**7.2 Antibiotic prophylaxis**

Children with congenital heart diseases or a compromised immune system are candidates for endocarditis prophylaxis. We administer single injection of amoxicillin and gentamicin just before start of the procedure. In children sensitive to amoxicillin, vancomicin is given. For ERCP, a flouroquinolone is also added.

### **7.3 Time out**

"Time-out" is an important component before any procedure on the patient. It is done immediately prior to starting the procedure and is performed to prevent any medical error by conducting a final verification of correct patient, procedure, and site. The timeout should also ensure that correct equipment, drugs and personnel to perform sedation are available. It is an active communication among all procedural team members that should be consistently performed prior to all procedures.

On-site equipment of appropriate sizes should be available prior to the procedure and include the following: (i) pulse oximetry (ii) suction and catheters; (iii) noninvasive blood pressure measurement equipment (iv) positive pressure O2 delivery system (v) emergency kit with age and size appropriate drugs and resuscitation equipment.

#### **7.4 Documentation before sedation**

Although endoscopy has a relatively low risk as compared to other surgical procedures, it is important that all pediatric endoscopists be prepared for complications associated with either the procedure or the sedation. In turn, all patients and their families must be well informed prior to the endoscopy and the initiation of sedation about the possible risks of the procedure and of the sedation. It is extremely important to find a delicate balance between the full disclosure of the invasive nature of the procedure and related complications and anticipated parental and patient responses to the disclosed information.

Documentation before sedation must include the following:


#### **7.5 Topical anesthetic spray and premedication**

For upper gastrointestinal endoscopy, pre-medication with topical sprays and oral sedatives prior to IV line insertion are used at many centers. Topical lidocaine applications (gel, sprays, inhalers or lollipops) have been used as an addition to sedation with varying results. Some formulations are associated with nausea, vomiting and gagging and might increase the need for sedation. Ayoub et al. performed a single-blind, randomized, prospective study (Ayoub, Skoury et al. 2007) to compare topical lidocaine application by means of a lollipop with the spray group and found that, gag reflexes in the lollipop group were significantly

achalasia and gastric outlet obstruction, because retained food in the esophagus or stomach may increase the risk of aspiration. Infants and neonates are not fasted for long and often

Children with congenital heart diseases or a compromised immune system are candidates for endocarditis prophylaxis. We administer single injection of amoxicillin and gentamicin just before start of the procedure. In children sensitive to amoxicillin, vancomicin is given.

"Time-out" is an important component before any procedure on the patient. It is done immediately prior to starting the procedure and is performed to prevent any medical error by conducting a final verification of correct patient, procedure, and site. The timeout should also ensure that correct equipment, drugs and personnel to perform sedation are available. It is an active communication among all procedural team members that should be

On-site equipment of appropriate sizes should be available prior to the procedure and include the following: (i) pulse oximetry (ii) suction and catheters; (iii) noninvasive blood pressure measurement equipment (iv) positive pressure O2 delivery system (v) emergency

Although endoscopy has a relatively low risk as compared to other surgical procedures, it is important that all pediatric endoscopists be prepared for complications associated with either the procedure or the sedation. In turn, all patients and their families must be well informed prior to the endoscopy and the initiation of sedation about the possible risks of the procedure and of the sedation. It is extremely important to find a delicate balance between the full disclosure of the invasive nature of the procedure and related complications and

1. Informed consent: Informed consent must involve disclosure by the endoscopist and deliberation by the parents or legal guardians. If the patient is an adolescent, it is appropriate to obtain informed assent. A separate consent form for sedation may be

For upper gastrointestinal endoscopy, pre-medication with topical sprays and oral sedatives prior to IV line insertion are used at many centers. Topical lidocaine applications (gel, sprays, inhalers or lollipops) have been used as an addition to sedation with varying results. Some formulations are associated with nausea, vomiting and gagging and might increase the need for sedation. Ayoub et al. performed a single-blind, randomized, prospective study (Ayoub, Skoury et al. 2007) to compare topical lidocaine application by means of a lollipop with the spray group and found that, gag reflexes in the lollipop group were significantly

kit with age and size appropriate drugs and resuscitation equipment.

anticipated parental and patient responses to the disclosed information.

Documentation before sedation must include the following:

**7.5 Topical anesthetic spray and premedication** 

require to be put on IV fluids during fasting.

For ERCP, a flouroquinolone is also added.

consistently performed prior to all procedures.

**7.4 Documentation before sedation** 

**7.2 Antibiotic prophylaxis** 

**7.3 Time out** 

required. 2. Verbal instructions 3. Dietary precautions 4. Health evaluation

weaker and patients were better able to tolerate scope introduction and manipulation during the procedure. Sedation was needed by 96% of patients given spray, but by only 32% of patients in the lollipop group (P <0.001). All these were adults and its extrapolation to pediatric population may be difficult.

Topical application is only effective when the anesthetic is delivered to the posterior pharynx. This system requires depression of the tongue and elicitation of a gag reflex with a tongue blade during spraying, which may be highly unpleasant for children. Opponents of the pharyngeal anesthesia postulate that this increases the distress in children (Ament, Berquist et al. 1988), whereas the proponents have propagated the more generally held view that it is the pharyngeal stimulation from the endoscope that causes more patient agitation (Evans, Saberi et al. 2006). We have in our setup never used topical anesthetics prior to endoscopy and after giving IV sedation, children of all ages tolerate endoscope well.

