Indian J Gastroenterol (March–April 2015) 34(2):158–163 DOI 10.1007/s12664-015-0556-5
ORIGINAL ARTICLE
A survey of procedural sedation for pediatric gastrointestinal endoscopy in India Barath Jagadisan 1
Received: 27 October 2014 / Accepted: 31 March 2015 / Published online: 29 April 2015 # Indian Society of Gastroenterology 2015
Abstract Background Sedation practices for pediatric gastrointestinal endoscopic procedures (PGEP) vary based on infrastructure, availability of trained personnel, and local protocols. Data on prevalent sedation practices is lacking from India. This study aimed to survey the sedation practices for PGEP in India. Methods A mailing list was constituted with the e-mail addresses of the members of the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition, Indian Academy of Pediatrics, Association of Surgeons of India, Indian Association of Pediatric Surgeons, and Indian Society of Gastroenterology. The web-based survey was sent by e-mail. Results Of the 498 recipients, who responded through the survey link, 91 did not complete the survey. Among those who completed the survey, 91 performed PGEP. Among these 91, 12.1 % performed PGEP without sedation or general anesthesia. Anesthetist involvement was associated with use of propofol based-sedation. Of the respondents, 70.3 % found non-anesthetist administered propofol sedation unacceptable while 38.5 % of the centers had a policy against it. Two-thirds of the respondents were assisted by an anesthetist for most PGEP. An operating room (OR) was used for PGEPs by 23.1 %. PGEP in a non-teaching hospital, non-availability of pediatrician in the endoscopy room, use of an OR for PGEP, and the easy availability of an anesthetist were strongly associated with the involvement of an anesthetist. Conclusions The survey indicates a high frequency of involvement of anesthetists and use of OR. This survey should
* Barath Jagadisan [email protected] 1
Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605 006, India
serve as an impetus to evaluate the cost of PGEP in India and the training accorded to non-anesthetists for procedural sedation. Keywords Children . Developing country . Gastrointestinal endoscopy . India . Procedural sedation . Survey
Introduction Gastrointestinal endoscopies are common diagnostic or therapeutic procedures across all ages. Sedation during endoscopy decreases pain and psychological trauma, ensures successful and smooth completion of procedure, and improves ease of procedure for the endoscopist while ensuring patient safety [1]. Among adults, sedation is not universally used for routine diagnostic esophagogastroduodenoscopies (EGD) and colonoscopies [2, 3]. Mandatory sedation is reserved for complex or prolonged procedures or for some specific therapeutic procedures. In contrast, it is always advisable to perform even simple diagnostic pediatric gastrointestinal endoscopic procedures (PGEP) under sedation [4]. Even though there is usually a good agreement in literature regarding the need for sedation in PGEP, the sedation practices are variable including the person administering sedation and the choice of drugs [1]. Institutional resources, logistics of scheduling an operation theater, availability of anesthetist, procedural volume, institutional policies, and cost and availability of trainees may be some of the factors that dictate sedation practices for PGEP [5–7]. In literature, there is an increasing interest in non-anesthetist administered sedation and increased use of propofol (including non-anesthetist administered propofol sedation (NAAP)) [8, 9]. While there is data from the West and Taiwan to understand the sedation practices in PGEPs, no data is available from developing countries such as India [10–12]. A reflection
Indian J Gastroenterol (March–April 2015) 34(2):158–163
of sedation practices in the country is needed to provide an understanding of resource availability for endoscopy services (both material and human), the possible economic burden on patients for endoscopic procedures, variability in protocols, and institutional policies. Such a characterization will assist in framing guidelines that account for local resources while identifying focus areas for future training of personnel. A survey was designed to characterize the sedation practices for PGEP in India. The focus was on the utilization of an anesthetist’s services and the operating room (OR) which determine procedural cost and understanding the variation in sedation protocols. In the unique context of India, where PGEPs are performed by people with and without a formal training in a pediatric medical or surgical speciality (adult physicians, adult gastroenterologist, surgical gastroenterologist, general surgeon, general pediatricians, pediatric gastroenterologists, and pediatric surgeons), restriction of any PGEP-related survey to any one of these groups would be a poor reflection of the current status.
