/fentanyl (n = 20). Age-adjusted analyses suggested that patients sedated with ketamine were comparably more quiet (P = .002). Conclusions. A pilot trial of ketamine at our institution was associated with episodes of laryngospasm. In addition, children sedated with ketamine moved and required restraint similarly to patients sedated with midazolam/fentanyl. Physician perceptions may be affected by the fact that children who received ketamine were less likely to vocalize distress.

General considerations and updates in pediatric gastrointestinal diagnostic endoscopy

Gastrointestinal and colonic endoscopic examinations have been performed in pediatric patients in Korea for 3 decades. Endoscopic procedures are complex and may be unsafe if special concerns are not considered. Many things have to be kept in mind before, during, and after the procedure. Gastrointestinal endoscopy is one of the most frequently performed procedure in children nowadays, Since the dimension size of the endoscopy was modified for pediatric patients 15 years ago, endoscopic procedures are almost performed routinely in pediatric gastrointestinal patients. The smaller size of the scope let the physicians approach the diagnostic and therapeutic endoscopic procedures. But this is an invasive procedure, so the procedure itself may provoke an emergence state. The procedure-related complications can more easily occur in pediatric patients. Sedation-related or procedure-related respiratory, cardiovascular complications are mostly important and critical in the care. The endoscopists are required to consider diverse aspects of the procedure - patient preparation, indications and contraindications, infection controls, sedation methods, sedative medicines and the side effects of each medicine, monitoring during and after the procedure, and complications related with the procedure and medicines - to perform the procedure successfully and safely. This article presents some important guidelines and recommendations for gastrointestinal endoscopy through literature review.

Insufflation vs intubation during esophagogastroduodenoscopy in children

OBJECTIVES

We compared adverse airway events during esophagogastroduodenoscopy (EGD) in children managed with insufflation vs intubation.

BACKGROUND

Optimum airway management during EGD in children remains undecided.

METHODS/MATERIALS

Following IRB approval and written informed parental consent, children between 1 and 12 years of age presenting for EGD were randomized to airway management with insufflation (Group I), intubation/awake extubation (Group A), or intubation/deep extubation (Group D). All subjects received a standardized anesthetic with sevoflurane in oxygen. Using uniform definitions, airway adverse events during and after EGD recovery were recorded. Categorical data were analysed with Chi-square contingency tables or Fisher's exact test as appropriate.

RESULTS

Analyzable data were available for 415 subjects (Group I: 209; Group A: 101; Group D: 105). Desaturation, laryngospasm, any airway adverse event, and multiple airway adverse events during EGD were significantly more common in subjects in Group I compared to those in Groups A and D. Complaints of sore throat, hoarseness, stridor, and/or dysphagia were more common in subjects in Groups A and D. Analysis of confounders suggested that younger age, obesity, and midazolam premedication were independent predictors of airway adverse events during EGD.

CONCLUSIONS

Insufflation during EGD was associated with a higher incidence of airway adverse events, including desaturation and laryngospasm; intubation during EGD was associated with more frequent complaints related to sore throat. As our results show that insufflation during EGD offers no advantage in terms of operational efficiency and is associated with more airway adverse events, we recommend endotracheal intubation during EGD, especially in patients who are younger, obese, or have received midazolam premedication.

Use of oral midazolam in pediatric upper gastrointestinal endoscopy

BACKGROUND

The purpose of this prospective, randomized study was to compare the safety and efficacy of oral versus i.v. midazolam in providing sedation for pediatric upper gastrointestinal (GI) endoscopy.

METHODS

Sixty-one children (age <16 years) scheduled for upper GI endoscopy were studied. Patients were randomly assigned to receive oral or i.v. midazolam. Measurements were made and compared for vital signs, level of sedation, pre- and post-procedure comfort, anxiety during endoscopy, ease of separation from parents, ease and duration of procedure, and recovery time.

RESULTS

Patients were aged 1-16 years (mean 7.5 + or - 3.42 years); 30 patients received oral medication, and 31 received i.v. medication. There were no statistically significant differences in age or gender between groups. There were no significant differences in level of sedation, ease of separation from parents, ease of ability to monitor the patient during the procedure, heart rate, systolic arterial pressure, or respiratory rate. Oxygen saturation was significantly lower in the i.v. group than the oral group 10 and 30 min after removal of the endoscope, and recovery time was longer in the oral than the i.v. group.

CONCLUSIONS

Oral administration of midazolam is a safe and effective method of sedation that significantly reduces anxiety and improves overall tolerance for children undergoing esophagogastroduodenoscopy.

Clinical trial: a randomized, study comparing meperidine (pethidine) and fentanyl in adult gastrointestinal endoscopy

BACKGROUND

There is little evidence to guide choice between meperidine (pethidine) and fentanyl for sedation for gastrointestinal endoscopy.

AIM

To compare meperidine with fentanyl in terms of procedure time and analgesia.

METHODS

Single centre randomized controlled trial. Patients received narcotic doses and midazolam at the discretion of the attending endoscopist who was unaware of narcotic assignment. Endoscopy and recovery times were then recorded. The main outcome was total procedure time, defined as endoscopy time plus recovery time. Patient discomfort was assessed prior to discharge via visual analogue scale (VAS).

RESULTS

In total, 55 patients were randomized to meperidine [44 colonoscopy and 11 esophagogastroduodenoscopy (EGD)] and 56 to fentanyl (45 colonoscopy and 11 EGD). Total procedure time was shorter for those receiving fentanyl (mean = 87.7 min) than for those receiving meperidine (mean = 102.9 min) (P = 0.05). The difference between the groups was explained by a shorter mean recovery time in the fentanyl group (63.0 min) than in the meperidine group (76.2 min) (P = 0.07). Based on post procedure pain scores, examinations with meperidine (mean = 1.99) were less painful when compared with those receiving fentanyl (mean = 2.86, P = 0.03).

