Pediatric Endoscopy

[Noyac]

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I'm trying to get a feel for how people are doing these cases. Mostly in the younger Pedi population. Ages like 3-6 yrs. these pts seem to be coming for reflux symptoms.

In the adults having EGD for reflux, we don't usually intubate to protect the airway. Or maybe we do, I don't. But what's the general consensus in the pedi population?

 

[HalO'Thane]

I would say about 95% of the time I stick an LMA and maintain anesthesia with a volatile agent. Our GI docs are pretty amenable to this. Most of the time they can slide their scope past the LMA. Occasionally I will deflate the cuff of the LMA to allow them to pass it more easily. Most of these patients, as you have mentioned, have GERD. However, most of the time their reflux symptoms are post prandial and are usually not of any concern if properly NPO. Exceptions that would make me lean toward intubation include: bleeding/anemia, concerns for gastroparesis or achalesia (usually they will have had an Upper GI under flouro), extremes of age and size, possible foreign body or other emergent procedures where the patient is not NPO. I know that in the adult world it is rare to stick an airway device of any kind into a patient for an EGD. However, I have found in pediatric patients they are less cooperative with lighter sedation and are more prone to apnea, obstruction, or laryngospasm under MAC.

 

[partydoc]

we do a ton of these at our childrens hospital, usually an LMA unless there's a reason for a tube.

 

[ZzzPlz]

Why the lma? Do you do lma's for all your adults? Kids are just little adults right?

 

[IlDestriero]

Mask induction, IV, natural airway with Prop bolus/infusion or LMA with sevo.
I like LMAs and use them all the time, a couple of the GI guys don't want them and prefer intubation if we want to do something to secure the airway. I usually do those cases with a natural airway. 1mg/kg lido IV right before the scope goes in.
I intubate all the little ones (<12 mo.)
If you need an EGD as a baby you'd probably benefit from a secured airway.


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Il Destriero

 

[HalO'Thane]

Why the lma? Do you do lma's for all your adults? Kids are just little adults right?

As I mentioned earlier, my experience has been that kids are more prone to airway obstruction and apnea vs adults. I have found that the LMA provides a bit more upper airway support and allows me to temporarily assist with their ventilation if needed, particularly at the beginning of the case after induction and during placement of the scope, which is typically the most stimulating portion of the case.

 

[WholeLottaGame7]

Typically prop/native airway unless really small, really large, or really concerned about aspiration.

 

[Noyac]

I forgot to mention the LMA.
A very good option and the GI guy has done it this way.
We are starting to do these cases, so I wanted to see how others were doing them.
Thanks everyone.

 

[deleted59964]

our GI docs do these supine (much to my annoyance) , so I intubate these with remi or alfentanil

 

[sigrhoillusion]

I forgot to mention the LMA.
A very good option and the GI guy has done it this way.
We are starting to do these cases, so I wanted to see how others were doing them.
Thanks everyone.

LMA for most where I did peds fellowship.

 

[IlDestriero]

our GI docs do these supine (much to my annoyance) , so I intubate these with remi or alfentanil

I believe that there is GI literature that suggests that the supine position increases the risk of aspiration. Not exactly surprising, but it's in their literature. Our guys also have said that the supine position is associated with duodenal hematoma.
I do them lateral if I'm going with a natural airway. The only significant aspiration I had was several years ago with one of these quick EGD cases supine in an otherwise healthy and NPO tween with a chronic abdominal pain work up.


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Il Destriero

 

[Noyac]

We do them supine.

 

[aneftp]

On a related topic. Does anyone do peds endo at stanalone Gi facility with no anesthesia machine?

People are trying to push for that. In not taking about 14 year old peds either. I'm talking as young as age 3 outpatient. It's crazy some of these Gi docs get greedier and greedier. I wouldn't feel comfortable with anesthesia machine available with peds at stand a lone facility.

 

[HalO'Thane]

On a related topic. Does anyone do peds endo at stanalone Gi facility with no anesthesia machine?

People are trying to push for that. In not taking about 14 year old peds either. I'm talking as young as age 3 outpatient. It's crazy some of these Gi docs get greedier and greedier. I wouldn't feel comfortable with anesthesia machine available with peds at stand a lone facility.