Methodology A mailing list was constituted with the e-mail addresses of the members of the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition, Indian Academy of Pediatrics, Association of Surgeons of India, Indian Association of Pediatric Surgeons, and Indian Society of Gastroenterology. Since there was some overlap in the membership of individuals, all duplicates were removed, and the final list comprised of 16,360 email addresses. The survey was created on www.surveymonkey.com with skip logic. The skip logic of the survey terminated the survey at various points to exclude those who have emigrated from India and those who do not perform endoscopies. Among those who performed endoscopies, only those who performed PGEP were posed with further questions. The questions were related to the sedation practices, availability and training of personnel, infrastructure, and logistic issues related to sedation for PGEP in children 75 %) of the PGEP
Without sedation/general anesthesia Non-propofol sedation Propofol-based sedation GA with elective intubation/laryngeal mask With sedation but nature of drugs unknown Operating room Endoscopy room Yes No Pediatrician Non-pediatric resident Anesthetist Nurse under directions from the endoscopist Pediatric intensivist Sedation never employed Sedation GA with airway intubation
11 (12.1) 27 (29.7) 37 (40.6) 12 (13.2) 4 (4.4) 21 (23.1) 70 (76.9) 60 (65.9) 31 (34.1) 17 (18.7) 3 (3.3) 53 (58.2) 6 (6.6) 5 (5.5) 7 (7.7) 56 (61.5) 26 (28.6)
Anesthetist never been involved Sedation never used (unsedated PGEP/ under GA) Diazepam and ketamine Midazolam alone Midazolam and ketamine Midazolam and fentanyl Propofol and fentanyl Propofol and ketamine Propofol alone Propofol and midazolam No single regimen, wide assortment Do not know No premedication used Oral midazolam Nasal midazolam Promethazine Triclofos Do not know Yes
9 (9.9) 5 (5.5) 1 (1.1) 6 (6.6) 28 (30.8) 4 (4.4) 11 (12.1) 15 (16.5) 11 (12.1) 1 (1.1) 5 (5.5) 4 (4.4) 67 (73.6) 9 (9.9) 7 (7.7) 1 (1.1) 1 (1.1) 6 (6.6) 15 (16.5)
No Yes No Exclusive GA (never sedated)
76 (83.5) 68 (74.7) 17 (18.7) 6 (6.6)
Location of most (75 %) of the PGEP Anesthetist called for most (75 %) of the PGEP Personnel who administered sedation if PGEP had ever been done under sedation
Anesthetist’s preference whenever an anesthetist was involved
Preferred sedation regimen whenever sedation was used
Premedication used
Propofol ever been administered by a non-anesthetist in the endoscopy room Routine supplemental oxygen for sedation
PGEP pediatric gastrointestinal endoscopic procedures, GA general anesthesia
PGEP by the respondents who worked in centers that train residents in endoscopy (4/30) and the use of GA by respondents who worked in centers that do not train residents in endoscopy (8/61) (p=1; odds ratio 0.98; 95 % confidence interval (CI) 0.27–3.56). Fourteen of the 21 centers that were
performing PGEP predominantly in the OR had an endoscopy room that is equipped for GA as against 45 of the 70 centers that were performing PGEP predominantly in the endoscopy room. The difference was not statistically significant (p=0.84; odds ratio 1.11; 95 % CI 0.4–3.11). Ease of scheduling an OR
Indian J Gastroenterol (March–April 2015) 34(2):158–163 Table 2 Availability of personnel, infrastructure, and logistic issues related to sedation in the workplace among those who were performing pediatric gastrointestinal endoscopic procedures (n=91)
161
Survey
Responses
Frequencies n (%)
Availability of residents (trainees) in the endoscopy rooma
