**7. Preparation for the procedure**

#### **7.1 Fasting**

Conventionally, fasting for solids for 6 hours and liquids for 2 to 4 hours is recommended (Tolia, Peters et al. 2000). Longer periods of fasting may be required for conditions such as

Sedation for Pediatric Endoscopies 49

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

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

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

endoscopy and after giving IV sedation, children of all ages tolerate endoscope well.

advise the patient not to travel if he/she has had sclerotherapy in the past 24 hours.

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

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

pediatric population may be difficult.

**8. Post procedure instructions** 

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 require to be put on IV fluids during fasting.
