Читать книгу Practical Pediatric Gastrointestinal Endoscopy - Группа авторов - Страница 40

A thorough presedation assessment is crucial in order to identify patients at risk for adverse events. Sedation for endoscopy must be tailored for each individual, yet preparations should be approached in the same stepwise fashion for every patient. The components of a presedation evaluation should include (i) informed consent, (ii) verbal and written instructions for postprocedure issues, (iii) the child’s medical history, (iv) physical exam, and (v) a risk assessment.

Informed consent specific to the procedural sedation must be obtained and documented in accordance with institutional guidelines. Verbal and written instructions to the parent or guardian should include the objectives of the sedation as well as anticipated effects during and after the procedure. Patients must know whom to contact after the procedure if any medical issue arises after being discharged from the hospital

The medical history should focus on any current or past medical illnesses affecting the cardiovascular, respiratory, hepatic or renal systems, which may affect the child’s response to the medications chosen. Consultation with a pharmacist may be necessary when there is a concern for drug interaction. Previous experiences with procedures should be elicited in order to uncover events that the child may be predisposed to, and a family history regarding anesthesia should be obtained. A thorough history of allergies to any medications or foods is important. As an example, propofol is manufactured in an oil‐in‐water base with egg and soybean oil, and therefore is contraindicated for use in a patient with egg or soybean allergy.

The physical exam must include a complete set of vital signs, which includes temperature, heart and respiratory rate, blood pressure, and pulse oximetry. A current weight is needed for appropriate medication dosing. Particular attention must be paid to the oropharynx for findings such as micrognathia, facial dysmorphism, loose teeth, tonsillar hypertrophy, or any other condition which could affect the airway. Heart exam should focus on the presence of murmurs or gallops which could indicate anatomical or functional issues. The airway exam should focus on the presence of stridor or wheezing.

Risk assessment includes assigning an ASA physical status classification level (Appendix I). Children who are Class I and II are considered appropriate candidates for minimal, moderate, and deep sedation. Situations which would indicate consultation with an anesthesiologist would be ASA class III or IV, children with congenital heart or pulmonary disease, significant upper or lower airway obstruction (such as tonsillar hypertrophy or poorly controlled asthma), or morbid obesity. Neurologic conditions such as poorly controlled seizures, central apnea, or severe developmental delay are also considered high risk, and warrant consultation with appropriate specialty services.