Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists

Table 7 The list of sedatives/analgesic, adjuvant medicines and antagonists with usual dosage regimens, and main contraindications

Medicine generic name	Route	Dose	Time to start sedation/analgesia (after iv application)	Sedation/analgesia duration	Repeating time and dose	Contraindications	Comments	Ref.
Sedative/analgesic
Fentanyl	iv	1–2 μg/kg (up to 50 μg)	0.5 s	20–40 min (30–60 min)	3 min 1–1.25 μg/kg		Due to higher clearance younger children need frequent dosing	[38,40]
Ketamine	iv slowly over 1 min; other routes have less predictive effects and different dosing – see the discussion	1–1.5 mg/kg	1–5 min	15 min	10 min	Severe cardiovascular disease, malignant hypertension, CSF obstructive states (controversial), intraocular pressure pathology; previous psychotic illness, hyperthyroidism or thyroid medicine use; porphyria	A single enantiomer S(+);	[8,40-42]
					0.5 mg/kg		the anesthetic management of seriously ill hypovolemic patients, it may be the agent of choice for managing children and burned patients; low cost
Meperidine	iv slowly over 1–2 min	0.3–2 mg/kg	3–6 min	60–180 min		Simultaneous treatment with monoamine oxidase inhibitors		[38,43,44]
Midazolam	iv slowly over 2–3 min; other routes have less predictive effects and different dosing	0.05–0.1 mg/kg in < 5 yr (max. 0.6 mg/kg); in 6–12 yr 0.025–0.05 mg/kg (max.0.4 mg/kg); in older than 12 yr 2–2.5 mg (in total not per kg BW)	2–3 min	45–60 min	Repeating doses every 2–5 min until desired effect; in children 6 mo–5 yr total dose up to 0.6 mg/kg or max. 6 mg; in 6–12 yr total dose up to 0.4 mg/kg or max. 10 mg; in older than 12 yr additional boluses of 1 mg until desired sedation	Respiratory depression, hypotension	Rarely used as a sole sedative; might be used to sedate the frightened child before iv catheter placement; mostly combined with opioids; paradoxical irritation in 1%–5% of patients	[38-40]
Nitrous oxide	Inhalation	Mostly the mixture of nitrous oxide (50%) and oxygen	0.5–1 min	5 min	Continuously or “on demand”	Pneumothorax, bowel obstruction, head injury, pregnancy	Its use limited to anaesthesiologists	[38,40,45]
Propofol	iv	2 mg/kg in infants and young children (younger than 3 yr); 1 mg/kg in children older than 3 yr	1–2 min	5–15 min	1 mg/kg (infants and children up to 3 yr); 0.5 mg/kg (children older than 3 yr) to reach the desired sedation; may be continuously infused at 100 μg/kg per min and increasing the speed of infusion by 50 μg/kg per min for prolonged procedures	Egg or soy allergy	For additional medication to alleviate infusion pain see text; alfentanil but not fentanyl increases propofol blood level; in many countries the use is limited to anaesthesiologists	[38,40,46]
Sevoflurane	Inhalation	Different concentrations according to the age				Duchenne’s muscular dystrophy, moderate to severe liver disease of unknown aetiology, history of malignant hyperthermia	Its use limited to anaesthesiologists	[47-49]
Antagonists
Flumazenil	iv	0.02 mg/kg (max. 1 mg)	1–3 min	30 min	1 min; same dose	Chronic benzodiazepine use; ingestion of drugs that increase the risk for seizures development (e.g., cyclic antidepressants, cyclosporine, and others)	Due to its shorter duration of action than most of benzodiazepines (e.g., midazolam) repeated doses may be needed	[38,40]
Naloxone	iv or i.m.	0.1 mg/kg (max. 2 mg)	2 min	20–40 min	2 min; same dose	Hypersensitivity only	Due to its shorter duration of action than most of opioids (e.g., fentanyl) repeated doses may be needed	[38,40]