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YOUR PATIENT

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An 8-year-old presents for esophagogastroduodenoscopy (EGD) for gastroesophageal reflux disease (GERD).

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PREOPERATIVE CONSIDERATIONS

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Gastroesophageal reflux disease is one of the most common comorbidities in our field. It is more prevalent in patients with neurologic impairment, obesity, repaired esophageal atresia or other congenital esophageal diseases, and cystic fibrosis. GER is a normal physiologic process that occurs several times per day in healthy infants, children, and adults. GERD is present when the reflux of gastric contents causes troublesome symptoms and/or complications. Patients may present with asthma, bronchopulmonary dysplasia, or apparent life-threatening events that may be related to pulmonary aspiration.

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ANESTHETIC MANAGEMENT

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  • Rapid-sequence induction, which has its own risks in pediatric anesthesia, may be necessary.

  • If pulmonary aspiration is not a leading concern (ie, symptoms are not severe and are mostly postprandial) and the patient is school-aged, tracheal intubation can be avoided and a total intravenous anesthesia technique can be used, with supplemental oxygen being supplied through a nasal cannula.

  • In smaller children, a mask induction and endotracheal intubation is the most practical choice. This allows insertion and manipulation of the endoscope without impeding the patency of the airway.

  • The most stimulating part of this procedure is the insertion of the endoscope. To facilitate the insertion of the endoscope in the esophagus, the head can be flexed while the patient is in left lateral position.

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POSTOPERATIVE CONSIDERATIONS

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In infants, prolonged insufflation and the use of high insufflation pressures can lead to a distended abdomen that may impede ventilation. Intestinal perforation can present with a similar picture.

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DOs and DON’Ts

  • ✓ Do flex the head during the insertion of the scope.

  • ✓ Do choose a rapid-sequence induction in patients with severe GERD, particularly when the patient regurgitates food even after adequate fasting.

  • ⊗ Do not use high insufflation pressures in infants.

  • ✓ Do intubate young children.

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CONTROVERSIES

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Topicalization of the larynx may decrease the incidence of laryngospasm during insertion of the endoscope, but it results in an unprotected airway during and after emergence from anesthesia.

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SURGICAL CONCERNS

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The incidence of intestinal perforation is low (0.1%). Signs of a perforation are an unusually distended abdomen, abdominal pain, fever, and subcutaneous or mediastinal air. Injuries during an EGD in a stable patient without peritonitis can be managed conservatively; colonic perforation during a sigmoidoscopy requires immediate surgical repair.

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FACTOID

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More than 25% of adults in the United States use antisecretory medications at least 3 times per month.

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