Paediatric Endoscopy

Take home messages

• There's no one right way to anaesthetise a child for endoscopy, but there are plenty of ways to mess it up
• Intubation is probably the best plan if you're in any doubt about the patient or procedure (or endoscopist...)
• Don't forget the gas

An elective paediatric endoscopy list

Today I was placed onto an elective paediatric endoscopy list with three cases, so to consolidate my own knowledge and pass on some tips and tricks, I thought a post might be nice.

So here we go.

The list:

• 9 year old for OGD
• 9 year old for OGD and colonoscopy
• 16 year old for OGD and colonoscopy

In this instance, all three children were generally fit and well with no cardiorespiratory comorbidities or developmental problems, however our poor teenager had been suffering with rather severe Crohn's for a year or so, including the need for infliximab infusions.

A quick overview of some of the specific conditions the kids may have:

Patients on endscopy lists often have allergies or intolerances, which is frequently the reason for the endoscopy in the first place - remember that children with a soy or egg allergy can still have propofol*.

*I imagine there are a lot of people who would agree it's sensible to try something else if a patient has a history of vigorous anaphylaxis to egg.

Specific Anaesthetic Considerations

As always, start your answer with something along the lines of 'comprehensive preoperative assessment with history and examination'

Anaesthetic technique

Questions to address when deciding your plan of attack:

• Are you going to protect the airway?
• Are you going to breathe for them?

Option 1: Sedation only with native airway

So apparently, NICE recommends midazolam for OGD and midazolam + fentanyl (or equivalent opioid) for colonoscopy, however the evidence seems to suggest that it's not as good as propofol TCI and has higher risk of complications than general anaesthesia.

Overview | Sedation in under 19s: using sedation for diagnostic and therapeutic procedures | Guidance | NICE

National Institute for Health and Care Excellence (NICE)

This is what we did for our first patient on the list:

• IV cannulation with Ametop
• Lidocaine to numb the vein
• TCI and high flow nasal oxygen
• Propofol titrated up to 3.5 microgram per ml as a target plasma concentration
• 400mcg alfentanil titrated to respiratory rate for the more stimulating parts of the procedure
• High flow nasal oxygen set at 60 litres per minute

The procedure was quick and uneventful, the child remained spontaneously breathing throughout and so as soon as the endoscope was out, we switched of the propofol and swapped the HFNO to a conventional facemask and wandered straight round to recovery.

Fun fact - Apparently some endoscopists find the biomechanics of spontaneous breathing are helpful for colonoscopy.

Option 2 - Supraglottic Airway

I've never done it this way myself - I've only ever tubed or used high flow nasal oxygen with sedation - but apparently it works quite well.

Just remember to use a smaller IGEL than you might otherwise have picked.

Interestingly there is also the LMA Gastro that has a dedicated endoscope port, which works moderately well according to many people, but I've never seen it used myself and it's not licensed in children so maybe ignore this bit.

Intubation

By now I'm hoping you're familiar with Anaestheasier's third rule.

While many clinicians will opt to tube when others might not, there are a few scenarios in which you should definitely be thinking of grabbing a laryngoscope:

• If they're less than a year old or really tiny (<10kg) then it's probably best not to mess around, given they desaturate so quickly and SGAs don't tend to sit all that well
• If they're known to have significant airway issues or obstructive sleep apnoea
• Significant cardiac or respiratory co-morbidity is pretty much always an indication for intubation in any patient, (so stick this down in a CRQ if you're struggling for answers)
• High risk of aspiration, including GORD or congenital oesophageal problems
• Some particular procedures (such as PEG tubes) generally need intubation, especially if they're going to take a long time or need multiple position changes for the patient

Because of the length of the procedures and potential need to reposition, we opted to intubate both of our second two patients on this list.

• IV cannulation with Ametop
• Lidocaine to numb the vein
• Preoxygenation with 100% oxygen
• Fentanyl bolus
• Propofol bolus for induction
• Parent allowed to kiss their child and escorted swiftly out at this point
• Rocuronium bolus
• Intubation using direct laryngoscopy and cuffed ET tube
• Wheeled into theatre and positioned in left lateral position
• No need for bite block as paralysis given
• Fentanyl boluses as required
• Sugammadex prior to wake up

Where I work, patients need to be extubated before transfer to recovery, so there was a bit of a delay while we waited for our sleepy little ones to resurface, but it wasn't a high-paced list so the safety of intubation hugely outweighed any downsides.

All three kids were reviewed on the ward afterwards - comfortable, happy and - crucially - blissfully unaware of the morning's events.

Gas problems

No matter how diligently your endoscopist deflates the stomach and oesophagus prior to removing their scope, there will always be air in the stomach when it comes to wake up time.

This can present a number of issues:

• Discomfort and pain
• Nausea and vomiting
• Aspiration risk
• Splinting of abdomen and respiratory compromise

Gently pressing on the abdomen, or event a quick naso- or orogastric tube can help remove some of that air and make your life a little easier.

Useful Tweets

Not strictly relevant but cool - these clever people managed to get all the way to the jejunum in a bleeding adult using a paediatric colonoscope.

References and Further Reading

• BJA ed - Anaesthesia for children having endoscopy on a gastroenterology list
• https://litfl.com/button-battery-update/

Looking for free CRQs for the FRCA?

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Revision for the Royal College of Anaesthetists Fellowship exam

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