Pediatric residents were available Residents available but they were not pediatricians Residents were not available Yes No Easy Difficult Easily available Not easily available Not available at all Yes No PALS trained Not trained in PALS Did not know about PALS training Non-anesthetist never been involved
36 (39.6) 19 (20.9)
Training of residents in pediatric endoscopy Ease of scheduling a PGEP in the operating room Ease of availing the services of an anesthetist for PGEP Endoscopy room equipped for GA with elective intubation for PGEP PALS training of a non-anesthetist involved in sedation for PGEP
a
36 (39.6) 30 (33) 61 (67) 58 (63.7) 33 (36.3) 71 (78) 19 (20.9) 1 (1.1) 59 (64.8) 32 (35.2) 24 (26.4) 10 (11) 3 (3.3) 54 (59.3)
It was not necessary that the resident was getting trained in endoscopy
PGEP pediatric gastrointestinal endoscopic procedures, GA general anesthesia, PALS pediatric advanced life support
for PGEP was more often seen in centers where PGEP was commonly performed in the OR compared to centers where PGEP was commonly performed in the endoscopy room (18/ 21 vs. 40/70; p=0.02; odds ratio 4.5; 95 % CI 1.21–16.69). Only 6.6 % (6/91) of the respondents used sidestream capnography always. Sixteen out of 91 (17.6 %) stated that children less than 3 months of age had also undergone PGEP under sedation in their center. While 64/91 (70.3 %) opined that non-anesthetists should not be allowed to administer propofol for PGEP, 20/91 (22 %) felt that they should be allowed, and 7/91 (7.7 %) had no opinion on the issue. There was a policy on preventing propofol administration by non-anesthetists in 35/91 (38.5 %) centers while it was allowed in 9/91 (9.9 %) centers. In 31/91 (34.1 %) centers, there was no policy on the issue, or the respondent did not know about any such policy in 16/91 (17.6 %) cases.
Discussion This survey aimed to provide a reflecting of sedation practices for PGEP in India. Even though a sizeable number of PGEP were performed under sedation, a significant number of respondents (13.2 %) preferred GA for more than 75 % of their PGEP. The use of GA for PGEP might prolong the hospital stay which in turn might translate to higher cost for the
patients. Another significant group of respondents (12.1 %) were performing PGEP without either sedation or GA. PGEP performed without sedation/GA is likely to affect the psychological well-being of children who undergo such procedures. Such a practice may be a reflection of poor availability of manpower to provide either GA or sedation for PGEP or a reflection of the infrastructure. Formal sedation teams are not available within a pediatric unit even in many tertiary care centers in India, and the need is very often met by an anesthetist. Since most PGEPs were being performed in teaching hospitals, the development of organized pediatric sedation services and teams in teaching hospitals by training pediatricians in procedural sedation for PGEP might translate into better availability of pediatric sedation services in both these teaching hospitals and also in non-teaching hospitals and clinics in the community. A wide array of sedation protocols was used but the combination of midazolam and ketamine was still the single most commonly used combination for PGEP (30.8 %). Propofol or propofol-based combinations together constituted up to 40.7 % of the preferred regimen. Unfortunately, no premedication was used in up to 73.6 % cases. Routine supplemental oxygen was not used by 18.7 % of the respondents. The involvement of anesthetists was associated with more frequent use of propofol.
