Is Carbon Dioxide Insufflation During Endoscopy in Children as Safe and as Effective as We Think?

Abstract

Objectives: Distension of the gastrointestinal lumen is crucial for visualization and advancement during endoscopic procedures. An increasing number of pediatric centers now use carbon dioxide (CO2) preferentially over air as many adult studies and a few pediatric studies have concluded that CO2 is better tolerated than air, especially for colonoscopy. Aims: The aim of the study was to determine if CO2 is as safe and as effective as air and if it reduces abdominal discomfort and distension in children undergoing upper endoscopy and colonoscopy. Methods: Double blinded, prospective, randomized clinical study. Patient- and nursing-reported outcomes of pain and distension were recorded. End tidal CO2 (EtCO2) was monitored continuously with a CO2-sampling nasal cannula for patients undergoing procedural sedation and via the endotracheal tube for those who were intubated. Results: One hundred seventy-eight patients with 180 procedures were enrolled, 91 procedures were randomized to receive CO2, and 89 to air. Groups did not differ significantly with respect to nursing-assessed abdominal discomfort, change in girth from baseline, or endoscopist-perceived ease of inflation. Use of CO2 was associated with transient spikes in the EtCO2 (≥60 mmHg) in a significant number of patients during sedated upper endoscopy without endotracheal intubation. There was a reduction of bloating and flatulence for all procedures in the CO2 group. Conclusions: The benefits of using CO2 for insufflation were minimal in our patients. The observed transient elevations of EtCO2 during sedated upper endoscopy raise concerns of possible systemic hypercarbia. The wisdom of its routine use for all pediatric endoscopic procedures is questioned.

Insufflation of Carbon Dioxide versus Air During Colonoscopy Among Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…After the analysis of complete articles, seven studies were selected, of which two were excluded because they were not randomized controlled studies. Finally, we included five RCTs [24][25][26][27][28] for analysis (Fig. 1).…”

“…Five RCTs [24][25][26][27][28] were included and 358 patients were identified: 178 in the CO 2 insufflation group and 180 in the air insufflation group. The characteristics of the individual studies are listed in Table 1.…”

“…On assessment of the risk of bias, the studies by Dike et al, 24 Dharmarj et al, 25 and Kresz et al 26 were considered low risk, whereas the studies by Thornhill et al 27 and Homan et al 28 had some concerns . Risk of bias was assessed globally and by outcomes (Supplementary File 1).…”

“…Four studies [24][25][26]28 in which 256 patients were included (CO 2 insufflation group, n = 127; air insufflation group, n = 129) re- ported the procedure time. In the statistical analysis, no statistical significance was shown between groups (MD, 10.84; 95% CI, -2.55 to 24.22; p= 0.11) (Fig.…”

“…We decided to conduct the first systematic review with meta-analysis comparing the benefits of CO 2 versus ambient air insufflation during pediatric colonoscopy. In this study, we included five RCTs [24][25][26][27][28] with good quality and adequate methodological design, including 358 pediatric patients. Furthermore, it was found that there was no statistical difference in terms of colonoscopy time, demonstrating that the type of gas used during the procedure does not influence the duration of the procedure.…”