text:
River-God & Naiad Nymph, Campanian red-
figure amphora C4th B.C., British Museum
THE POTAMOI were the gods of the rivers and streams of the earth, sons of the great earth-encirling river Okeanos. Their sisters were the Okeanides, goddesses of streams, clouds and rain, and their daughters were the Naiades, nymphs of fresh-water springs.
The River-God was depicted in one of three forms:--as a man-headed bull; or a bull-horned man with the body of serpentine-fish from the waist down; or as a man reclining with an arm resting upon an amphora jug pouring water.
[1.1] OKEANOS & TETHYS (Hesiod Theogony 337, Aeschylus Seven 304 Diodorus Siculus 4.69.1, Hyginus Preface, Nonnus Dionysiaca 23.76)
[1.2] OKEANOS (Homer Iliad 21.190, Philostratus Elder 2.8)
THE NAIADES (Philostratus Imagines 2.27, et. al.)
AIAS A River-God of Epeiros (modern day Albany).
AKIS A River-God of the island of Sikelia (Sicily) in southern Italy. He was originally a mortal boy loved by the Nereis Galateia. The jealous Kyklops Polyphemos crushed him beneath a stone.
Homer, Iliad 21. 190 ff (trans. Lattimore) (Greek epic C8th B.C.) :
"Zeus is stronger than the Potamoi (Rivers) that run into the sea, so the generation of Zeus is made stronger than that of a River . . . Not powerful Akheloios matches his strength against Zeus, not the enormous strength of Okeanos with his deep-running waters, and all springs and all deep wells have their waters of him, yet even Okeanos is afraid of the lightning of great Zeus."
Hesiod, Theogony 337 ff (trans. Evelyn-White) (Greek epic C8th or 7th B.C.) :
"Tethys bore to Okeanos the swirling Potamoi (Rivers), Neilos, Alpheios, and deep-eddying Eridanos, Strymon and Maiandros, Istros of the beautiful waters, Phasis and Rhesos and silver-swirling Akheloios, Nessos and Rhodios, Heptaporos and Haliakmon, Grenikos and Aisepos, and Simoeis, who is godlike, Hermos and Peneios, and Kaikos strongly flowing, and great Sangarios, and Ladon, and Parthenios, Euenos and Ardeskos, and Skamandros, who is holy.
She brought forth also a race apart of daughters, who with Lord Apollon and the Potamoi have the young in their keeping all over the earth, since this right from Zeus is given them . . . There are three thousand . . . Okeanides . . . and as many again are the rest of the Potamoi (Rivers), murmurously running, sons of Okeanos and the lady Tethys was their mother, and it would be hard for a mortal man to tell the names of all of them; but each is known by those who live by him."
Aeschylus, Seven Against Thebes 304 ff (trans. Weir Smyth) (Greek tragedy C5th B.C.) :
"What more fertile plain will you find in place of ours [Thebes] . . . this deep-soiled land and the water of Dirke which is the most nourishing of the streams (potamoi) that earth-encircling (gaiaokhos) Poseidon [i.e. Okeanos] and Tethys' children pour forth."
Apollonius Rhodius, Argonautica 1. 498 ff (trans. Rieu) (Greek epic C3rd B.C.) :
"He [Orpheus] sang of . . . how Ourea (Mountains) rose, and how, together with their Nymphai, the murmuring Potamoi (Rivers) and all four legged creatures came to be."
Callimachus, Hymn 1 to Zeus 18 ff (trans. Mair) (Greek poet C3rd B.C.) :
"[In Arkadia, before the birth of Zeus :] Mighty Ladon flowed not yet, nor Erymanthos, clearest of rivers; waterless was all Arkadia; yet was it anon to be called well-watered. For at that time when Rhea loosed her girdle, full many a hollow oak did watery Iaon bear aloft, and many a wain did Melas carry and many a serpent above Karnion, wet though it now be, cast its lair; and a man would fare on foot over Krathis and many pebbled Metope, athirst: while that abundant water lay beneath his feet." [N.B. In this early age the Arkadian river-beds were dry because the Rivers were yet to be born.]
Diodorus Siculus, Library of History 4. 69. 1 (trans. Oldfather) (Greek historian C1st B.C.) :
"To Okeanos and Tethys, so the myths relate, were born a number of sons who gave their names to Rivers (Potamoi), and among them was Peneios, from whom the river Peneios in Thessalia later got its name."
Diodorus Siculus, Library of History 4. 72. 1 :
"According to the myths there were born to Okeanos and Tethys a number of children who gave their names to Rivers (Potamoi), and among their number were Peneios and Asopos."