162 Table 3
Indian J Gastroenterol (March–April 2015) 34(2):158–163 Association of responses to the involvement of an anesthetist in pediatric gastrointestinal endoscopic procedures Anesthetist involvementa n=91
Variables
Availability of pediatric residents in the endoscopy roomb Residents being trained in PGEP Easily available services of an anesthetist for PGEP Propofol based regimes for sedation used Endoscopist with a formal training in a pediatric specialityc PGEP performed in operating room Nature of workplace
Available Unavailable Yes No Yes No Yes No Yes No Yes No Teaching hospital Non-teaching hospital
Yes (n=60)
No (n=31)
15 45 17 43 56 4 34 26 29 31 20 40 31 29
21 10 13 18 15 16 3 28 20 11 1 30 26 5
p-value
Odds ratio (95 % CI)
ORIGINAL ARTICLE
A survey of procedural sedation for pediatric gastrointestinal endoscopy in India Barath Jagadisan 1
Received: 27 October 2014 / Accepted: 31 March 2015 / Published online: 29 April 2015 # Indian Society of Gastroenterology 2015
Abstract Background Sedation practices for pediatric gastrointestinal endoscopic procedures (PGEP) vary based on infrastructure, availability of trained personnel, and local protocols. Data on prevalent sedation practices is lacking from India. This study aimed to survey the sedation practices for PGEP in India. Methods A mailing list was constituted with the e-mail addresses of the members of the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition, Indian Academy of Pediatrics, Association of Surgeons of India, Indian Association of Pediatric Surgeons, and Indian Society of Gastroenterology. The web-based survey was sent by e-mail. Results Of the 498 recipients, who responded through the survey link, 91 did not complete the survey. Among those who completed the survey, 91 performed PGEP. Among these 91, 12.1 % performed PGEP without sedation or general anesthesia. Anesthetist involvement was associated with use of propofol based-sedation. Of the respondents, 70.3 % found non-anesthetist administered propofol sedation unacceptable while 38.5 % of the centers had a policy against it. Two-thirds of the respondents were assisted by an anesthetist for most PGEP. An operating room (OR) was used for PGEPs by 23.1 %. PGEP in a non-teaching hospital, non-availability of pediatrician in the endoscopy room, use of an OR for PGEP, and the easy availability of an anesthetist were strongly associated with the involvement of an anesthetist. Conclusions The survey indicates a high frequency of involvement of anesthetists and use of OR. This survey should
* Barath Jagadisan [email protected] 1
Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605 006, India
serve as an impetus to evaluate the cost of PGEP in India and the training accorded to non-anesthetists for procedural sedation. Keywords Children . Developing country . Gastrointestinal endoscopy . India . Procedural sedation . Survey
Introduction Gastrointestinal endoscopies are common diagnostic or therapeutic procedures across all ages. Sedation during endoscopy decreases pain and psychological trauma, ensures successful and smooth completion of procedure, and improves ease of procedure for the endoscopist while ensuring patient safety [1]. Among adults, sedation is not universally used for routine diagnostic esophagogastroduodenoscopies (EGD) and colonoscopies [2, 3]. Mandatory sedation is reserved for complex or prolonged procedures or for some specific therapeutic procedures. In contrast, it is always advisable to perform even simple diagnostic pediatric gastrointestinal endoscopic procedures (PGEP) under sedation [4]. Even though there is usually a good agreement in literature regarding the need for sedation in PGEP, the sedation practices are variable including the person administering sedation and the choice of drugs [1]. Institutional resources, logistics of scheduling an operation theater, availability of anesthetist, procedural volume, institutional policies, and cost and availability of trainees may be some of the factors that dictate sedation practices for PGEP [5–7]. In literature, there is an increasing interest in non-anesthetist administered sedation and increased use of propofol (including non-anesthetist administered propofol sedation (NAAP)) [8, 9]. While there is data from the West and Taiwan to understand the sedation practices in PGEPs, no data is available from developing countries such as India [10–12]. A reflection
Indian J Gastroenterol (March–April 2015) 34(2):158–163
of sedation practices in the country is needed to provide an understanding of resource availability for endoscopy services (both material and human), the possible economic burden on patients for endoscopic procedures, variability in protocols, and institutional policies. Such a characterization will assist in framing guidelines that account for local resources while identifying focus areas for future training of personnel. A survey was designed to characterize the sedation practices for PGEP in India. The focus was on the utilization of an anesthetist’s services and the operating room (OR) which determine procedural cost and understanding the variation in sedation protocols. In the unique context of India, where PGEPs are performed by people with and without a formal training in a pediatric medical or surgical speciality (adult physicians, adult gastroenterologist, surgical gastroenterologist, general surgeon, general pediatricians, pediatric gastroenterologists, and pediatric surgeons), restriction of any PGEP-related survey to any one of these groups would be a poor reflection of the current status.
