**1. Introduction**

52 Gastrointestinal Endoscopy

support the growth of microorganisms. The dosage of this drug should be lowered if the patients are hemodynamically unstable. There is no antagonist available for this drug.

Flumazenil is a specific benzodiazepam antagonist and will rapidly reverse the sedative and respiratory effects of benzodiazepines. In patients who are taking benzodiazepines for seizures or drug dependency, seizures may recur if flumazenil is given. The recommended dose of flumazenil is 10 μg/kg up to 1 mg intravenously. Antagonism begins within 1–2 minutes and lasts approximately 1 hour. Since resedation after 1 hour is known to occur with diazepam, the patient must be carefully monitored for at least 2 hours. Flumazenil should not be administered for the routine reversal of the sedative effects of

Naloxone reversal of meperidine due to respiratory depression may precipitate seizures caused by normeperidine. The initial dose for respiratory depression is 1–2 μg/kg titrated to affect every 2–3 minutes. A dose of 10–100 μg/kg up to 2 mg may be required for

Sedation for pediatric endoscopy is generally given to have a smooth and comfortable procedure. With proper safety precautions and adopting uniform guidelines, adverse events can be reduced to very low levels. However, pediatric endoscopy team must always be

Ament, M. E., W. E. Berquist, et al. (1988). "Fiberoptic upper intestinal endoscopy in infants

Ammar and M. (2003). "Complications after outpatient upper GI endoscopy in children: 30 day follow-up." The American Journal of Gastroenterology 98(7): 1508-1511. Ayoub, C., A. Skoury, et al. (2007). "Lidocaine lollipop as single-agent anesthesia in upper

Bishop, P. R., M. J. Nowicki, et al. (2002). "Unsedated upper endoscopy in children."

Cote, C. J., D. A. Notterman, et al. (2000). "Adverse sedation events in pediatrics: a critical incident analysis of contributing factors." Pediatrics 105(4 Pt 1): 805-814. Evans, L. T., S. Saberi, et al. (2006). "Pharyngeal anesthesia during sedated EGDs: is "the

Lightdale, J. R., L. B. Mahoney, et al. (2007). "Methods of sedation in pediatric endoscopy: a survey of NASPGHAN members." J Pediatr Gastroenterol Nutr 45(4): 500-502. Mahoney, L. B. and J. R. Lightdale (2007). "Sedation of the Pediatric and Adolescent Patient for GI Procedures." Curr Treat Options Gastroenterol 10(5): 412-421. Thakkar, K., H. Elserag, et al. (2007). "Complications of pediatric EGD: a 4-year experience in

Tolia, V., J. M. Peters, et al. (2000). "Sedation for pediatric endoscopic procedures." J Pediatr

spray" beneficial? A meta-analysis and systematic review." Gastrointest Endosc

benzodiazepam, but reserved for reversal of respiratory depression only.

and children." Pediatr Clin North Am 35(1): 141-155.

GI endoscopy." Gastrointest Endosc 66(4): 786-793.

PEDS-CORI." Gastrointestinal Endoscopy 65(2): 213-221.

Gastrointestinal endoscopy 55(6): 624-630.

Gastroenterol Nutr 30(5): 477-485.

**10.4 Antagonists/reversal agents** 

respiratory arrest.

**11. Conclusions** 

**12. References** 

63(6): 761-766.

prepared for severe respiratory adverse events.

The field of pediatric sedation and analgesia has evolved over the past two decades. The growing number of pediatric gastrointestinal endoscopy procedures requiring sedation and analgesia are recognized even in developing countries. It is well accepted that children undergoing diagnostic and therapeutic gastrointestinal endoscopic procedures should receive sedation and/or anesthesia. Nevertheless, considerable practice variation prevails. The ability to provide safe and effective sedation and analgesia is an important skill for physicians involved in pediatric patients. Children are more prone to anxiety in the acute setting. Procedural sedation and analgesia is the use of sedative, analgesic and dissociate drugs to provide anxiolysis, analgesia, sedation and motor control during painful and unpleasant procedures.

Intravenous sedation for pediatric gastrointestinal endoscopic procedure is ubiquitous in any hospital that cares for children and depending on the institution and country. The developing countries have no their practice guidelines. The guidelines established by the American Academy of Pediatrics (AAP) (Cote et al., 2006), the American Society of Anesthesiologists (ASA, 2002) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) serve as the standard for institutional policy development in the area of pediatric intravenous sedation.