Philostratus the Elder, Imagines 2. 8 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"[The river] Meles through his son [Homer] will grant to the Peneios to be 'silver-eddied,' to the Titaresios to be 'nimble' and 'swift,' and to the Enipeus to be 'divine,' and to the Axios to be 'all-beautiful,' and he will also grant to the Xanthos to be born from Zeus, and to Okeanos that all rivers spring from him."
Pseudo-Hyginus, Preface (trans. Grant) (Roman mythographer C2nd A.D.) :
"From Oceanus and Tethys [were born] the Oceanides . . . Of the same descent Rivers: Strymon, Nile, Euphrates, Tanais, Indus, Cephisus, Ismenus, Axenus, Achelous, Simoeis, Inachus, Alpheus, Thermodon, Scamandrus, Tigris, Maeandrus, Orontes."
Cicero, De Natura Deorum 3. 20 (trans. Rackham) (Roman rhetorician C1st B.C.) :
"If Terra the Earth is divine, so also is the sea . . . and therefore the Flumina (Rivers) [Potamoi] and Fontes (Springs) [Pegaiai] too."
Nonnus, Dionysiaca 24. 43 ff (trans. Rouse) (Greek epic C5th A.D.) :
"Respect the water of your Lamos [a River-God] who cherished your childhood; remember Maionia your own country, for [the River] Hydaspes is brother of your charming [River] Paktolos. Grant now this one boon to all these Rivers, my brothers [i.e. they are all sons of Okeanos]."
Nonnus, Dionysiaca 23. 76 ff :
"You [the River Hydaspes] mingle with other Rivers, with your Father Okeanos himself and Tethys your mother, rolling down a flood.'"
The Rivers or selected River-Gods were sometimes described as sons of Zeus, the god of rain.
Homer's Epigrams 1 (trans. Evelyn-White) (Greek epic B.C.) :
"The divine stream, eddying Hermos, whom deathless Zeus begot."
Ptolemy Hephaestion, New History Book 4 (summary from Photius, Myriobiblon 190) (trans. Pearse) (Greek mythographer C1st to C2nd A.D.) :
"The author [Hephaestion] speaks of double appellations in Homer; one is that used among the gods, the other current among men; the Xanthos is the only river which is a son of Zeus."
Valerius Flaccus, Argonautica 5. 205 ff (trans. Mozley) (Roman epic C1st A.D.) :
"O [River] Phasis, offspring of fecund Jove [Zeus].'"
Aeschylus, Fragment 84 Xantriae (from Scholiast on Aristophanes, Frogs 1344) (trans. Weir Smyth) (Greek tragedy C5th B.C.) :
"For the Nymphai Kreniai (nymphs of the springs), the glorious goddesses mountain-born . . . the life-giving children of Inakhos, the Argive river."
Apollonius Rhodius, Argonautica 4. 1141 ff (trans. Rieu) (Greek epic C3rd B.C.) :
"Nymphai gathered flowers . . . Some of these Nymphai were daughters of the River Aigaios."
Callimachus, Hymn 4 to Delos 112 ff (trans. Mair) (Greek poet C3rd B.C.) :
"Ye Nymphai Thessalides (of Thessalia), offspring of a river [Peneios], tell your sire to hush his great stream."
Callimachus, Hymn 4 to Delos 252 ff :
"The Nymphai of Delos, offspring of an ancient River [Inopos]."
Quintus Smyrnaeus, Fall of Troy 2. 459 ff (trans. Way) (Greek epic C4th A.D.) :
"By the deep flow of Aisepos' stream, where is a fair grove of the bright-haired Nymphai . . . which Aisepos' daughters planted, screening it with many and manifold trees."
Quintus Smyrnaeus, Fall of Troy 6. 470 ff :
"Nymphaios' stream, hard by a cave, a wide and wondrous cave : sacred it is men say, unto the Nymphai, even all that haunt the long-ridged Paphlagonian hills."
Quintus Smyrnaeus, Fall of Troy 11. 245 ff :
"All the Nymphai were wailing, daughters born of [the Rivers] Xanthos and fair-flowing Simois."
Antoninus Liberalis, Metamorphoses 22 (trans. Celoria) (Greek mythographer C2nd A.D.) :
"The Nymphai [of Mount Othrys], were not descended from Zeus, but that Deino had given birth to them, with the River Sperkheios was the father."
Antoninus Liberalis, Metamorphoses 26 :
"The boy Hylas went carrying a pail to the River Askanios to fetch water . . . and when the Nymphai, who were the daughters of this River, saw and fell in love with him, they pulled him in."
Philostratus the Elder, Imagines 2. 27 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"Nymphai . . . [and] the Potamoi (Rivers) from which they are sprung."