Methodology A mailing list was constituted with the e-mail addresses of the members of the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition, Indian Academy of Pediatrics, Association of Surgeons of India, Indian Association of Pediatric Surgeons, and Indian Society of Gastroenterology. Since there was some overlap in the membership of individuals, all duplicates were removed, and the final list comprised of 16,360 email addresses. The survey was created on www.surveymonkey.com with skip logic. The skip logic of the survey terminated the survey at various points to exclude those who have emigrated from India and those who do not perform endoscopies. Among those who performed endoscopies, only those who performed PGEP were posed with further questions. The questions were related to the sedation practices, availability and training of personnel, infrastructure, and logistic issues related to sedation for PGEP in children 75 %) of the PGEP
Without sedation/general anesthesia Non-propofol sedation Propofol-based sedation GA with elective intubation/laryngeal mask With sedation but nature of drugs unknown Operating room Endoscopy room Yes No Pediatrician Non-pediatric resident Anesthetist Nurse under directions from the endoscopist Pediatric intensivist Sedation never employed Sedation GA with airway intubation
11 (12.1) 27 (29.7) 37 (40.6) 12 (13.2) 4 (4.4) 21 (23.1) 70 (76.9) 60 (65.9) 31 (34.1) 17 (18.7) 3 (3.3) 53 (58.2) 6 (6.6) 5 (5.5) 7 (7.7) 56 (61.5) 26 (28.6)
Anesthetist never been involved Sedation never used (unsedated PGEP/ under GA) Diazepam and ketamine Midazolam alone Midazolam and ketamine Midazolam and fentanyl Propofol and fentanyl Propofol and ketamine Propofol alone Propofol and midazolam No single regimen, wide assortment Do not know No premedication used Oral midazolam Nasal midazolam Promethazine Triclofos Do not know Yes
9 (9.9) 5 (5.5) 1 (1.1) 6 (6.6) 28 (30.8) 4 (4.4) 11 (12.1) 15 (16.5) 11 (12.1) 1 (1.1) 5 (5.5) 4 (4.4) 67 (73.6) 9 (9.9) 7 (7.7) 1 (1.1) 1 (1.1) 6 (6.6) 15 (16.5)
No Yes No Exclusive GA (never sedated)
76 (83.5) 68 (74.7) 17 (18.7) 6 (6.6)
Location of most (75 %) of the PGEP Anesthetist called for most (75 %) of the PGEP Personnel who administered sedation if PGEP had ever been done under sedation
Anesthetist’s preference whenever an anesthetist was involved
Preferred sedation regimen whenever sedation was used
Premedication used
Propofol ever been administered by a non-anesthetist in the endoscopy room Routine supplemental oxygen for sedation
PGEP pediatric gastrointestinal endoscopic procedures, GA general anesthesia
PGEP by the respondents who worked in centers that train residents in endoscopy (4/30) and the use of GA by respondents who worked in centers that do not train residents in endoscopy (8/61) (p=1; odds ratio 0.98; 95 % confidence interval (CI) 0.27–3.56). Fourteen of the 21 centers that were
performing PGEP predominantly in the OR had an endoscopy room that is equipped for GA as against 45 of the 70 centers that were performing PGEP predominantly in the endoscopy room. The difference was not statistically significant (p=0.84; odds ratio 1.11; 95 % CI 0.4–3.11). Ease of scheduling an OR
Indian J Gastroenterol (March–April 2015) 34(2):158–163 Table 2 Availability of personnel, infrastructure, and logistic issues related to sedation in the workplace among those who were performing pediatric gastrointestinal endoscopic procedures (n=91)
161
Survey
Responses
Frequencies n (%)
Availability of residents (trainees) in the endoscopy rooma
Pediatric residents were available Residents available but they were not pediatricians Residents were not available Yes No Easy Difficult Easily available Not easily available Not available at all Yes No PALS trained Not trained in PALS Did not know about PALS training Non-anesthetist never been involved
36 (39.6) 19 (20.9)
