Sedation for Diagnostic Upper Gastrointestinal Endoscopy: a Survey of the Francophone Pediatric Hepatology, Gastroenterology, and Nutrition Group

• Introduction
• Materials and Methods
• Results
• Discussion
• Acknowledgments
• References

Background and Study Aims: A survey of sedation usage in children undergoing diagnostic upper gastrointestinal endoscopy was undertaken among the members of the Francophone Pediatric Hepatology, Gastroenterology, and Nutrition Group.
Materials and Methods: A questionnaire regarding the mode of sedation used for noninterventional upper gastrointestinal endoscopy, relative to the patient’s age and clinical condition, was sent to all members of the Group. The sample included 51 pediatric endoscopy centers (33 university hospitals, eight general hospitals, and 10 private practices).
Results: The response rate was 84 % (43 of 51) overall, and 100 % for university hospitals. Forty percent of the pediatric endoscopy centers routinely offered children and/or parents a choice between general anesthesia and conscious sedation. Only 14 % of the pediatric endoscopists surveyed routinely conducted upper gastrointestinal endoscopy under general anesthesia, irrespective of the patient’s age or the indication for endoscopy. Patients under the age of 6 months underwent endoscopy as follows: 35 % under conscious sedation, 22 % under general anesthesia, and 43 % with no sedation. After the age of 6 months, endoscopy was conducted as follows: 45 % under conscious sedation, 47 % under general anesthesia, and 8 % with no sedation. Midazolam was the most common drug used for conscious sedation. In patients aged 3 - 5, inhaled nitrous oxide was used instead of midazolam for conscious sedation in 12 % of pediatric endoscopies, and local anesthesia with lidocaine (Xylocaine) in 24 %. In those over the age of 5, the proportions of centers using inhaled nitrous oxide and lidocaine increased to 19 % and 42 %, respectively.
Conclusions: These results clearly show that the mode of sedation used in noninterventional upper gastrointestinal endoscopy in the pediatric age group is highly variable.

Introduction

Upper gastrointestinal endoscopy in pediatric patients has become a common procedure during the last 20 years, following the development of smaller, age-appropriate fiber endoscopes. However, the optimal sedation in children undergoing diagnostic gastrointestinal endoscopy remains an unresolved question. Sedation techniques vary within each country and around the world, and no consensus has been reached on the best method of sedation for upper gastrointestinal endoscopy, particularly in infants [1]. Evaluating current practices is important in the effort to develop improvements. To determine the current state of practice, a survey of sedation practices was conducted in May 2002 among members of the Francophone Pediatric Hepatology, Gastroenterology, and Nutrition Group (Groupe Francophone d’Hépatologie, Gastroentérologie et Nutrition Pédiatrique GFHGNP).

Materials and Methods

A questionnaire regarding the mode of sedation used for noninterventional upper gastrointestinal endoscopy, relative to the patient’s age and clinical condition, was sent by e-mail to all members of the Group. The Group includes 51 pediatric endoscopy centers (33 university hospitals, eight general hospitals, and 10 private practices). The questionnaire covered endoscopies conducted for the diagnosis of esophageal, gastric or duodenal disease, with or without biopsy. All therapeutic endoscopic procedures that generally require general anesthesia, such as balloon dilation, sclerotherapy, and band ligation of esophageal varices, as well as the removal of esophageal or gastric foreign bodies, were excluded from the study. The drugs used for conscious sedation, whether an anesthesiologist was present during the procedure, and the use of local anesthesia were also recorded. Questionnaires were returned by 43 pediatric endoscopy centers (33 university hospitals, six general hospitals, and four private practices).

Three categories were used in the study to characterize the sedation regimen: none; conscious sedation administered by the endoscopy staff; and general anesthesia. Conscious sedation was defined as ”a medically controlled state of depressed consciousness that allows protective reflexes to be maintained, retains the patient’s ability to maintain the patent airway continuously, and permits appropriate response by the patient to physical stimulation or verbal command” [2]. Protective reflexes include maintenance of a patent airway and protection again vomiting and aspiration. Deep sedation was defined as a medically controlled state of depressed consciousness or unconsciousness from which the patient is not easily aroused. In general anesthesia, a medically controlled state of unconsciousness exists, accompanied by the loss of protective airway reflexes [1]. In fact, levels of sedation are best viewed as a continuum of states ranging from minimum sedation (anxiolysis) to general anesthesia. In the present survey, the general anesthesia group included all patients undergoing general anesthesia per se, with or without intubation, as well as patients undergoing deep sedation as defined above. Lidocaine (Xylocaine) was most often used with midazolam or nitrous oxide, and the endoscopy was then assigned to the group with conscious sedation. When lidocaine was used alone, the endoscopy was assigned to the group not receiving sedation. If general anesthesia was used, the type of narcotic agent used by the anesthesiologist was not recorded. Information concerning the size of the endoscope used was not recorded either.

