Pediatrics

Physiological Differences
Pharmacologic considerations
Patient care and assessment

It is well accepted that children undergoing gastrointestinal endoscopy should receive sedation for the procedure.  Nevertheless, considerable practice variation prevails. Potential methods for sedating children include endoscopist-administered IV sedation, anesthesiologist-administered propofol sedation, or anesthesiologist-administered inhalational general anesthesia. Regardless of regimen used, the safe administration of sedation to children requires an awareness of the particular needs of this population.  In particular, children are at risk for agitation during sedated procedures, adding to stress for both patients and clinical staff. General anesthesia provides the advantage of complete patient immobility but also entails increased access to and utilization of resources.

Traditionally, pediatric populations span the first two decades of life and encompass both newborns and teenagers.  Doses of sedatives in children should always be weight adjusted.  It is also important to tailor sedative regimens to developmental stage.  Generally speaking, the American Academy of Pediatrics has published a set of criteria that should be met to safeguard the needs of children undergoing sedation. 

Summary of American Academy of Pediatrics Guidelines for Sedation of Children
  • No administration of sedation medications without medical supervision
  • Careful pre-sedation evaluation for underlying medical or surgical conditions that could increase risk from sedation 
  • Appropriate pre-procedure fasting for elective procedures; balance between sedation depth and risk of aspiration for urgent procedures in patients unable to fast
  • Careful airway examination to identify abnormalities that could increase the potential for airway obstruction
  • Thorough understanding of the pharmacokinetic and pharmacodynamic effects and drug interactions of medications used for sedation
  • Appropriate monitoring during and after the procedure
  • Properly equipped and staffed recovery area
  • Recovery to point of consciousness before discharge and appropriate discharge instructions

 

Physiological Differences

Anatomical and physiological differences between children and adults can make children more vulnerable to the adverse effects of sedatives. In addition, children's psychological needs and ability to cooperate will vary based on their developmental stage and need to be taken into consideration by the clinician performing the procedure. 

Airway anatomy (see Airway Management)

Physiological differences 

  • Larynx located higher in the neck
  • Narrow oropharyngeal passages
  • Large tongue

Sedation considerations

  • Hyperextension of the neck may worsen airway obstruction
  • Large tongue can fall toward the roof of mouth in sedated child and obstruct airway
  • Critical to choose appropriately-sized oral airway if used; soft nasal airways more appropriate in mild and moderate sedation.
  • Airway obstruction is major cause of hypoxemia in children; airway should be reassessed frequently for signs of obstruction
  • Reduced ventilation caused by prone or supine positions, or by constraining garments or restraints, may result in hypoventilation
Respiratory function

Physiological differences

  • Increased metabolic rate resulting in higher oxygen consumption
  • Less alveolar space
  • Sternum and ribs more pliable in children

Sedation considerations

  • Decrease in breathing rate due to sedation can cause significant respiratory insufficiency
  • Chest wall retractions and abdominal muscle use are used to identify respiratory distress
Cardiovascular system

Physiological differences

  • Normal parameters for heart rate, respiration, and blood pressure vary based on child’s age
  • Circulatory response to hypoxia in young children is bradycardia
  • Heart rate primary factor determining changes in pediatric cardiac output
  • Active parasympathetic nervous system
  • Drugs that slow heart rate will cause a drop in cardiac output and decrease circulation times

Sedation considerations

  • Knowledge of age-appropriate vital signs is critical
  • 100% oxygen should be administered when heart rate decreases
  • Hypoxia, deep sedation, and painful events can produce bradycardia
  • Decrease in circulation times results in longer onset and prolonged length of action for sedation medications
Body Composition

Physiological differences

  • Large body surface to body mass and thinner skin can result in dehydration and/or rapid loss of body heat
  • Higher total body water
  • Decreased tolerance for starvation and tendency to become hypoglycemic when fasting

Sedation considerations

  • Children should be well draped and room temperature adjusted to prevent hypothermia 
  • May need maintenance fluids for circulatory support especially for children under age 8 and children who have been NPO for significant time
  • Replacement fluids should contain 2.5% dextrose and half normal saline
Hepatic & renal function