Ovid, Metamorphoses 6. 15 (trans. Melville) (Roman epic C1st B.C. to C1st A.D.) :
"Nymphae would often leave their vine-clad slopes of Tmolus, often leave Pactolus' stream."
Colluthus, Rape of Helen 1 ff (trans. Mair) (Greek poetry C5th to 6th A.D.) :
"Ye Nymphai Troiades (of Troy), children of the river Xanthos, who oft-times . . . array you for the dance on Ida, come hither, leaving the sounding river."
Nonnus, Dionysiaca 14. 143 ff (trans. Rouse) (Greek epic C5th A.D.) :
"The water Neiades . . . offspring of the river Lamos."
See also the River-God pages for the parentage of individual Naiades.
The River-Gods attended the assembly of the gods on Mount Olympos.
Homer, Iliad 20. 4 ff (trans. Lattimore) (Greek epic C8th B.C.) :
"But Zeus, from the many-folded peak of Olympos, told Themis to summon all the gods into assembly. She went everywhere, and told them to make their way to Zeus' house. There was no Potamos (River) that was not there, except only Okeanos, there was not one of the Nymphai who live in the lovely groves, and the springs of rivers and grass of the meadows, who came not. These all assembling into the house of Zeus cloud-gathering took places among the smooth-stone cloister walks."
Philostratus the Elder, Imagines 2. 27 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"[From a description of an ancient Greek painting at Neapolis (Naples) :] The Birth of Athena. These, wonder-struck beings are gods and goddesses, for the decree has gone forth that not even the Nymphai may leave the heavens, but that they, as well as the Potamoi (Rivers) from which they are sprung, must be at hand; and they shudder at the sight of Athena, who at this moment has just burst forth fully armed from the head of Zeus."
Statius, Thebaid 1. 205 ff (trans. Mozley) (Roman epic C1st A.D.) :
"[Zeus calls an assembly of the gods :] A crowd of wandering Demigods (semidei) and Amnes (Rivers), of one kin with the high Nubes (Clouds), and Venti (Winds), their clamours hushed by fear, throng the golden halls [of Olympos]."
Poseidon as the god of water was the king of the river-gods. Apollon and the Rivers were protectors of the young (cf. River-Gods, Protectors of the Young below).
Homer, Iliad 12. 18 ff (trans. Lattimore) (Greek epic C8th B.C.) :
"Poseidon and Apollon took counsel to wreck the wall [left behind by the Greeks at Troy after their departure], letting loose the strength of Rivers upon it, all the Rivers that run to the sea from the mountains of Ida, Rhesos and Heptaporos, Karesos and Rhodios, Grenikos and Aisepos, and immortal Skamandros and Simoeis . . . Phoibos Apollon turned the mouths of these waters together and nine days long threw the flood against the wall, and Zeus rained incessantly, to break the wall faster and wash it seaward. And the shaker of the earth himself holding in his hands the trident guided them, and hurled into the waves all the bastions' strengthening of logs and stones . . . and turned the rivers again to make their way down the same channel where before they had run the bright stream of their water."
Hesiod, Shield of Heracles 472 ff (trans. Evelyn-White) (Greek epic C8th or 7th B.C.) :
"[The river] Anauros, swelled by a rain-storm, blotted out the grave and memorial of Kyknos; for so Apollon, Leto's son, commanded him."
Pseudo-Apollodorus, Bibliotheca 2. 13 (trans. Aldrich) (Greek mythographer C2nd A.D.) :
"The land [of Argos] was without water, thanks to Poseidon, who, in anger at [the River] Inakhos for testifying that the region belonged to Hera, had dried up even the springs."
Pausanias, Description of Greece 2. 15. 4 (trans. Jones) (Greek travelogue C2nd A.D.) :
"This river [Inakhos], with the rivers Kephisos and Asterion, judged concerning the land between Poseidon and Hera. They decided that it belonged to Hera, and so Poseidon made their waters disappear. For this reason neither Inakhos nor either of the other rivers I have mentioned provides any water except after rain. In summer their streams are dry except those at Lerna."
Pausanias, Description of Greece 2. 22. 4 :
"Poseidon inundated the greater part of the country [of Argos] because Inakhos and his assessors decided that the land belonged to Hera and not to him. Now it was Hera who induced him to send the sea back."
Philostratus the Elder, Imagines 2. 14 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"[From a description of a painting depicting the release of the flood waters from the plain of Thessaly :] The Thessalians in early times were not permitted by the Peneios to have any land at all, since mountains encompassed the level spaces, which the stream continually flooded because it had as yet no outlet. Therefore Poseidon will break through the mountains with his trident and open a gateway for the River [i.e. creating the Vale of Tempe.] . . . The River [Peneios] rejoices as one exulting; and, keeping the usual posture of resting on his elbow (since it is not customary for a river to stand erect), he takes up the river Titaresios as being light water and better to drink and promises Poseidon that he will flow out in the course he had made."