Results

The response rate was 84 % (43 of 51 centers) overall, and 100 % for university hospitals. The numbers of endoscopies performed in the participating centers varied from 15 to 1000 per year. Forty percent of the pediatric endoscopy centers routinely offered children and/or parents, depending on the patient’s age, a choice between general anesthesia and conscious sedation. Only 14 % of the pediatric endoscopists routinely conducted upper gastrointestinal endoscopy examinations with the patient under general anesthesia, whatever the age of the patient and/or indication for endoscopy. The remaining 46 % of units that did not use routine general anesthesia or did not offer a choice between general anesthesia and conscious sedation usually performed conscious sedation with midazolam or nitrous oxide, and used general anesthesia only in a few specific cases (recurrent endoscopy procedures, agitated patients, or at the parents’ request). In patients under 6 months of age, upper gastrointestinal endoscopy was performed as follows: 35 % of cases under conscious sedation, 22 % under general anesthesia, and 43 % with no sedation. In patients over 6 months of age, upper gastrointestinal endoscopy was performed as follows: 45 % of cases under conscious sedation, 47 % under general anesthesia, and 8 % with no sedation (Table [1]). There was no relation between the size of the endoscopy unit and the type of sedation used (none, conscious sedation, or general anesthesia; Table [2]). There were also no differences between university hospitals and general hospitals or private practice endoscopy units with regard to the type of sedation used (Table [3]). Midazolam, administrated either rectally (in two-thirds of the cases), intravenously, or orally, was the most common drug used for conscious sedation. Only two of the 43 units used drugs other than midazolam and nitrous oxide for conscious sedation - i.e., hydroxyzine and alimenazine. In patients aged 3 - 5, inhaled nitrous oxide was used in place of midazolam for conscious sedation by 12 % of centers and local anesthesia (lidocaine) by 24 %, compared with patients over 5 years of age, in whom the use of inhaled nitrous oxide and lidocaine increased to 19 % and 42 % of centers, respectively. The most important factors determining the conditions in which pediatric endoscopists conducted endoscopy using general anesthesia were the patient’s age (58 %), a request by the children and/or their parents (49 %), and repetition of endoscopic procedures (46 %). In total, 42 % (range 0 - 100 %) of noninterventional upper gastrointestinal endoscopic procedures were conducted with the patients under general anesthesia, whatever the patient’s age.

The questionnaire also showed that 10 % of pediatric endoscopists considered that an increased level of sedation was required for patients undergoing gastric biopsies. Similarly, 30 % of pediatric endoscopists considered that small-bowel biopsy also warranted either a greater level of sedation or required general anesthesia. In 35 % of the centers, an anesthesiologist was present in the endoscopy room to perform sedation or general anesthesia during upper gastrointestinal endoscopy. Only 46 % of pediatric endoscopists were satisfied with the sedation procedure they used for children undergoing endoscopy, and 48 % were studying ways of improving the procedure.

Discussion

There is continuing debate on whether upper gastrointestinal endoscopy is optimally performed with patients under general anesthesia or conscious sedation, irrespective of their age. Both techniques have advantages and disadvantages. General anesthesia provides better control of the airway in case tracheal intubation is needed, frees the endoscopist from providing and monitoring sedation, and potentially allows for a better examination [3]. Conscious sedation, however, reduces the recovery time and cost of the procedure [4]. In children undergoing upper gastrointestinal endoscopy with conscious sedation, minor complications such as an inability to complete the examination or hypoxia requiring intervention have been reported to occur in 0.03 - 1.8 % of cases [5].

In the present study, midazolam was found still to be the first-choice drug for conscious sedation, administered either rectally or intravenously. Midazolam is a very short-acting benzodiazepine, with a half-life of 2 - 6 hours. It is chosen because of these properties and the fact that it is possible for a nonanesthesiologist to use it at a low dosage i.e., 0.2 - 0.3 mg/kg. Higher doses of midazolam may be used by an anesthesiologist before performing general anesthesia. However, the questionnaire did not specifically inquire into the dosage of drugs used for sedation or the type of drugs used for general anesthesia. As with other benzodiazepines, midazolam provides sedation and antegrade amnesia, but has no intrinsic analgesic properties. It is mainly given to block any memory of an unpleasant and potentially painful procedure. However, paradoxical reactions occur in 1.4 - 11.4 % of children who are given benzodiazepines for upper gastrointestinal endoscopy [6]. These include inconsolable crying, combativeness, dysphoria, disorientation, and agitation, all of which can interfere with adequate endoscopic examination. However, it is usually possible to complete upper gastrointestinal endoscopy successfully with the patient under conscious sedation using midazolam, in 87 - 99 % of children [6].

