**5. References**

Algren, C.L. & Algren, C.T. (1997). Pediatric sedation: essentials for the perioperative nurse. *Nursing Clinics of North America,* Vol. 32, No. 1, pp. 17-30

Cardiopulmonary complications account for more than half of the major complications during endoscopy (Lamireau et al., 1998) and are often related to hypoxia, especially in children less than 1-year old (Lamireau et al., 1998 & Lightdale et al., 2008). In a study by Barbi et al., using propofol in 811 children undergoing upper endoscopy, desaturation on supplemental oxygen is 3%, and major desaturation was noted in 0.7% of all the children. Additionally, a study by Yldzdas et al. demonstrated that the use propofol and midazolam fentanyl in 126 children who were randomly assigned to different sedation regimens had a 16.6% incidence of respiratory depression as shown by high end-tidal carbon dioxide (>50 mmHg). The higher incidence of respiratory depression reflected the better detection of respiratory depression by the use of end-tidal carbon dioxide. The adverse events in our clinical practice are comparable to those in the studies that did not use end-tidal carbon

dioxide monitoring (Balsells et al., 1997; Malviya et al., 1997 & Barbi et al., 2006).

**4. Post-pediatric gastrointestinal endoscopic period (Recovery and** 

Following sedation it is important that patient monitoring continue until the children are fully awake and ready for discharge. The recovery area should be equipped with oxygen, suction, and equipment for tracheal intubation. Monitoring equipment including non-invasive blood pressure, pulse oximetry, electrocardiography, and ventilation monitoring should be available as well. Patients should be discharged only when they have met specific criteria.

2. a return to the level of consciousness that is similar to the baseline for that patient

5. speech and ambulation appropriate for age should return to pre-sedation level

Patients who received reversal drugs such as naloxone or flumazenil may require longer periods of observation, because the half-life of the offending agent may exceed that of the reversal medication and lead to resedation. At the time of discharge, specific written and verbal instruction and information as well as the status of the child should be given to a parent, legal guardian or other responsible adult. Specific instructions should be given to the child's family instructing them what to do if the child should appear sedated or have any other medical problems. In the western countries, most of GIE procedures for children can be safely done with ambulatory setting. However, the majority of pediatric GIE procedures

In summary, no method of intravenous sedation can be universally applied to all children requiring gastrointestinal endoscopic procedures. However, in a tertiary care teaching hospital in a developing country, intravenous sedation for pediatric gastrointestinal endoscopic procedures can be safely and effectively performed outside the operating room with a multidrug sedation regimen utilizing anesthesiologists and anesthetic personnel with appropriate

Algren, C.L. & Algren, C.T. (1997). Pediatric sedation: essentials for the perioperative nurse.

*Nursing Clinics of North America,* Vol. 32, No. 1, pp. 17-30

**discharge)** 

1. stable vital signs

3. pain under control

basic monitoring.

**5. References** 

The criteria for discharge should include:

4. adequate muscle strength to maintain a patent airway

in eastern countries like Thailand are done with inpatient setting.

6. nausea and/or vomiting should be controlled.


**Part 2** 

**The Esophagus** 


**Part 2** 

**The Esophagus** 

60 Gastrointestinal Endoscopy

Krauss, B. & Green, S.M. (2000). Sedation and analgesia for procedures in children. *New* 

Krauss, B. & Green, S.M. (2006). Procedural sedation and analgesia in children. *Lancet*, Vol.

Krystal J.H. et al. (1994). Subanesthetic effects of the noncompetitive NMDA antagonist,

Lightdale J.R. et al. (2008). Efficiency of propofol versus midazolam and fentanyl sedation at

Lowrie L. et al. (1998). The pediatric sedation unit: a mechanism for pediatric sedation.

Mace S.E. et al. (2004). Clinical policy: Evidence-based approach to pharmacological agents

Malviya, S.; Voepel-Lewis, T. & Tait, A.R. (1997). Adverse events and risk factors associated

Meredith J.R. et al. (2008). Pediatric procedural sedation and analgesia. *Journal of* 

Nowicki, M.J. & Vaughn, C.A. (2002). Sedation and anesthesia in children for endoscopy.

O'Hare R.A. et al. (2001). Recovery from propofol anesthesia supplemented with remifentanil. British Journal of Anaesthesia, Vol. 86, No. 3, pp. 361-365. Pena, B.M.G. & Krauss, B. (1999). Adverse events of procedural sedation and analgesia in a

Pitetti R.D. et al. (2003). Safe and efficacious use of procedural sedation and analgesia by

Sury M.R.J. (2004). Paediatric sedation. *Continuing Education in Anaesthesia, Critical Care and* 

Sury, M.R.J. & Smith, J.H. (2008). Deep sedation and minimal anesthesia. *Pediatric Anesthesia,*

Tolia, V.; Peters, J.M. & Gilger, M.A. (2000). Sedation for pediatric endoscopic procedures. *Journal of Pediatric Gastroenterology and Nutrition,* Vol. 30, No. 5, pp. 477-485 Van Natta, M.E. & Rex, D.K. (2006). Propofol alone titrated to deep sedation versus propofol in