The guideline defines terms throughout and in particular:

*Minimal sedation*: a drug-induced state which patients respond normally to verbal commands.

*Moderate sedation (conscious sedation)*: a drug-induced depression of consciousness which patients respond purposefully to verbal commands. Spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

*Deep sedation*: a drug-induced depression of consciousness which patients can not be easily aroused but respond purposefully after repeated verbal or painful stimulation. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

*General anesthesia*: a drug-induced loss of consciousness which patients are not arousable, even by painful stimulation. Patients often require assistance in maintaining a patent airway. Cardiovascular function may be impaired.

Intravenous Sedation for Pediatric Gastrointestinal Endoscopy in a Developing Country 55

safely with various sedative combinations with proper monitoring and anesthesiology

Patient monitoring during the procedure should be included continuous monitoring of heart rate and oxygen saturation, and intermittent recording of respiratory rate and blood pressure. Additionally, capnography detects increasing levels of carbon dioxide before desaturation occurs and can detect early inadequately ventilation (Krauss & Green, 2000). However, the cost of capnometer is relatively high. The developing countries like Thailand have none or few capnometers, though this monitor is not routinely used. A sedative drug can only be considered safe after experience in hundreds or thousands of cases. Good protocols are important for the safety and success of the intravenous sedation technique. Depending on the procedure, pediatric intravenous sedation can involve monotherapy or combination therapy. Each regimen and administration of intravenous sedation must be carefully personalized for each patient. When administered, the drugs should be given as an appropriate initial dose with subsequent doses until titrated to effect. However, the most important factor is the judgement of the physician (ASA, 2002; Sury, 2004; Cote et al., 2006;

Common drug-receptor systems used by anesthesiologists in Thailand include the following:

Sedation should be administered based on the patient's weight and titrated by response. Dosing requirements for individual patients may vary significantly based on the patient's psychosocial development and attention to the surrounding environment by the endoscopy team. Adequate time should be allowed between doses to assess sedation effects and determine the need for additional medication. For example, midazolam should be titrated to the effect with at least three minutes between doses, while fentanyl should have five minutes between doses. Higher doses of sedative/analgesic agents are frequently needed in preschool, school aged and preteen patients compared with those used in teenage children. The most common intravenous sedation regimen for pediatric gastrointestinal endoscopic procedure is the use of an opioid and a benzodiazepine combination to achieve analgesia and amnesia (Dar & Shah, 2010). Many safe regimens were reported. Consequently, anesthesiologist or the anesthetic personnel must exercise extreme caution while administering the intravenous sedation for pediatric gastrointestinal endoscopic procedure. The use of intravenous sedation drugs is reliability, efficacy and easy titration to achieve the end point.

Fentanyl is a potent synthetic opioid with no intrinsic anxiolytic or amnestic properties. It has high lipid solubility allows for quick penetration of the blood-brain barrier, resulting in a very rapid onset of action (<1 minute) and short duration of action (30-45 minutes) (Nowicki & Vaughn, 2002; Dar & Shah, 2010). Fentanyl lacks of direct of myocardial depressant effects, and absence of histamine release, making it an excellent choice for intravenous sedation. Intravenous fentanyl can be easily and rapidly titrated for painful procedures (Kennedy et al., 1998; Pitetti et al., 2003). The combination of fentanyl and midazolam is a popular intravenous sedation regimen, with a safety profile when both

Krauss & Green, 2006; Vespasiano et al., 2007; Meredith et al., 2008).

2. Gamma-aminobytyric acid (GABA) receptors: propofol

4. N-methyl-D-aspartate (NMDA) receptors: ketamine

However, monitoring during the procedure is essential.

**3.1 Analgesic drugs 3.1.1 Fentanyl** 

1. Opioid receptors: fentanyl, meperidine

3. Benzodiazepine receptors: midazolam

service supervision.

In this report, the author will seek to examine the role of anesthesiologists in determining the field of pediatric intravenous sedation, and the current status of intravenous sedation for pediatric gastrointestinal endoscopic procedures in Siriraj GI Endoscopy Center, Siriraj Hospital, Thailand. Additionally, this review is divided into three parts: 1. the pre-pediatric gastrointestinal endoscopic assessment period, 2. the intra-pediatric gastrointestinal endoscopic management period, and 3. the post-pediatric gastrointestinal endoscopy period.
