J Korean Med Sci.  2021 May;36(20):e136. 10.3346/jkms.2021.36.e136.

Procedural Sedation for Pediatric Upper Gastrointestinal Endoscopy in Korea

Affiliations
  • 1Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
  • 2Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
  • 3Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
  • 4Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
  • 5Department of Pediatrics, Hallym University College of Medicine, Chuncheon, Korea
  • 6Department of Pediatrics, Korea University Anam Hospital, Seoul, Korea
  • 7Department of Pediatrics, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
  • 8Department of Pediatrics, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
  • 9Department of Pediatrics, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
  • 10Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
  • 11Department of Pediatrics, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
  • 12Department of Pediatrics, Inje University Ilsan Paik Hospital, Goyang, Korea
  • 13Department of Pediatrics, Daegu Catholic University School of Medicine, Daegu, Korea
  • 14Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
  • 15Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Korea
  • 16Department of Pediatrics, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
  • 17Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea

Abstract

Background
Sedative upper endoscopy is similar in pediatrics and adults, but it is characteristically more likely to lead to respiratory failure. Although recommended guidelines for pediatric procedural sedation are available within South Korea and internationally, Korean pediatric endoscopists use different drugs, either alone or in combination, in practice. Efforts are being made to minimize the risk of sedation while avoiding procedural challenges. The purpose of this study was to collect and analyze data on the sedation methods used by Korean pediatric endoscopists to help physicians perform pediatric sedative upper endoscopy (PSUE).
Methods
The PSUE procedures performed in 15 Korean pediatric gastrointestinal endoscopic units within a year were analyzed. Drugs used for sedation were grouped according to the method of use, and the depth of sedation was evaluated based on the Ramsay scores. The procedures and their complications were also assessed.
Results
In total, 734 patients who underwent PSUE were included. Sedation and monitoring were performed by an anesthesiologist at one of the institutions. The sedative procedures were performed by a pediatric endoscopist at the other 14 institutions. Regarding the number of assistants present during the procedures, 36.6% of procedures had one assistant, 38.8% had 2 assistants, and 24.5% had 3 assistants. The average age of the patients was 11.6 years old. Of the patients, 19.8% had underlying diseases, 10.0% were taking medications such as epilepsy drugs, and 1.0% had snoring or sleep apnea history. The average duration of the procedures was 5.2 minutes. The subjects were divided into 5 groups as follows: 1) midazolam + propofol + ketamine (M + P + K): n = 18, average dose of 0.03 + 2.4 + 0.5 mg/kg; 2) M + P: n = 206, average dose of 0.06 + 2.1 mg/kg; 3) M + K: n = 267, average dose of 0.09 + 0.69 mg/kg; 4) continuous P infusion for 20 minutes: n = 15, average dose of 6.6 mg/kg; 5) M: n = 228, average dose of 0.11 mg/kg. The average Ramsay score for the five groups was 3.7, with significant differences between the groups (P < 0.001). Regarding the adverse effects, desaturation and increased oxygen supply were most prevalent in the M + K group. Decreases and increases in blood pressure were most prevalent in the M + P + K group, and bag-mask ventilation was most used in the M + K group. There were no reported incidents of intubation or cardiopulmonary resuscitation. A decrease in oxygen saturation was observed in 37 of 734 patients, and it significantly increased in young patients (P = 0.001) and when ketamine was used (P = 0.014). Oxygen saturation was also correlated with dosage (P = 0.037). The use of ketamine (P < 0.001) and propofol (P < 0.001) were identified as factors affecting the Ramsay score in the logistic regression analysis.
Conclusion
Although the drug use by Korean pediatric endoscopists followed the recommended guidelines to an extent, it was apparent that they combined the drugs or reduced the doses depending on the patient characteristics to reduce the likelihood of respiratory failure. Inducing deep sedation facilitates comfort during the procedure, but it also leads to a higher risk of complications.

Keyword

Children; Endoscopy; Ketamine; Midazolam; Propofol; Sedation
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