Ovid, Metamorphoses 1. 275 & 332 ff (trans. Melville) (Roman epic C1st B.C. to C1st A.D.) :
"[Zeus floods the earth in the Great Deluge :] Nor was Jove's [Zeus'] wrath content with heaven above [i.e. with rainstorms]; his sea-blue brother [Poseidon] brings his waters' aid, and summons all the Amnes (Rivers) to attend their master's palace. `Now time will not wait for many words,' he says, `pour out your strength--the need is great! Unbar your doors! Away with dykes and dams and give the floods free rein!'
The Flumina (Streams) returned and freed their fountains' flow and rolled in course unbridled to the sea. Then with his trident Neptunus [Poseidon] struck the earth, which quaked and moved to give the waters way. In vast expanse across the open plains the Flumina (Rivers) spread and swept away together crops, orchards, vineyards, cattle, houses, men, temples and shrines with all their holy things. If any home is left and, undistorted, resists the huge disaster, over its roof, the waters meet and in their whirling flood high towers sink from sight; now land and sea had no distinction; over the whole earth all things were sea, a sea without a shore . . .
[After the floods had destroyed the race of man :] The Rector Pelagi (Lord of the Sea) [i.e. Poseidon] laid by his three-pronged spear and calmed the waves and, calling from the deep Triton, sea-hued, his shoulders barnacled with sea-shells, bade him blow his echoing conch to bid the Flumina (Rivers), waves and floods retire. He raised his horn, his hollow spiralled whorl, the horn that, sounded in mid ocean, fills the shores of dawn and sunset round the world; and when it touched the god's wet-bearded lips and took his breath and sounded the retreat, all the wide waters of the land and sea heard it, and all, hearing its voice, obeyed."
Ovid, Metamorphoses 8. 577 ff :
"[The River-God Akheloios prays to Poseidon to turn his love Perimele into an island :] `O thou whose lot won the world's second share, the wandering waves, God of the Trident, thou to whom at last all we pure holy river make our way, Neptunus [Poseidon], be present now and hear my prayer . . . Grant her to have a place, or be herself a place, that I'll embrace!'
The ruler of the ocean gave assent and every wave was shaken by his nod."
Nonnus, Dionysiaca 39. 38 ff (trans. Rouse) (Greek epic C5th A.D.) :
"Once it is said among the Argives that Earthshaker [Poseidon] made water dry, and a horse's hoof left prints of the dust of river Inakhos dried up." [Cf. Pausanias above.]
Nonnus, Dionysiaca 43. 286 ff :
"[Poseidon led the sea- and river-gods into battle against Dionysos when the two vied for the hand of Beroe :] The Potamoi (Rivers) came roaring into the battle with Dionysos, encouraging their lord, and Okeanos gaped a watery bellow from his everflowing throat while Poseidon's trumpet sounded to tell of the coming strife; the deeps rounded into a swell rallying to the Trident [i.e. Poseidon summoned the power of all the waters]."
Nonnus, Dionysiaca 43. 372 ff :
"[The River-Gods arrived at the wedding of Poseidon and Beroe bearing gifts :] Persian Euphrates gave the girl the webspinner's embroidered wares [i.e. silk]; Iberian Rhenos brought gold; old Paktolos came bringing the like offerings from his opulent mines . . . Eridanos brought shining gifts, amber from the trees of the Heliades that trickle riches; and from the silver rock, all the metals of Strymon and all that Geudis has were brought as marriage-gift to Amymone [i.e. Beroe] by Seabluehair."
The gods of the largest rivers were the princes of their lesser fellows. In Greece the mighty Akheloios of Aitolia and Peneios and Thessalia earned this title.
Callimachus, Aetia Fragment 9 (trans. Trypanis) (Greek poet C3rd B.C.) :
"[Aeetes of Kolkhis speaks :] `Let Helios (the Sun) be my witness and Phasis the king of our Rivers.'"
Pausanias, Description of Greece 8. 38. 10 (trans. Jones) (Greek travelogue C2nd A.D.) :
"[Akheloos] is said by Homer in the Iliad to be the prince of all rivers."
Aelian, On Animals 14. 23 (trans. Scholfield) (Greek natural history C2nd to 3rd A.D.) :
"The largest of the rivers of Europe, the Istros, rises from only a few springs and moves in a direction facing the first assaults of the sun. Later, many Rivers rise with one accord as though they were escorting him--for he is the King of the Rivers of that country."