No anesthesia machine and needing to sedate a three-year-old at a standalone GI facility? That sounds pretty crazy to me, but I guess I might be more conservative than most people. Those kids are often in daycare and they are always sick and you may not know the extent of their URI. They spasm. They obstruct. Even if they don't undergo a general anesthetic I would still prefer to have all of our tools at our disposal.

 

[ambiturner]

I wouldn't be excited about not having a machine - at minimum you should have sux and an MH kit. And a lot of maplesons/Ambubags.

 

[aneftp]

I wouldn't be excited about not having a machine - at minimum you should have sux and an MH kit. And a lot of maplesons/Ambubags.

I'm just saying. At a gi center I used to cover 8-9 years ago. They were trying to bring peds endo on board. They had peds gastrointestist in the practice as well. They owned the facility that was attached to their own main office. It's a huge center. Bigger than most surgery centers

But they wanted to do peds endo. I told sure. Need a modern anesthesia machine that would cost them even for refurbished $40-60k. Once they got those numbers they just said F it. And just went back to doing the peds patients at the hospital.

 

[Noyac]

We will then start to read about pedi endo deaths like we do now with the pedi dentals.

 

[IlDestriero]

Kids love to get pre op IVs. What's the problem?


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Il Destriero

 

[sigrhoillusion]

Pedi nose jobs. Gotta look nice for the Osh Kosh Bgosh catalog.

 

[IlDestriero]

Pedi nose jobs. Gotta look nice for the Osh Kosh Bgosh catalog.

I did one today for a "traumatic injury with deviated septum" from years ago. Sure...
Birth trauma maybe?
It looks nicer now I'm sure.


--
Il Destriero

 

[shift_roro]

Mostly mask / IV / prop gtt + NC, but I will have a low threshold to just intubate if they are small (e.g. <2yo, <15kg) or the reflux is really bad.

 

[sleepallday]

We do a lot of pediatric scopes. They all get pre-op IV's and we do a prop MAC

 

[Noyac]

So we have done a couple months of these pedi Endo cases and a couple observations I had were that these pts are such a pleasure to work with compared to a lot of the typical Endo pts. Second observation was that down sizing the LMA seems to be helpful. For example putting a 2 1/2 in instead of a 3. Probably most noticeable among the younger population (2-6yr olds). And lube is important. I started with basic KY but found the silicone spray to be more slippery.

Thoughts?

 

[deleted59964]

Second observation was that down sizing the LMA seems to be helpful. For example putting a 2 1/2 in instead of a 3. Probably most noticeable among the younger population (2-6yr olds). And lube is important. I started with basic KY but found the silicone spray to be more slippery.

Thoughts?

Helpful in what way? To make passing the scope easier?
I don't use lma's for these, but my colleagues that do deflate the cuff a bit at the time of passing the scope and then reinflate

 

[Noyac]

Helpful in what way? To make passing the scope easier?
I don't use lma's for these, but my colleagues that do deflate the cuff a bit at the time of passing the scope and then reinflate

Yes for passing the scope. I will deflate the cuff if needed but in my extremely limited experience I these cases I "think" downsizing the LMA might be a good option.

 

[deleted162650]

Thoughts??

I think I'm gonna see you on To Catch a Predator if you keep saying things like this:

the younger population (2-6yr olds). And lube is important. I started with basic KY but found the silicone spray to be more slippery.

 

[Noyac]

Thoughts??

I think I'm gonna see you on To Catch a Predator if you keep saying things like this:

You are a sick bastard.

And I need to be more careful when I write ****.

 

[Psai]

Thoughts??

I think I'm gonna see you on To Catch a Predator if you keep saying things like this:

Those pedi patients are a pleasure to work with

 

[dhb]

Not so much the pedi parents 😉

 

[ph8]

Mask induction, IV, natural airway with Prop bolus/infusion or LMA with sevo.
I like LMAs and use them all the time, a couple of the GI guys don't want them and prefer intubation if we want to do something to secure the airway. I usually do those cases with a natural airway. 1mg/kg lido IV right before the scope goes in.
I intubate all the little ones (<12 mo.)
If you need an EGD as a baby you'd probably benefit from a secured airway.


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Il Destriero

Ditto for my approach.