#### **8. Post procedure instructions**

After the procedure, children are retained in the hospital for 2 hours (conscious sedation) – 8 hours (general anaesthesia) depending upon the types of anaesthesia and the procedures. If any intervention has been done, child is advised to stay longer till they are stable. Approximately 2 hours after the procedure, if the child is conscious and awake, he / she can be offered something to drink. Most children sleep after leaving the hospital. When child wakes, he or she may be drowsy. Some children are sleepy for the remainder of the day. After child wakes up, do not allow him or her to walk alone for at least 4 hours. Child may feel suddenly dizzy and fall without warning. The sedative can affect the child's coordination ability and balance. For the first 12 hours after waking up the child should not do anything that requires alertness, coordination, or balance. The care providers are told that the sedative sometimes causes the child to behave in unexpected ways. However, by the next day child's behavior should return to normal. For infants it is okay to give "clear liquids" (water, apple juice, tea) after getting home. Wait approximately 30 minutes to make sure child does not choke or vomit. Then milk, formula or other foods may be given. If child can drink without vomiting or choking, he or she can have the foods he or she usually eats. The patient is instructed to return/seek medical help for recurrent vomiting and if any of the common effects listed above last more than 12 hours, or if child's pain increases. We also advise the patient not to travel if he/she has had sclerotherapy in the past 24 hours.

#### **9. Sedation related complications and their management**

There are no good published studies that have documented adverse events following pediatric sedation. Cote et al reported on the adverse sedation events in children in a study published in 2000 (Cote, Notterman et al. 2000). This study was a critical incident analysis of contributory factors. The primary event in both the hospital-based and non-hospital-based patients was respiratory, the secondary event was cardiac arrest, and the third was inadequate resuscitation. Drug–drug interactions, inadequate monitoring, inadequate medical evaluation, lack of an independent observer, and inadequate management of resuscitation were also some of the other causes of adverse sedation events. Successful outcome was related to the use of pulse oximetry in patients compared to those without any monitoring. At pediatric gastroenterology division of All India Institute of Medical Sciences, New Delhi, India, 4874 endoscopies were done over the past two and a half years. Following adverse events were observed amongst them (Table 3). Most complications from sedation

Sedation for Pediatric Endoscopies 51

from 7 to 19 hours. It can also be associated with hypotension seizures, extra pyramidal

Midazolam has now become the preferred drug in many pediatric endoscopy suites. It is a benzodiazepine with three to six times greater potency than diazepam. It is given in the dose of 0.1-0.3 mg/kg/dose intravenously. Midazolam provides three advantages over diazepam. It provides patients better anterograde and retrograde amnesia for the procedure. It has a shorter half life and there appears to be no resedation as seen with diazepam. The onset of action for a dose of midazolam is within 1 to 5 minutes, and it achieves its peak effect in approximately 30 minutes to 1 hour. Unlike other benzodiazepines, the clearance of

Ketamine in low doses can cause intense analgesia with minimal respiratory and cardiovascular depression. Typical doses are 1–2 mg/kg intravenous. The onset occurs in less than 1 minute, with a peak effect in several minutes and duration of action in approximately 15 minutes. Higher doses (2mg/kg) or supplementation with other sedatives or narcotics may produce deep sedation or general anesthesia. Ketamine should always be administered with an atropine (0.1 mg/kg) or glycopyrrolate (0.01 mg/kg) since profuse

Cardiovascular stability and blood pressure are usually maintained. Typically, ketamine has been associated with hallucinations during emergence in up to 12% of patients. It may be reduced by administration of benzodiazepam. It is contraindicated in patients with head injury, open globe injury, hypertension, and psychosis. It is recognized that ketamine can induce apnea in neonates as well as a decrease response to hypocarbia, laryngospasm, and

Propofol is a short-acting sedative hypnotic. It is available in an Intralipid formulation. It has no analgesic properties, but it does have antiemetic and antipruritic properties. Although small doses of propofol (25–50 μg/(kg min) can provide "conscious sedation'' in adults with deep sedation, airway obstruction quickly occurs in pediatric patients. It is titrated with an infusion pump and should be administered by individuals with advanced airway skills. There has been a lot of enthusiasm in using this agent in pediatric intensive care units and in Endoscopy suites. Cases of fatal metabolic acidosis, mild cardiac failure, and lipemic serum have been reported in children which limits its use for prolonged periods of time. Short-term sedation with propofol has been associated with no such problems. Propofol should be administered in large veins since it can cause pain on injection. Respiratory depression/apnea and hypotension are related to the dose, rate and coadminstration with other CNS depressants. Hypotension occurs from using the medication, especially when it is given rapidly. Anaphylactic reactions and bacterial contaminations have been described and have been attributed to the lipid formulation in which it is dispensed. Strict aseptic technique must be used when one uses propofol because it may

reactions, and severe prolonged life-threatening respiratory depression.

midazolam is dose related (i.e., increased clearance with increased dosage).

secretions from ketamine alone may induce laryngospasm.

coughing. There is no antagonist available.

**10.2 Benzodiazepines 10.2.1 Midazolam** 

**10.3 Systemic anesthetics** 

**10.3.1 Ketamine** 

**10.3.2 Propofol** 

are avoidable. Children below one year are at the highest risk and need special attention. Desaturation and apnea are the most frequently encountered adverse effects which can be quickly reversed with administration of 02/ increasing flow. Uniform guidelines for both in hospital and out of hospital sedation must include appropriate personnel skilled in airway management and resuscitation. Health care personnel who sedate children for procedures must have advanced airway and resuscitation skills.


Table 3. Incidence of various adverse events observed over a period of two and a half years following endoscopies at the pediatric gastroenterology division of All India Institute of Medical Sciences, New Delhi, India