Ovid, Metamorphoses 1. 568 ff (trans. Melville) (Roman epic C1st B.C. to C1st A.D.) :
"Here is the home, the mansion, the retreat of that majestic Amnis (River) [Peneios of Thessalia]; seated here within a rock-hewn cavern he dispensed justice to all his waters and their Nymphae. Hither assemble first the neighbouring streams, restless Enipeus, old Apidanus, Spercheus poplar-fringed, gently Amphrysos and Aeas."
River-Gods were sometimes described as the first kings of the land. The most famous of these were Asopos, river-king of Sikyonia, Inakhos, river-king of Argos, and Eurotas, river-king of Lakedaimonia. In the rationalisations of late antiquity, these figures were often redefined as kings who gave their names to rivers, rather than Rivers themselves.
Pausanias, Description of Greece 2. 15. 4 (trans. Jones) (Greek travelogue C2nd A.D.) :
"The oldest tradition in the region now called Argolis is that when Inakhos was king he named the river after himself."
Pausanias, Description of Greece 3. 1. 2 :
"On the death of Myles his son Eurotas succeeded to the throne. He led down to the sea by means of a trench the stagnant water on the plain, and when it had flowed away, as what was left formed a river-stream, he named it Eurotas (Fair-flowing)."
Pausanias, Description of Greece 9. 1. 1 :
"The Plataians know of no king except Asopos and Kithairon before him, holding that the latter gave his name to the mountain, the former to the river."
For MORE information on these River-God kings see:--
River metamorphosis MYTHS include:--
(1) The Metamorphosis of SELEMENUS (A rustic transformed into a River)
(2) The Metamorphosis of EUENOS (A prince transformed into a River)
(3) The Metamorphosis of AKIS (A rustic transformed into a River)
Some amorous river-god MYTHS include:--
(1) The Contest of Heracles & ACHELOUS (Shape-shifting River-God)
(2) The Love of ACHELOUS & Perimele (A girl transformed into a river-island)
(3) The Love of ALPHEUS & Arethusa (Chases the Nymph across the sea)
(4) The Love of Tyro for the ENIPEUS (Girl falls in love with the River)
(5) The Love of HALYS & Sinope (Nymphe avoids River-God)
(6) The Love of CRIMISUS & Aegesta (Girl seduced in the guise of a dog)
(7) The Love of ORONTES & Meliboea (River-God floods Syria)
For MYTHS of fighting River-Gods :--
(1) Heracles versus ACHELOUS (Suitors' Contest)
(2) SCAMANDER versus Achilles & Hephaestus (The Trojan War)
(3) HYDASPES versus Dionysus (The Indian War)
(4) ISMENUS versus Hippomedon (Seven Against Thebes)
MYTHS of River-Gods and their daughters include:--
(1) INACHUS & his daughter Io (Girl seduced by Zeus)
(2) Abduction of the Daughters of ASOPUS (River-god struck by thunderbolt)
Homer, Iliad 5. 773 ff (trans. Lattimore) (Greek epic C8th B.C.) :
"They came to Troy land and the two running rivers where Simoeis and Skamandros dash their waters together, there the goddess of the white arms, Hera, stayed her horses, slipping them from the chariot . . . and Simoeis grew as grass ambrosia for them to graze on."
Homer, Iliad 21. 211 ff :
"The deep-whirling River [Skamandros] spoke to him [Akhilleus] in anger and in mortal likeness, and the voice rose from the depth of the eddies . . . The River in a boiling surge was upon him and rose making turbulent all his waters, and pushed off the many dead men whom Akhilleus had killed piled in abundance in the stream; these, bellowing like a bull, he shoved out on the dry land, but saved the living in the sweet waters hiding them under the huge depths of the whirling current."
Homer, Iliad 21. 305 ff :
"[The River Skamandros] high uplifting the wave of his waters gathered it to a crest, and called aloud upon Simoeis : `Beloved brother . . . make full your currents with water from your springs, and rouse up all your torrents and make a big wave rear up and wake the heavy confusion and sound of timbers and stones . . .'
The purple wave of the River fed from the bright sky lifted high."
Homer, Odyssey 11. 236 ff (trans. Shewring) (Greek epic C8th B.C.) :
"She [Tyro] fell in love with the river-god Enipeos, whose waters are the most beautiful of any that flow on earth; and she haunted his beguiling streams. But in place of Enipeos, and in his likeness, there came the god [Poseidon] who sustains and who shakes the earth. He lay with her at the mouth of the eddying river, and a surging wave, mountain-high, curled over them and concealed the god and the mortal girl."
Aeschylus, Prometheus Bound 88 ff (trans. Weir Smyth) (Greek tragedy C5th B.C.) :
"[The Titan Prometheus calls on the whole of nature to witness his torment :] `O you bright sky of heaven (dios aithêr), you swift-winged breezes (takhypteroi pnoiai), you river-waters (pêgai potamôn) [i.e. the Potamoi], and infinite laughter of the waves of sea (pontos), O universal mother Earth (panmêtôr gê), and you, all-seeing orb of the sun (panoptês kyklos hêlios), to you I call! See what I, a god, endure from the gods."