CONCLUSIONS

Fentanyl shortened total procedure time by reducing recovery time. A simple change in narcotic choice could increase endoscopy unit efficiency.

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.

Endoscopic sedation in pediatric practice

Best sedation practices for pediatric endoscopy involve the consideration of many patient factors, including age, medical history, clinical status, and anxiety level, as well as physician access to anesthesia support. A recent survey of pediatric gastroenterologists suggests that endoscopist-administered intravenous (iv) sedation and anesthesiologist-administered propofol represent common sedation regimens in children. Technical advances in ventilatory monitoring are contributing to increased patient safety for all children undergoing gastrointestinal procedures, regardless of sedation type.

Paediatric endoscopy performed by adult-service gastroenterologists

BACKGROUND

Children often travel from district hospitals to teaching centres for endoscopic procedures by paediatric gastroenterologists. A 10-year district hospital experience of 'adult-service' gastroenterologists endoscoping children is reported with the aim of quantifying the workload, indications, sedation/anaesthesia practices, findings and safety of paediatric endoscopy performed by adult-service gastroenterologists.

METHODS

Data on endoscopic procedures in patients younger than 16 years of age between 1997 and 2006 were obtained from hospital case-notes and computerized endoscopy/histology databases and were analysed.

RESULTS

A total of 174 procedures (118 gastroscopies, 41 colonoscopies and 15 flexible sigmoidoscopies) were performed in 162 children. The median (interquartile range) age was 11.5 (5-14) years. Sixty-nine percent of patients were referred by paediatricians and 31% by general practitioners /other adult specialties. Children referred as outpatients waited a total of 50 (23.5-95) days from referral to procedure. Inpatient children waited 3 (1-4) days for their procedure. General anaesthesia was used in 89% (63 of 71) endoscopic procedures in children aged below 11 years and 100% of 47 procedures in children aged below 6 years. In contrast, 96% (99 of 103) procedures in children aged 11 years or older were done in the endoscopy unit with intravenous or no sedation. Organic disease was identified from 90 (52%) procedures. The most common diagnoses were coeliac disease (41), inflammatory bowel disease (26), gastro-oesophageal reflux (six) and foreign body removal (seven). No endoscopic complications occurred.

CONCLUSION

General gastroenterologists supported by paediatricians can provide endoscopic services for children safely and promptly in their local hospital. This is appropriate for the management of common gastrointestinal problems affecting children.

Efficiency of propofol versus midazolam and fentanyl sedation at a pediatric teaching hospital: a prospective study

BACKGROUND

Many pediatric endoscopists are adopting propofol in their practices, with the expectation that propofol will increase their overall efficiency.

OBJECTIVE AND SETTING

To compare the efficiency of propofol versus midazolam and fentanyl by measuring elapsed times between initial intravenous administration and patient discharge at a pediatric teaching hospital.

DESIGN

Endoscopy times were prospectively collected for consecutive patients who were undergoing either anesthesiologist-administered propofol or endoscopist-administered midazolam and fentanyl. The effect of the type of sedation on these times was assessed by using multiple linear regression by adjusting for other candidate predictors, including concomitant use of other sedatives, endotracheal intubation by anesthesiologists, and the presence of fellow trainees.

MAIN OUTCOME MEASUREMENTS

Time to onset of sedation (time sedation started to scope in), procedure time (endoscope in to endoscope out), discharge time (endoscope out to hospital discharge), and total time (sedation started to hospital discharge).

RESULTS

The times for 134 children (mean age 12 +/- 5 years) to receive propofol sedation were compared with those of 195 children (13 +/- 5 years) who received midazolam and fentanyl. Midazolam and fentanyl cases disproportionately included EGDs (P < .001) and patients who were classified as American Society of Anesthesiologists I (P < .03). Patients who received propofol had shorter times until sedated, similar procedure times, longer discharge times, and comparable total times. Multivariate analyses confirmed that fellow participation prolonged the procedure times (P < .0001), and endotracheal intubation prolonged propofol times (P <. 01), but adjusting for these did not change the comparison results.

CONCLUSIONS

Anesthesiologist-administered propofol sedation in a pediatric teaching endoscopy unit may not lead to faster hospital times when compared with endoscopist-administered midazolam and fentanyl. These results are not explained by controlling for patient characteristics, the presence of a trainee, the sedative doses, or endotracheal intubation for airway management.

Sedation of the pediatric and adolescent patient for GI procedures

There remains no ideal sedative for pediatric and adolescent patients undergoing gastrointestinal procedures. Instead, pediatric gastroenterologists must consider many factors, including patient age, medical history, clinical status, anxiety level, as well as targeted sedation level, to select the appropriate methods and agents to achieve optimal sedation for endoscopy. The two primary types of sedation are endoscopist-administered intravenous (IV) sedation and anesthesiologist-administered general anesthesia. If IV sedation is used, pediatric endoscopists must be prepared for children to become agitated, adding to stress for both patients and clinical staff. General anesthesia provides the advantage of complete patient immobility but also entails increased costs and utilization of hospital resources. Technical advances in electronic monitoring, both in the pediatric endoscopy suite and operating room settings, are contributing to increased patient safety. Nevertheless, sedation-related events, independent of type of sedation or regimen, represent the most common complications of pediatric endoscopy.