*Techniques in Gastrointestinal Endoscopy,* Vol. 4, No. 4, pp. 225-130

responses. *Archieves of General Psychiatry*, Vol. 51, No. 3, pp. 199-214 Lamireau, T.; Dubreuil, M. & Daconceicao, M. (1998). Oxygen saturation during

ketamine, in humans. Psychomimetic, perceptual, cognitive and neuroendocrine

esophagogastroduodenoscopy in children: general anesthesia versus intravenous sedation. *Journal of Pediatric Gastroenterology Nutrition,* Vol. 27, No. 2, pp. 172–175 Lewis, K.P. & Stanley, G.D. (1999). Pharmacology. *International Anesthsiology Clinics*, Vol. 37,

a pediatric teaching hospital: a prospective study. *Gastrointestinal Endoscopy,* Vol.

used in pediatric sedation and analgesia in the emergency department. *Journal of* 

with the sedation of children by nonanesthesiologists. *Anesthesia and Analgesia*, Vol.

pediatric emergency department. *Annals of Emergency Medicine*, Vol.34, No. 4, pp.

nonanesthesiogists in a pedatric emergency department. *Archieves Pediatric and* 

combination with opioids and or benzodiazepines and titrated to moderate sedation for colonoscopy. *American Journal of Gastroenterology,* Vol. 101, No. 10, pp. 2209–2217 Vespasiano, M; Finkelstein, M & Kurachek, S. (2007). Propofol sedation: intensivists' experience with 7304 cases in a children's hospital. *Pediatrics*, Vol. 120, No. 6, pp. e 1411-1417 Yldzdas, D.; Yapcoglu, H. & Ylmaz H.L. (2004). The value of capnography during sedation

or sedation analgesia in pediatric minor procedures. *Pediatric Emergency Care*, Vol.

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367, No. 9512, pp. 766-780

No. 1, pp. 73-86

67, No. 7, pp. 1067–1075

85, No. 6, pp. 1207–1213

*Pain,* Vol. 4, No. 4, pp. 118-122

Vol. 18, No. 1, pp. 18–24

20, No. 3, pp. 162–165.

483-490

*Pediatrics,* Vol. 102, No. 3, pp. e 30

*Pediatric Surgery*, Vol. 39, No. 10, pp. 1472-1484

*Emergencies, Trauma and Shock,* Vol*.* 1, No. 2, pp. 88-96

*Adolescent Medicine*, Vol. 157, No. 11, pp. 1090-1096

**6** 

*Spain* 

**Endoscopic Aspects of Eosinophilic** 

Alfredo J. Lucendo1 and Susana Jiménez-Contreras2 *1Department of Gastroenterology, Hospital General de Tomelloso 2Department of Gastroenterology, Hospital Virgen de Altagracia* 

**Esophagitis: From Diagnosis to Therapy** 

Eosinophilic esophagitis (EoE) represents a chronic, immune/antigen mediated disease characterized by esophageal dysfunction and eosinophilic inflammation (Liacouras et al., 2011). The past few years have witnessed a progressive rise in diagnosed cases of EoE, which has become the second most common chronic esophageal disease after gastroesophageal reflux (Lucendo, 2010). In spite of this, EoE remains underdiagnosed in many cases, especially because endoscopic findings are usually much harder to detect than those observed in esophageal growths (such as neoplasms) or erosive disorders. A great variety of endoscopic findings has been described in literature for EoE patient, including an apparently normal esophagus, which suggests that changes in this organ's appearance are not only complex, but also subtle enough to be overlooked by an endoscopist unaccustomed

At the same time, research efforts aimed at providing efficient therapy for this chronic illness has also intensified. Unfortunately, no treatment strategies have been commonly accepted to date, making adequate management of these patients somewhat controversial (González-Castillo et al., 2010). That being said, 3 different therapeutic approaches have been used effectively in patients with EoE. The first approach involves endoscopic dilation, a technique which is frequently able to solve alterations in the caliber of the esophagus, including a narrowing of the lumen (Schoepfer et al., 2009). From the earliest documented cases, mechanical dilation has been used as a treatment option for EoE, similar to the way it is used in other cases of fibrous esophageal stenosis, such as peptic stenosis or following caustication. The classification of EoE as an immunoallergic disorder has led to a second approach, namely that of treating patients with drugs for bronchial asthma (Furuta & Straumann, 2006). However, because no specifically approved drugs are currently available for EoE

 From the first studies performed on children with EoE, allergies to certain dietary components have been demonstrated to contribute significantly to its pathogenesis; indeed, it is well-documented that both the symptoms of the disease and histology levels improve after eliminating certain foods from the diet (Liacouras et al., 2005). However, while early studies based exclusively on elemental diets showed enormous efficacy in reverting EoE

(Kelly et al., 1995), this approach is not plausible in adults or chronic patients.

**1. Introduction** 

to diagnosing this disease.

patients, these treatment must be due out label.