A minority of pediatric endoscopists in the present study (treating 19 % of the patients over 5 years of age and 12 % of those aged 3 - 5) used inhaled nitrous oxide. In pediatric practice, nitrous oxide analgesia has previously been shown to be effective in children for different forms of pain, and also during upper gastrointestinal endoscopy [7] [8]. So far as we are aware, only one paper on the use of nitrous oxide inhalation during gastrointestinal endoscopy in pediatric patients has so far been published, by our own group [8]. Nitrous oxide provides rapid and effective analgesia without heavy sedation, but requires cooperation on the part of the children. Further studies are urgently needed to obtain further insights into the role of nitrous oxide inhalation in pediatric gastrointestinal endoscopy. At present, we consider that nitrous oxide inhalation can first be administered in a cooperative child over the age of 5 years, in combination with local anesthesia with lidocaine. The efficacy of nitrous oxide inhalation can probably be improved in combination with midazolam, but there are as yet no published studies on this topic. During upper gastrointestinal endoscopy, most children indicate that the cervical area is the main site of pain [8]. The use of local pharyngeal anesthesia (with lidocaine) might result in less discomfort during the procedure, but this was administered by only 42 % of the pediatric endoscopists in the present survey.

An anesthesiologist who can maintain the patient’s airway during both endoscopy and the recovery period and who can gradually increase the sedation if necessary should ideally administer sedation. Fourteen percent of pediatric endoscopists routinely performed upper gastrointestinal endoscopy with the patient under general anesthesia, whatever the patient’s age or the indication for upper gastrointestinal endoscopy. While the reasons for routine use of general anesthesia for endoscopic procedures were not studied in this survey, they usually included the physician’s perception that conscious sedation is inadequate in comparison with general anesthesia, a feeling that pediatric patients may not be fully cooperative (which may interfere with the performance of the endoscopy), and concerns about losing control of the airway in infants and toddlers [1] [9]. In addition, the presence of an anesthesiologist relieves the endoscopist of the need to manage the patient’s airway and vital signs. Unfortunately, the availability of anesthesiologists is low in most pediatric hospitals in France. An anesthesiologist was always present during the endoscopy procedure to provide sedation in only 35 % of the centers, taking charge of sedation and increasing it if required. This figure of course included the 14 % of units in which all endoscopy procedures were performed under general anesthesia. In France, general anesthesia is always administered by a qualified anesthesiologist, and endoscopists are only permitted to administer conscious sedation. A trained medical observer devoting his or her full attention to the patient’s sedation and cardiorespiratory well-being can take the place of the anesthesiologist if conscious sedation is chosen.

In a study on patients’ attitudes to sedation for diagnostic upper endoscopy, Hedenbro and Lindblom showed that approximately two-thirds of adult patients undergoing upper gastrointestinal endoscopy, when given a choice, choose to avoid sedation. In this group of patients, discomfort during the procedure was found to be preferable to the postprocedural drug effects [10]. On the other hand, endoscopy is considered to be invasive and uncomfortable by 70 - 80 % of adult patients if the procedure is conducted without sedation, compared with only 10 % if sedation with midazolam is administered [11]. In the present study, the decision for or against administering sedation or general anesthesia was left to the patient and his or her parents after appropriate counseling, including clear explanation of all options, as was provided by 40 % of the pediatric endoscopists. However, patients’ and parents’ choices have also been found to be affected by pediatric endoscopists’ views on the issue [5]. Optimal sedation for children undergoing diagnostic pediatric gastrointestinal endoscopy remains an unresolved question in the Francophone Pediatric Hepatology, Gastroenterology and Nutrition Group, as is also the case in other countries. Lee et al. have shown that music can reduce the dosage of sedative medication required for colonoscopy in adults, and Bishop et al. have shown that unsedated upper gastrointestinal endoscopy can be carried out safely and successfully in children [5] [12].

The results of this survey clearly show the degree of variability among centers in the mode of sedation used for noninterventional upper gastrointestinal endoscopy in the pediatric age group. Although these topics were not studied here, the availability of equipment and the cost of different types of sedation may also influence sedation practices. Everyday practice in upper gastrointestinal endoscopy in children is still often unsatisfactory, since a relevant number of children still undergo upper gastrointestinal endoscopy with no anesthesia or sedation. General anesthesia is probably not the gold standard for upper gastrointestinal endoscopy in children. The objective in pediatric centers should be to adjust the degree of sedation administered individually in each case, taking into account age, the individual child, family anxiety, whether the endoscopy is a repeat procedure, the size of the endoscope, and the duration of the procedure relative to the number of biopsies required. Further studies are urgently required in order to compare the tolerance for and efficacy of sedation versus general anesthesia in children requiring upper gastrointestinal endoscopy. The availability of anesthesiologists continues to be by far the most limiting factor in ensuring optimal sedation during upper gastrointestinal endoscopy in children.

