Comparing Sedatives for Pediatric Upper Endoscopy

Abstract

To the Editor: Compared with propofol, fewer studies have investigated sevoflurane-based regimens for pediatric endoscopy and procedural sedation; mainly to avoid postoperative nausea, despite its low cost and complication rates (1,2). We showed a single dose of dexamethasone, significantly reduces nausea after pediatric upper endoscopy under deep sedation with sevoflurane, with no extra side effects (3). Most works compare propofol with other drug combinations and any direct comparison of the reported rates of postoperative nausea (8.2%) and laryngospasm/bronchospasm (4.1%) with results of other studies should be attempted with caution (1,3). Procedural techniques can also account for these differences. Furthermore, there are reports of laryngospasm in up to 3.7% of children during endoscopy under propofol-only regimens (4) and some studies report lower cases of laryngospasm (1.7%), but more emergency calls (4%) to treat other airway complications (5). As our subjects first received sodium thiopental, they accepted the mask with little difficulty; however, the independent effects of thiopental on the outcomes remain unclear (3). Reviews of self-reports, uncontrolled observations, and studies that do not differentiate between professional and less-skilled sedation teams provide limited conclusions (6,7). Other agents are routinely combined with propofol to address the common injection pain (5) and concerns about causing deeper-than-intended sedation states. These agents may cause complications and prolong recovery. As some reviews exclude studies that used propofol only for maintenance and not induction, the importance of this limitation cannot be ignored (8,9). We therefore believe until more high-quality works—that are randomized and directly compare regimens in similarly defined settings—are conducted, declaring a certain agent as the standard of care is not adequately substantiated.