Aeschylus, Prometheus Bound 431 ff :
"[Okeanos sympathises with the chained Titan Prometheus :] `The waves of the sea (pontos) utter a cry as they fall, the deep laments, the black abyss of Aides rumbles in response, and the streams of pure-flowing rivers (potamoi) lament your piteous pain.'"
Aesop, Fables 258 (from Syntipas 4) (trans. Gibbs) (Greek fable C6th B.C.) :
"The Potamoi (Rivers) came together in order to make a complaint against Thalassa (the Sea). They told her, `Why is it that we come to you with waters that are sweet and fit to drink, but you change them into something salty and undrinkable?' In response to the Potamoi's (Rivers') criticism, Thalassa (the Sea) replied, `Don't come, and you won't get salty!'"
Callimachus, Hymn 5 The Bath of Pallas 49 ff (trans. Mair) (Greek poet C3rd B.C.) :
"For mingling his waters with gold and with flowers, Inakhos will come from his pastoral hills, bringing fair water for the Bath of Athena."
Strabo, Geography 10. 2. 19 (trans. Jones) (Greek geographer C1st B.C. to C1st A.D.) :
"Others, conjecturing the truth from the myths, say that the [the river-god] Akheloios, like the other Rivers, was called [and depicted in art] 'like a bull' from the roaring of its waters, and also from the the bendings of its streams, which were called Horns, and 'like a serpent' because of its length and windings, and 'with front of ox' for the same reason that he was called 'bull-faced.'"
Lycophron, Alexandra 1405 ff (trans. Mair) (Greek poet C3rd B.C.) :
"The plains of the Sithonians and the fields of Pallene, where the ox-horned [River] Brykhon . . . fattens with his waters."
Philostratus the Elder, Imagines 1. 5 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"[Ostensibly a description of an ancient Greek painting at Neapolis (Naples) :] About Neilos (the Nile) the Pekheis (Dwarfs) are sporting, children no taller than their name implies [i.e. 'cubit-tall'] . . . Some sit on his shoulders, some cling to his curling locks, some are asleep on his arms, and some romp on his breast. And he yields them flowers, some form his lap and some from his arms, that they may weave them into crowns and, sacred and fragrant themselves, may have a bed of flowers to sleep upon. And the children climb up one on another with sistra in their hands, instruments the sound of which is familiar to that river. Crocodiles, however, and hippopotami, which some artists associate with Neilos (the Nile) in their paintings, are now lying aloof in its deep eddies so as not to frighten the children. But that the River is Neilos (the Nile) is indicated, my boy, by symbols of agriculture and navigation, and for the following reason : At its flood Neilos (the Nile) makes Egypt open to boats; then, when it has been drunk up by the fields, it gives the people a fertile land to till; and in Aithiopia, where it takes its rise, a divinity is set over it as its steward, and he it is who sends forth its water at the right seasons. This divinity has been painted so as to seem heaven-high, and he plants his foot on the sources, his head bent forward like Poseidon. Toward him the River is looking, and it prays that its infants may be many."
[N.B. The infants are the Karpoi, godlings of the fruits of the earth.]
Philostratus the Elder, Imagines 1. 11 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"[From a description of an ancient Greek painting depicting the death of Phaethon, who is cast from the chariot of the sun into the stream of the river Eridanos :] The River [Eridanos] also laments, emerging from his eddying stream, and offers his bosom to receive Phaethon--for the attitude is of one ready to receive--and soon he will harvest the tears of the Heliades [i.e. amber]; for the breezes and the chills which it exhales will turn into stone the tear-drops of the poplar trees, and it will catch them as they fall and conduct them through its bright waters to the barbarians by Okeanos."
Philostratus the Elder, Imagines 1. 17 :
"[From a description of an ancient Greek painting painting depicting the race of Pelops at Olympia :] The [the river-god] Alpheios leaps from his eddy to pluck a crown of wild olive for Pelops as he drives along the bank of the river."
Philostratus the Elder, Imagines 1. 25 :
"[From a description of an ancient Greek painting at Neapolis (Naples) :] The stream of wine which is on the island of Andros, and the Andrians who have become drunken from the river, are the subject of this painting. For by act of Dionysos the earth of the Andrians is so charged with wine that it bursts forth and send up for them a river . . .
Consider, however, what is to be seen in the painting : The River-[god] lies on a couch of grape-clusters, pouring out its stream, a river undiluted and of agitated appearance; thyrsoi grow about it like reeds about bodies of water."