Physiological differences

  • Hepatic and renal function less developed

Sedation considerations

  • Length of action of drugs is longer to reduced hepatic function
  • Clearing times may be faster due to higher circulating volumes
Developmental characteristics

Physiological differences

  • Neurologic system not well developed in children younger than 8 to 10 years old
  • Significant psychological stress often associated with medical procedure especially at younger ages

Sedation considerations

  • Familiarity with normal age appropriate behaviors of child can help in identifying changes in child's level of functioning
  • Supplying age appropriate information before the procedure can reduce anxiety and allow for the use of less sedation

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Pharmacologic considerations for pediatric patients

The American Academy of Pediatrics Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures states the following goals for sedation in children:

  • Guard the patient's safety, privacy and welfare
  • Minimize physical discomfort and pain
  • Control anxiety
  • Minimize psychological trauma and maximize the potential for amnesia
  • Control behavior and movement to allow safe completion of the procedure
  • Return the patient to state in which safe discharge is possible

Sedation techniques and regimens

An ideal pediatric sedation regimen is characterized by rapid onset, rapid recovery, minimal adverse effects, and rapid metabolism to prevent cumulative effect.  To best achieve these goals, the AAP recommends that clinicians designing sedation regimens for children select the lowest dose of the drug with the highest therapeutic value for the procedure; the fewest number of drugs possible; and the drug best suited to the type and goal of the procedure.

The ASGE guideline on Modifications in Endoscopic Practice for Pediatric Patients outlines the following recommendations regarding sedation agents: 

Commonly used regimens:

  • Midazolam with or without fentanyl or meperidine is most commonly used for moderate sedation in children.
  • Midazolam has a shorter duration of action than other commonly used benzodiazepines. Dose response curve is highly variable; weight-based dosing produces variable levels of sedation in agitated children of the same weight. 
  • Incorporation of midazolam in sedation regimens results in improved amnesia effects.
  • Less midazolam is needed when fentanyl is administered, than when meperidine is given with midazolam.
  • Oral and nasal premedication with benzodiazepines can be useful in pediatric patients before administering IV moderate sedation. Peak concentrations and effects of midazolam are reached 10 minutes after intranasal administration and about 20 to 30 minutes after oral ingestion.
  • Patients have shorter recovery times when fentanyl is used compared with meperidine.
  • General anesthesia and propofol are commonly used for pediatric endoscopy, usually due to patient's age or anticipated intolerance for the procedure. Other indications include:
    • complexity of the planned procedure
    • physician preferences
    • patient's other medical conditions
    • institutional guidelines
  • Children metabolize propofol differently from adults due to larger central volumes of distribution and more rapid clearance of drugs.

Dosing:

  • Sedation should be administered based on the patient's weight and titrated by response.
  • Adequate time should be allowed between doses to assess sedation effects and determine the need for additional medication.  For example, midazolam should be titrated to effect with at least 3 minutes between doses, while fentanyl should have 5 minutes between doses.
  • Dosing requirements for individual patients may vary significantly based on the patient's psychosocial development and attention to the surrounding environment by the endoscopy team.
  • Higher doses of medications are frequently needed in preschool, elementary school aged, and preteen children compared with those used in teenage patients.

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Patient care and assessment of pediatric patients

As a group, pediatric patients have needs that require particular attention in assessment, monitoring and care.

Patient assessment

As with adult patients, a thorough pre-procedure assessment should be preformed prior to the endoscopic procedure. A complete health history and physical exam should be performed including the designation of an American Society of Anesthesiologists (ASA) score and recording baseline vital signs. Patient factors including cardiac, pulmonary, renal or hepatic function abnormalities which may affect response to sedation and analgesia should be explored. In addition, the clinician should complete a focused airway assessment. Consultations with the pediatrician, anesthesiologist or medical specialist should be sought where appropriate. In addition, a thorough review should be performed of the patient's current medications including over-the-counter and herbal supplements.  According to standards outlined by The Joint Commission, all perioperative nursing care is conducted by a registered nurse.

