**3. Patient assessment and risk stratification**

Patient assessment and risk stratification is the most important initial step in planning for endoscopy in a child. This should be done at two stages. The first time is when the decision to perform an endoscopy has been made (i.e. in the outpatient clinic etc.) and once just before commencing the procedure. It is just like doing a pre-anesthetic check-up before any surgery.

#### **4. ASA classification for pre anesthetic status**

The ASA classification is used to identify at risk patients and plan sedation accordingly (Table. 1). This classification system although in vogue for nearly 5 decades does not specifically address issues related to children. Healthy neonates and infants do not tolerate similar anesthetics well in comparison to older children and young adults. For these reasons, in further discussions, sedation for endoscopy infants and neonates has been taken up separately.

Sedation for Pediatric Endoscopies 47

and percutaneous endoscopic gastrostomy placement are typically selected for general

Sedatives should not be administered in a facility unsupervised by medically trained personnel or where appropriate monitoring equipment and manpower are not available, since unrecognized complications may lead to disaster. The method of sedation is determined by the endoscopist and the needs of the patient. Many factors must be considered, including the patient's condition, ASA classification, patients age, the type of procedure (i.e., diagnostic versus therapeutic), the anticipated level of cooperation from the patient, the parents' and patient's preference after being provided these choices and explanation of their

There is a wide variation in the method of practice of sedation. Within city of Delhi, India five pediatric gastroenterology setups practice different approaches ranging from no sedation at all to moderate sedation and a mix of deep sedation and general anaesthesia. From other published literature as well, the message is not consistent (Lightdale, Mahoney, et al. 2007). This probably reflects an uncertainty in the optimal method of sedation and the lack of proper guidelines according to the authors. Comfort of pediatric endoscopist for

A conscious sedation protocol is followed at the pediatric gastroenterology division of All India Institute of Medical Sciences, New Delhi, India. For infants below 6 months no sedation is given, while all other children including those under going procedures receive

All children are given the following drugs according to the following protocol prior to

Table 2. Concentration, method of preparation and dosage of drugs used for pediatric sedation at the Pediatric Gastroenterology division, Department of Pediatrics, All India Institute of

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

2ml diazepam + 2ml 2% lignocaine\* +

6ml saline

**Preparation Concentration**

**after dilution (mg/ml)** 

5ml of saline 0.1 0.1 0.15

8 ml of saline 10.0 2.0 0.2

**Dose (mg/kg)** 

1.0 0.1 0.1

**Dose after dilution (ml/kg)** 

anesthesia and should be assessed by an anesthesiologist.

risks, as well as the endoscopist's experiences.

particular types of sedation is equally important.

**6. Method of sedation** 

moderate IV sedation.

endoscopy (Table 2).

Diazepam

**7.1 Fasting** 

**Drug Concentration** 

**(mg/ml)** 

5.0

\* Lignocaine is added for its cardiac stability

Medical Sciences, New Delhi, India

**7. Preparation for the procedure** 

Ketamine 5.0 2ml of drug +

Atropine 0.6 Dilute 1 ampoule in


Table 1. ASA (American Society of Anesthesiologist) classification of physical status
