**5. Sedation levels**

Depending on the type of endoscopic procedure, children may require no sedation (e.g., flexible sigmoidoscopy in an infant), intravenous sedation, or general anesthesia. Levels of sedation range from a continuum of mild sedation to deep sedation (Mahoney and Lightdale 2007). Therefore it is important to keep in mind that the child can pass on from light sedation to a deep sedation easily with the same combination of drugs and dosage. The endoscopist has to remain prepared for such eventualities.

#### **5.1 No sedation**

Unsedated upper endoscopy has been routinely performed in very young and adolescent patients at several institutions without any difference in outcomes (Bishop, Nowicki et al. 2002). In particular, flexible sigmoidoscopy, changes or removals of percutaneous endoscopically placed gastrostomy tubes and placement of pH or impedance probes can be performed without sedation (Mahoney and Lightdale 2007). The advantages of not getting sedation include minimal complications, earlier recovery and lower cost of the procedure.

#### **5.2 Light to moderate sedation**

This is an another name for conscious sedation and defined as a medically controlled state of depressed consciousness that allows protected reflexes to be maintained, retains the ability to maintain a patent airway independently and continuously, and permits appropriate responses by the patient to physical stimulation or verbal commands; for example, "open your eyes.''

#### **5.3 Deep sedation/analgesia**

Deep sedation is defined as a medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. It may be accompanied by a partial or complete loss of protective reflexes, and includes the inability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command.

#### **5.4 General anesthesia**

General anesthesia is defined as a medically controlled state of unconsciousness accompanied by a loss of protective reflexes, including the inability to maintain an airway independently and no purposeful response to physical stimulation or verbal command.

Children with the American Society of Anesthesiologists (ASA) physical status 3 and 4 and patients who are going to have procedures such as achalasia dilation, foreign body removal,

4 A patient with severe systemic disease that is a constant threat to life 5 A moribund patient who is not expected to survive without the operation 6 A declared brain-dead patient whose organs are being removed for donor

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

Depending on the type of endoscopic procedure, children may require no sedation (e.g., flexible sigmoidoscopy in an infant), intravenous sedation, or general anesthesia. Levels of sedation range from a continuum of mild sedation to deep sedation (Mahoney and Lightdale 2007). Therefore it is important to keep in mind that the child can pass on from light sedation to a deep sedation easily with the same combination of drugs and dosage. The

Unsedated upper endoscopy has been routinely performed in very young and adolescent patients at several institutions without any difference in outcomes (Bishop, Nowicki et al. 2002). In particular, flexible sigmoidoscopy, changes or removals of percutaneous endoscopically placed gastrostomy tubes and placement of pH or impedance probes can be performed without sedation (Mahoney and Lightdale 2007). The advantages of not getting sedation include minimal complications, earlier recovery and lower cost of the procedure.

This is an another name for conscious sedation and defined as a medically controlled state of depressed consciousness that allows protected reflexes to be maintained, retains the ability to maintain a patent airway independently and continuously, and permits appropriate responses by the patient to physical stimulation or verbal commands; for example, "open

Deep sedation is defined as a medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. It may be accompanied by a partial or complete loss of protective reflexes, and includes the inability to maintain a patent airway independently and respond purposefully to physical stimulation or verbal command.

General anesthesia is defined as a medically controlled state of unconsciousness accompanied by a loss of protective reflexes, including the inability to maintain an airway independently

Children with the American Society of Anesthesiologists (ASA) physical status 3 and 4 and patients who are going to have procedures such as achalasia dilation, foreign body removal,

and no purposeful response to physical stimulation or verbal command.

**ASA class Status** 

**5. Sedation levels** 

**5.1 No sedation** 

your eyes.''

1 A normal healthy patient

purposes

**5.2 Light to moderate sedation** 

**5.3 Deep sedation/analgesia** 

**5.4 General anesthesia** 

2 A patient with mild systemic disease 3 A patient with severe systemic disease

endoscopist has to remain prepared for such eventualities.

and percutaneous endoscopic gastrostomy placement are typically selected for general anesthesia and should be assessed by an anesthesiologist.