Monitoring

Guidelines set by the American Academy of Pediatrics for procedural monitoring of pediatric patients undergoing moderate sedation closely adhere to the requirements for monitoring of patients receiving general anesthesia. There should be a registered nurse specifically assigned to monitor the patient's cardiorespiratory status during and after the procedure. Vital signs should be recorded every 5 minutes. At least one person present should be specifically trained in pediatric rescue maneuvers; training in pediatric advanced life support is preferable. Monitoring should include: 

  • Visual observation. The patient's face and mouth and chest wall movement should be observed continuously.
  • Heart rate. Monitoring should be conducted with electrocardiogram (EKG) or precordial stethoscope.
  • Pulse oximetry. Pulse oximetry should be performed continuously.  However, it is important to recognize that pulse oximetry does not measure ventilation. In turn, capnography may allow early detection of arterial oxygen desaturation, even in the presence of supplemental oxygen.
  • Capnography. Capnography may be helpful to detect alveolar hypoventilation and reduce hypoxemia during procedural sedation in children.

Emergency Equipment

The resuscitative equipment available for pediatric procedures should reflect the equipment used for moderate sedation in adults with attention to the proper sizes and doses for the ages being treated. (For a complete list of specific equipment and medications for pediatric sedation, see the AAP guideline.)

To ensure a systematic approach, the SOAPME method is useful for planning. 

SOAPME Checklist
S (suction)
Size-appropriate suction catheters and a functioning oral suctioning tool (eg, Yankauer)
O (oxygen)
Adequate oxygen supply and functioning flow meters/other devices to allow its delivery
A (airway)
Size-appropriate airway equipment: nasopharyngeal and oropharyngeal airways, laryngoscope blades (checked and functioning), endotracheal tubes, stylets, face mask, bag-valve-mask or equivalent device. Confirm that devices are functioning.
P (pharmacy)
All the basic drugs needed to support life during an emergency, including antagonists as indicated
M (monitors)
Functioning pulse oximeter with size-appropriate oximeter probes and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, end-tidal carbon dioxide, ECG, stethoscope)
E (equipment)
Special equipment or drugs for a particular case


Postprocedure monitoring and discharge

In the Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures, the American Academy of Pediatrics specify the following criteria for postprocedure monitoring and discharge of patients who have undergone moderate sedation.  (See Recovery & Discharge: postsedation monitoring)

Postprocedure monitoring:

  • Observation in a recovery area fully equipped for emergency resuscitation
  • Recording of vital signs at specific intervals
  • Continued monitoring of heart rate and oxygen saturation until patient is sufficiently alert to meet discharge criteria
  • Movement to step-down area for less intense monitoring if necessary when sedation medication has a longer half-life
  • Longer observation for patients who have received reversal agents such as flumazenil or naloxone

Discharge:

  • Cardiovascular function and airway patency satisfactorily stable
  • Patient easily arousable with intact protective reflexes
  • Level of consciousness close to preprocedure levels
  • Age-appropriate speech and ambulation returned to pre-sedation levels
  • Ability to sit up if age and motor skills allow
  • Adequate hydration status

Upon discharge, specific oral and written discharge instructions should be given to the responsible adult who has accompanied the child to the procedure. These should include:

  • Signs and symptoms of potential complications
  • Steps to follow in case of complications
  • 24-hour emergency telephone number
  • Special instructions for observing child’s head position to prevent airway occlusion if child will travel in a car seat.

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Sources

American Society for Gastrointestinal Endoscopy. Modifications in endoscopic practice for pediatric patients. Gastrointestinal Endoscopy;2008(67):1-9.

Cote CJ, Wilson S. American Academy of Pediatrics: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics; 2006(118):2587-2602.

Hom J. Pediatrics, Sedation. eMedicine. January 14, 2008.

Kost M. Moderate Sedation/Analgesia: Core Competencies for Practice, 2nd Ed. St. Louis, MO: Saunders, St. Louis; 2004.p.202.

Lazear SE. Course 1055: Moderate sedation/analgesia. CME resources. Revised 01/01//06. 


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Last Updated September 29, 2008