Acknowledgments

The author wishes to thank his colleagues in the Groupe Francophone d’Hépatologie, Gastroentérologie et Nutrition Pédiatrique, who participated in the study and made it possible: C. Babakissa, K. Bargaoui, M. Ben Hariz, M. Besnard, C. Borderon, S. Boukthir, A. Breton, P. Broué, S. Cadranel, B. Caurier, A. Corboz, J.P. Chouraqui, A. Dabadie, E. Darviot-Duveau, B. Descos, D. Djeddi, M. Duché, D. Guimber, F. Huet, E. Jacquemin, N. Kalach, A. Lachaux, T. Lamireau, M. Larchet, C. Lenaerts, A. Maherzi, G. Molitor, A. Morali, C. Maurage, E. Mallet, J.F. Mougenot, O. Mouterde, M. Pletinckx, A. Poujol, M. Razemon, A. Rochette, F. Ruemmele, A. Said, M. Scaillon, J. Sarles, and P. Tounian.

References

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L. Michaud, M. D.

Unité de Gastro-entérologie, Hépatologie et Nutrition, Clinique de Pédiatrie, Hôpital Jeanne de Flandre

59037 Lille · France

Fax: +33-3-20445963

Email: l-michaud@chru-lille.fr

References

• 1 Chuang E, Zimmerman A, Neiswender K M, Liacouras C A. Sedation in pediatric endoscopy.  Gastrointest Endosc Clin North Am. 2001;  11 569-584
  PubMedSearch in Google Scholar
• 2 American Academy of Pediatrics Committee on Drugs, Section on Anesthesiology. Guidelines for the elective use of conscious sedation, deep sedation and general anaesthesia.  Pediatrics. 1985;  76 317-321
  PubMedSearch in Google Scholar
• 3 Lamireau T, Dubreuil M, Daconccicao M. Oxygen saturation during oesophago-gastroduodenoscopy in children: general anesthesia versus intravenous sedation.  J Pediatr Gastroenterol Nutr. 1998;  27 172-175
  CrossrefPubMedSearch in Google Scholar
• 4 Squires R H, Morriss F, Schleuterman S. et al . Efficacy, safety, cost of intravenous sedation versus general anesthesia in children undergoing endoscopic procedures.  Gastrointest Endosc. 1995;  41 99-104
  Search in Google Scholar
• 5 Bishop P R, Nowicki M J, May W L. et al . Unsedated upper endoscopy in children.  Gastrointest Endosc. 2002;  55 624-630
  CrossrefPubMedSearch in Google Scholar
• 6 Massanari M, Novitsky J, Reinstein L J. Paradoxical reactions in children associated with midazolam use during endoscopy.  Clin Pediatr. 1997;  36 681-684
  PubMedSearch in Google Scholar
• 7 Annequin D, Carbajal R, Chauvin P. et al . Fixed 50 % nitrous oxide mixture for painful procedures: a French survey.  Pediatrics. 2000;  105 E47
  CrossrefPubMedSearch in Google Scholar
• 8 Michaud L, Gottrand F, Ganga-Zandzou P S. et al . Nitrous oxide sedation in pediatric patients undergoing gastrointestinal endoscopy.  J Pediatr Gastroenterol Nutr. 1999;  28 310-314
  CrossrefPubMedSearch in Google Scholar
• 9 Hassall E. Should pediatric gastroenterologists be i.v. drug users?.  J Pediatr Gastroenterol Nutr. 1993;  16 370-372
  PubMedSearch in Google Scholar
• 10 Hedenbro J L, Lindblom A. Patient attitudes to sedation for diagnostic upper endoscopy.  Scand J Gastroenterol. 1991;  26 1115-1120
  PubMedSearch in Google Scholar
• 11 McCloy R F, Pearson R C. Which agents and how to deliver it? A review of benzodiazepine sedation and its reversal in endoscopy.  Scand J Gastroenterol Suppl. 1990;  19 7-11
  PubMedSearch in Google Scholar
• 12 Lee D WH, Chan K W, Poon C M. et al . Relaxation music decreases the dose of patient-controlled sedation during colonoscopy: a prospective randomized controlled trial.  Gastrointest Endosc. 2002;  55 33-36
  CrossrefPubMedSearch in Google Scholar

L. Michaud, M. D.

Unité de Gastro-entérologie, Hépatologie et Nutrition, Clinique de Pédiatrie, Hôpital Jeanne de Flandre

59037 Lille · France

Fax: +33-3-20445963

Email: l-michaud@chru-lille.fr