Overview
Definition:
Upper gastrointestinal (GI) endoscopy, or esophagogastroduodenoscopy (EGD), is a diagnostic and therapeutic procedure involving the insertion of a flexible endoscope into the esophagus, stomach, and duodenum
Sedation is crucial in pediatric patients to ensure patient comfort, cooperation, and to facilitate a safe and effective examination.
Epidemiology:
Upper GI endoscopy is performed for a variety of indications in children, including suspected gastroesophageal reflux disease (GERD), eosinophilic esophagitis, peptic ulcer disease, foreign body ingestion, and bleeding
The need for sedation is nearly universal in this age group due to the invasive nature of the procedure and varying levels of patient cooperation.
Clinical Significance:
Appropriate sedation is paramount for successful pediatric endoscopy, enabling accurate diagnosis, minimization of patient distress, and prevention of procedural complications
Understanding age-appropriate agents, dosages, monitoring, and potential adverse effects is critical for pediatricians, gastroenterologists, anesthesiologists, and residents preparing for DNB and NEET SS examinations.
Age Considerations
Infants:
Infants (0-1 year) often require deeper sedation due to their limited ability to cooperate and increased risk of airway compromise
Careful consideration of respiratory drive and cardiovascular stability is essential.
Toddlers And Preschoolers:
This age group (1-5 years) may exhibit fear and anxiety
Sedation aims for a calm, drowsy state with retained reflexes
Behavioral approaches and reassurance are also important.
School Aged Children And Adolescents:
Older children and adolescents (6+ years) can often tolerate lighter sedation or even conscious sedation with adequate pre-procedure explanation and psychological preparation
They may experience more anxiety related to loss of control.
Developmental Disabilities:
Children with developmental delays or special needs may require tailored sedation strategies, potentially involving deeper sedation or a combination of agents, with increased vigilance.
Sedation Agents And Protocols
Benzodiazepines:
Midazolam is commonly used for anxiolysis and amnesia
Intravenous (IV) doses typically range from 0.05-0.2 mg/kg, with a maximum of 5 mg
Oral midazolam can be used for pre-medication (0.25-0.5 mg/kg, max 10 mg).
Opioids:
Fentanyl provides analgesia and can augment sedation
IV doses are usually 1-2 mcg/kg, with a maximum of 50-100 mcg
Titrate slowly to effect.
Ketamine:
Ketamine offers dissociative anesthesia and potent analgesia, useful for more complex procedures or anxious children
IV doses range from 0.5-1 mg/kg, often combined with midazolam to mitigate emergence phenomena.
Propofol:
Propofol is a rapid-acting hypnotic agent offering excellent sedation with quick recovery
IV doses for monitored anesthesia care (MAC) range from 0.5-2 mg/kg for induction, followed by a continuous infusion of 25-100 mcg/kg/min
Requires advanced airway management skills and continuous cardiorespiratory monitoring.
Combination Therapy:
Often, a combination of agents (e.g., midazolam and fentanyl, or midazolam, fentanyl, and ketamine) is used to achieve optimal sedation and analgesia while minimizing individual agent-related side effects
Propofol may be used as a sole agent or in combination.
Pre Procedure Assessment And Preparation
History And Physical:
Thorough assessment of airway, cardiovascular status, and neurological function
Assess for any comorbidities (e.g., sleep apnea, cardiac, renal, hepatic dysfunction) that may affect drug metabolism or response.
Airway Assessment:
Mallampati score, thyromental distance, neck mobility, and presence of loose teeth are critical for predicting airway difficulty, especially with deeper sedation or general anesthesia.
Npo Status:
Adherence to fasting guidelines is crucial to reduce the risk of aspiration
Typical NPO times are 2 hours for clear liquids and 4-6 hours for solids, varying with age.
Informed Consent:
Detailed discussion with parents/guardians regarding the procedure, sedation risks, benefits, alternatives, and expected outcomes
This includes potential complications and the need for monitoring.
Patient Education:
Age-appropriate explanation to the child to reduce anxiety
This can involve explaining the "sleepy medicine" and the "camera stick" in simple terms.
Monitoring During Sedation
Continuous Cardiac Monitoring:
ECG to detect arrhythmias and ST segment changes
Continuous pulse oximetry for oxygen saturation (SpO2).
Respiratory Monitoring:
Capnography (end-tidal CO2 monitoring) is the gold standard for assessing ventilation, particularly with deeper sedation or propofol
Observation of respiratory rate, depth, and chest excursions.
Blood Pressure Monitoring:
Intermittent or continuous non-invasive blood pressure monitoring
Arterial line may be considered in high-risk patients or with anticipated major interventions.
Level Of Consciousness Assessment:
Regular assessment using objective scales (e.g., modified observer's early warning score) or subjective observation of response to verbal and tactile stimuli.
Airway Patency:
Ensuring adequate airway patency throughout the procedure
Use of oral or nasal airways as needed
Availability of resuscitation equipment and personnel.
Complications And Management
Respiratory Depression:
Manifests as hypoxemia, bradypnea, and shallow breathing
Management involves jaw thrust, chin lift, airway adjuncts, bag-valve-mask ventilation, and reversal agents if appropriate (e.g., flumazenil for benzodiazepines, naloxone for opioids).
Hypotension:
Can be caused by the sedative agents themselves or by decreased venous return
Management includes fluid boluses, vasopressor support (e.g., ephedrine, phenylephrine), and discontinuation of offending agents.
Laryngospasm And Bronchospasm:
May occur during airway manipulation
Management includes positive pressure ventilation, oxygen, and bronchodilators
Succinylcholine may be required for severe laryngospasm.
Emergence Delirium And Agitation:
More common with ketamine or rapid awakening from propofol
Management includes a calm environment, reassurance, and potentially low-dose benzodiazepines.
Allergy Or Anaphylaxis:
Rare but serious
Requires immediate cessation of the offending agent, oxygen, IV fluids, epinephrine, antihistamines, and corticosteroids.
Key Points
Exam Focus:
Understanding the pharmacokinetics and pharmacodynamics of common pediatric sedation agents is vital
DNB and NEET SS questions often focus on appropriate agent selection based on patient age and comorbidity, correct dosing, monitoring parameters, and management of common complications.
Clinical Pearls:
Always perform a thorough pre-sedation assessment
Titrate medications slowly to effect
Have resuscitation equipment and reversal agents readily available
Continuous monitoring is non-negotiable
Involve a dedicated sedation provider (anesthesiologist or experienced ED/GI nurse) when possible, especially for deeper sedation.
Common Mistakes:
Inadequate fasting leading to aspiration
Underestimating airway risks in obese or syndromic children
Over-sedation leading to respiratory compromise
Inadequate monitoring
Failure to have reversal agents available
Not adjusting doses for age, weight, or comorbidities.