Training of residents in pediatric endoscopy Ease of scheduling a PGEP in the operating room Ease of availing the services of an anesthetist for PGEP Endoscopy room equipped for GA with elective intubation for PGEP PALS training of a non-anesthetist involved in sedation for PGEP
a
36 (39.6) 30 (33) 61 (67) 58 (63.7) 33 (36.3) 71 (78) 19 (20.9) 1 (1.1) 59 (64.8) 32 (35.2) 24 (26.4) 10 (11) 3 (3.3) 54 (59.3)
It was not necessary that the resident was getting trained in endoscopy
PGEP pediatric gastrointestinal endoscopic procedures, GA general anesthesia, PALS pediatric advanced life support
for PGEP was more often seen in centers where PGEP was commonly performed in the OR compared to centers where PGEP was commonly performed in the endoscopy room (18/ 21 vs. 40/70; p=0.02; odds ratio 4.5; 95 % CI 1.21–16.69). Only 6.6 % (6/91) of the respondents used sidestream capnography always. Sixteen out of 91 (17.6 %) stated that children less than 3 months of age had also undergone PGEP under sedation in their center. While 64/91 (70.3 %) opined that non-anesthetists should not be allowed to administer propofol for PGEP, 20/91 (22 %) felt that they should be allowed, and 7/91 (7.7 %) had no opinion on the issue. There was a policy on preventing propofol administration by non-anesthetists in 35/91 (38.5 %) centers while it was allowed in 9/91 (9.9 %) centers. In 31/91 (34.1 %) centers, there was no policy on the issue, or the respondent did not know about any such policy in 16/91 (17.6 %) cases.
Discussion This survey aimed to provide a reflecting of sedation practices for PGEP in India. Even though a sizeable number of PGEP were performed under sedation, a significant number of respondents (13.2 %) preferred GA for more than 75 % of their PGEP. The use of GA for PGEP might prolong the hospital stay which in turn might translate to higher cost for the
patients. Another significant group of respondents (12.1 %) were performing PGEP without either sedation or GA. PGEP performed without sedation/GA is likely to affect the psychological well-being of children who undergo such procedures. Such a practice may be a reflection of poor availability of manpower to provide either GA or sedation for PGEP or a reflection of the infrastructure. Formal sedation teams are not available within a pediatric unit even in many tertiary care centers in India, and the need is very often met by an anesthetist. Since most PGEPs were being performed in teaching hospitals, the development of organized pediatric sedation services and teams in teaching hospitals by training pediatricians in procedural sedation for PGEP might translate into better availability of pediatric sedation services in both these teaching hospitals and also in non-teaching hospitals and clinics in the community. A wide array of sedation protocols was used but the combination of midazolam and ketamine was still the single most commonly used combination for PGEP (30.8 %). Propofol or propofol-based combinations together constituted up to 40.7 % of the preferred regimen. Unfortunately, no premedication was used in up to 73.6 % cases. Routine supplemental oxygen was not used by 18.7 % of the respondents. The involvement of anesthetists was associated with more frequent use of propofol.
162 Table 3
Indian J Gastroenterol (March–April 2015) 34(2):158–163 Association of responses to the involvement of an anesthetist in pediatric gastrointestinal endoscopic procedures Anesthetist involvementa n=91
Variables
Availability of pediatric residents in the endoscopy roomb Residents being trained in PGEP Easily available services of an anesthetist for PGEP Propofol based regimes for sedation used Endoscopist with a formal training in a pediatric specialityc PGEP performed in operating room Nature of workplace
Available Unavailable Yes No Yes No Yes No Yes No Yes No Teaching hospital Non-teaching hospital
Yes (n=60)
No (n=31)
15 45 17 43 56 4 34 26 29 31 20 40 31 29
21 10 13 18 15 16 3 28 20 11 1 30 26 5
p-value
Odds ratio (95 % CI)
