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

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 because many adult studies and a few pediatric studies have concluded that CO2 is better tolerated than air, especially for colonoscopy. AIMS: 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: 178 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. CONCLUSION: 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.