Philostratus the Elder, Imagines 2. 8 :
"[From a description of an ancient Greek painting representing the love of Kritheis and the river Meles :] A delightful feature of the painting is the figure of Meles lying on a bed of crocus and lotus blossoms and delighting in the hyacinth because of its fresh young bloom, and presenting an appearance delicate and youthful and not at all lacking in cleverness . . . It is a delightful feature also that he does not pour forth turbulent streams at his source, as boorish rivers are usually painted; nay, he but cuts a passage through the earth with the tips of his fingers and holds his hand beneath the water as it trickles noiselessly by; and to us it is clear that, for Kritheïs, this is no dream, nor ware you writing this love of yours in water; for the River loves you, I know it well, and he is devising a chamber for you both by lifting up a wave beneath which shall be your couch. If you do not believe me, I will tell you the very construction of the chamber; a slight breeze running under a wave causes it to curve over and makes it resonant and also of brilliant hue; for the reflection of the sun lends colour to the uplifted water . . .
Some Nereis or Naias . . . these goddesses dance together in honour of the river Meles, since it offers them fountains not far from its mouth."
Philostratus the Elder, Imagines 2. 14 :
"[From a description of an ancient Greek painting :] The River [Peneios] . . . keeping the usual posture of resting on his elbow--since it is not customary for a river to stand erect."
Philostratus the Younger, Imagines 4 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"[From a description of an ancient Greek painting depicting the river-god Akheloios :] Here a man that is half animal, for he has the forehead of a bull and a spreading beard, while streams of water run in floods from his chin."
Philostratus the Younger, Imagines 8 :
"[From a description of an ancient Greek painting :] You see the river [Phasis] himself lying on this deep bed of rushes; his countenance is grim, for his hair is thick and stands upright, his beard bristles, and his eyes glare; and the abundant water of the stream, since it does not flow from a pitcher as is usually the case, but comes in flood from his whole figure, gives us to understand how large a stream is poured into the Pontos."
Philostratus the Younger, Imagines 10 :
"[From a description of an ancient Greek painting :] The river Xanthos, which is represented . . . [with] its bed is lotus grass and rushes and foliage of tender reeds; it reclines instead of standing erect, and presses it foot on the sources to keep them within bounds."
Callistratus, Descriptions 7 (trans. Fairbanks) (Greek rhetorician C4th A.D.) :
"[From a description of a statue of the bard Orpheus :] You could see the bronze taking on the shape of rivers (potamoi) flowing from their sources toward the singing, and a wave of the sea (thalassa) raising itself aloft for love of the song, and rocks being smitten with the sensation of music, and every plant in its season hastening from its usual abode towards the music of Orpheus."
Ovid, Metamorphoses 1. 568 ff (trans. Melville) (Roman epic C1st B.C. to C1st A.D.) :
"There is a vale in Haemonia [Thessalia], enclosed with hanging forests, steep on every side; men name it Tempe. Here Peneus rolls at towering Pindus; foot his foaming course, and from his mighty fall the swirling clouds of mist drift down in rain upon the trees, and far the waters' wearying roar resounds. Here is the home, the mansion, the retreat of that majestic Amnis (River); seated here within a rock-hewn cavern he dispensed justice to all his waters and their Nymphae. Hither assemble first the neighbouring streams, restless Enipeus, old Apidanus, Spercheus poplar-fringed, gently Amphrysos and Aeas, doubtful whether to console Daphne's fond parent or congratulate. Soon other Rivers come, whose course's flow where'er their currents drive and lead at last their wandering waters weary to the sea. But one is absent, Inachus, withdrawn deep in his cave and weeping tears that swell his current, as he mourns in bitter grief Io, his daughter lost."
Ovid, Metamorphoses 2. 15 ff :
"[The earth and its gods depicted on the gates of the palace of the Sun :] On the land people and cities, woods and beasts were graven, Flumina (Rivers) and Nymphae and Rural deities."
Ovid, Metamorphoses 2. 238 ff :
"[When Phaethon, driving the chariot of the sun, scorched the earth :] The sad Nymphae bewailed their pools and springs; Boeotia mourned her Dirce lost, Argos Amymone, Ephyre Pirene; nor were Flumina (Rivers) safe though fortune's favour made them broad and deep and their banks far apart; in middle stream from old Peneus rose the drifting steam, from Erymanthus Phegaicus too and swift Ismenos, and Caicus Teuthranius and the Tanais; Maeander playing on his winding way; tawny Lycormas, Xanthus doomed to burn at Troy a second time [when Hephaistos set him aflame in the Trojan War]; Melas Mygdonius, that sable stream; the pride of Eurotas Taenarius. Euphrates Babylonius burned, Phasis, Hister [Danube] and Ganges were on fire, Orontes burned and racing Thermodon; Alpheus boiled, fire scorched Spercheus' banks. The gold that Tagus carried in his sands ran molten in the flames, and all the swans that used to charm the Maeonian banks with song huddled in mid Cayster sweltering. The Nilus in terror to the world's end fled and his head, still hidden; this seven mouths gaped dusty, seven vales without a stream. The same disaster dried the Ismarian rivers, Hebrus and Strymon, dried the lordly flow of the Hesperian waters, Rhodanus [Rhode] and Rhenus [Rhine] and Padus [Po], and Thybris [Tiber], promised empire of the world."
