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Anesthesia/sedation for esophagogastroduodenoscopy/transesophageal echocardiogram in pediatric patients may vary depending on the experience of the anesthesiologist. Important complications may arise in tracheal intubation. Our procedure eliminates these complications and provides a speedy and more comfortable awakening. In our procedure, intubation is not needed. Patients breathe spontaneously through a supraglottic device. This device has three lines that provide O2/ air /sevoflurane, collect CO2 to monitor ventilation, and also function as a guide for the introduction of the gastroscope.
1. Department of Anesthesiology. Children’s Hospital Virgen del Rocío. Seville. Spain.
2. M.D. Department of Anesthesiology , Virgen del Rocío Hospital , Seville. Spain
RecievedSep 12 2013 AcceptedDec 2 2013 PublishedDec 11 2013
CitationRamón Reina González , Ana Lomas (2013) INHALED SEDATION IN PEDIATRIC UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES. OUR EXPERIENCE. Science Postprint 1(1): e00009. doi:10.14340/spp.2013.12C0004
Copyright©2013 The Authors. Science Postprint published by General Healthcare Inc. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 2.1 Japan (CC BY-NC-ND 2.1 JP) License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
FundingThe authors has not been funded by any Foundation or other non-governmental source that has received funding from any organization with a real or potential interest in the subject matter, materials, equipment or devices discussed, or in any competing product or subject.
Competing interestsNo relevant competing interests were disclosed.
Ethics statementWe obtained permission from the parents during the pre-anesthetic consultation, to carry out the anesthesic procedure, as well as to take images and use them for scientific purposes. This work doesn’t form part of any study or trial, it is part of our daily work.
Corresponding authorRamón Reina González
AddressDepartment of Anesthesiology. Children’s Hospital Virgen del Rocío. Avda. Manuel Siurot s/n. Seville. Spain. 41013
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Esophagogastroduodendoscopy (EGD) is a diagnostic and therapeutic routine1 procedure. Due to the lack of cooperation of the pediatric patient, sedation requires intubation2,3 with controlled or spontaneous breathing. Intubation may result in a series of complications such as laryngeal and bronchial spasms, infections or need of more medication. Sedation procedures may vary depending on the experience of the anesthesiologist. These can be performed following different methods: endotracheal intubation, laryngeal mask, etc.1
We are presenting our sedation procedure: an inhaled moderate/deep sedation in which the patient is positioned in left lateral decubitus and a supraglottic device is inserted in the frontal part of the air cavity. This device incorporates three lines (Fig 1), one for administration of O2/air/sevoflurane (to maintain the patient’s sedation in a moderate/deep degree, allowing the patient to breathe on his/her own), another one for capnography and a center line, which is suitable for the insertion of the gastroscope, protecting it from the teeth of the patient (Fig 2, 3).
This article shows our medical experience in the sedation of patients undergoing esophagogastroduodendoscopy. It is not part of any study. It is based on our daily work of the last 10 years. Given that results have been satisfactory, we bring it to the attention of the scientific community.
All patients that underwent this procedure were first studied in preanesthesia, where parental consent was obtained.
The procedure was performed in pediatric patients 6 months and older with a common pathology of celiac disease, eosinophilic esophagitis, idiopathic abdominal pain, reflux esophagitis, helicobacter pyloric gastritis, etc. The weight of the patients ranged between 6-7 kg and 60-80 kg.
Hypnotics (sevoflurane - propofol)
Antitussive, analgesics, sedatives (alfenanil /fentanyl)
The use of morphine derivatives is indicated because of its double function: it provides an antitussive effect as well as analgesia, and boosts the hypnotic state. Alfenalil is preferred to fentanyl because of its half life.
After the standard monitoring (cardiac, peripheral oxygen saturation, blood pressure) we proceed to inhaled sedation with 50% 02/air and 1 minimum alveolar concentration (MAC) sevoflurane with a face mask.
Once sedated, a peripheral intravenous catheter is inserted and atropine 0.01 mg/kg, alfentanyl 10 mcg kg-1 and propofol 2-4mg kg-1 are injected.
Once that the appropriate sedation degree is obtained (moderate/deep) and, while maintaining spontaneous ventilation, the supraglottic device is inserted, attaching it to the face with straps or surgical tape. To maintain sedation, the supraglottic device is connected to a source of 02/air/sevoflurane and to a monitor to measure capnography. Continous fluidotherapy with Lactated Ringer’s solution is administered, and the dosage is adjusted to the patient’s weight.
Maintaining spontaneous ventilation, the patient is positioned in left lateral decubitus. Once the gastroscope is inserted, MAC sevoflurane is increased to 1.5-2 (3% of inhaled sevoflurane). The intake is regulated according to the patient’s response. It is necessary, in some occasions, to administer small doses of propofol. These types of explorations last from 10 to 15 minutes. Moments before the gastroscope is extracted, the flow of sevoflurane ends. The concentration of oxygen is increased up to 60-70%. After the gastroscope and the supraglottic device are extracted, the patient continues breathing on his/her own. Oxygen is applied with a facial mask. This way, the patient responds by opening his/her eyes in no more than 2 minutes.
With the patient hemodynamically stable, maintaining a pulse oximetry around 99-100%, and (in most cases) completely awake, the patient is transferred to the post-anesthesia care unit. There, the patient remains for 10-20 minutes. It is after this when the patient can be transferred to his/her hospital room. In 2-3 hours, the patient can be released from the hospital.
During the performance of this technique and with our anesthesia/sedation procedure, the hemodynamic parameters remain stable: cardiac frequency ranges around 115 heartbeats per minute for pediatric patients older than 10 years old, and up to 130-140 heartbeats per minute for younger patients. Respiratory frequency is maintained between 15-35 breaths per minute.
In the majority of cases, spontaneous ventilation is maintained throughout the procedure. However, there have been cases of brief pauses of apnea. In such cases the levels of sevoflurane MAC were lowered in order to regain spontaneous ventilation. There is only one observed case with apnea pauses that forced to extract the gastroscope and to proceed to tracheal intubation. It was an eight year old patient with Down syndrome, in which there was a very pronounced effect of sevoflurane. In another case, a patient briefly vomited. This was of no consequence, since the patient was positioned in left lateral decubitus. Other than these two cases, we have not had any other complications or any other instances worthy of note with the use of this anesthetic technique.
With our anesthetic/sedative technique and the use of the supraglottic device, hemodynamic and pulmonar complications that may derive from tracheal intubation are eliminated. The sedation of the patient is less invasive and the awakening is faster and comfortable. However, this procedure/technique requires previous training1,3,4.
In our experience, (with an average of 15 patients per week for over 10 years) this technique is a valid alternative to the tracheal intubation. It can be performed safely with moderate sedation and the insertion of a supraglottice device. This technique reduces the frequency of undesirable side effects such as laryngospasms, cardiovascular disorders or respiratory infections.
I would like to thank the nursing staff for their support and contribution to this work.
Reina González, R: anesthesiologist responsible of the airway
Lomas Lozano, A: anesthesiologist responsible of the Postanesthetic Care Unit