Ovid, Metamorphoses 3. 342 ff :
"Wave-blue water-nymph Liriope, whom once [the River] Cephisus in his sinuous flow embracing held and ravished."
Ovid, Metamorphoses 8. 547 ff :
"His [Theseus'] road was cut and progress halted by the swollen stream of Achelous. `Enter my abode, illustrious prince of Athens,' said the River; `Risk not my ravening torrent. It transports so often massive trees and sweeps away huge boulders headlong with a mighty roar. Tall stables standing by the banks I've seen borne down, their cattle with them. In that flood no strength could save the ox, nor speed the horse. And when the mountains free their snows, this spate drowns many a strong man in its swirling waves. Rest will be safer, till the stream resumes its usual bounds, till its own bed contains a slender flow.' . . .
Of porous pumice and rough tufa-rock the residence was built. The floor was damp and soft with moss, the ceiling diapered with shells of conch and murex laid in turn. And now the sun had measured two long thirds of daylight. Theseus with his company reclined on couches . . . Soon bare foot River-Nymphs arranged the tables and spread the banquet-board, and when the feast was cleared they set a jewelled bowl of wine."
Ovid, Metamorphoses 11. 47 ff :
"All wept and mourned for [the death of the bard] Orpheus; forest trees cast down their leaves, tonsured in grief, and Flumina (Rivers) too, men say, were swollen with their tears, and Naides wore, and Dryades too, their mourning robes of black and hair dishevelled."
Ovid, Metamorphoses 11. 762 ff :
"Two-horned Granicus [a Trojan river-god]."
Ovid, Metamorphoses 14. 599 ff (trans. Melville) :
"She [Venus-Aphrodite] bade the River [Numicius] wash from Aeneas all that death could waste and waft it in his silent stream to sea. Obeying Venus' bidding the horned god purged in his waters every mortal part and washed it all away--the best remained. So purified, his mother anointed him with heavenly perfume and . . . made her son a god."
[N.B. Glaukos is purified in a similar fashion by the Sea-Gods when transformed into a marine divinity, cf. Metamorphoses 13.900 ff.]
Valerius Flaccus, Argonautica 1. 105 ff (trans. Mozley) (Roman epic C1st A.D.) :
"They whose labour was in the fields and with the peaceful plough are aroused by the sight of Fauni [Satyroi] about the thickets and ways in the clear light of day, and woodland Goddesses [Dryades] and Rivers [Potamoi] with lofty horns."
Valerius Flaccus, Argonautica 5. 205 ff :
"O [River] Phasis . . . as mighty as great Enipeus or father Inachus outstretched in golden cave.'"
Valerius Flaccus, Argonautica 5. 425 ff :
"In frenzied desire savage [River] Phasis pursues [the Nymphe] Aea upon her native hills . . . the god has overcome her, and binds her fast beneath his rapid wave."
Statius, Thebaid 2. 218 ff (trans. Mozley) (Roman epic C1st A.D.) :
"Father Inachus himself, twin-horned, leans leftward upon his tilted urn [i.e. pouring forth his streams]."
Statius, Thebaid 4. 52 ff :
"Elisson [a river of eastern Akhaia] winding through his curving banks. An awful privilege has that river : it cleanses, so 'tis said, with its austere waters the Stygian Eumenides [Erinyes]; here are they wont to dip their faces and the horned snakes that gasp from drinking Phlegethon . . . the River itself flees from them as they bathe, and its pools grow livid with countless poisons."
Statius, Thebaid 4. 706 ff :
"When ebbing Nilus buries itself in mighty caverns and gathers into its mouth the life-giving streams of Eastern winters, the flood-deserted valleys steam, Aegyptos gapes wide and waits the expectant roar of her sire's waves, till by dint of many prayers he give sustenance to the Pharian fields and bring on a great year of harvest."
Statius, Thebaid 6. 275 ff :
"Father Inachus reclining leftward on the mound of a reedy bank and letting the streming urn flow free."
Statius, Thebaid 8. 359 ff :
"When Nilus [the River Nile] in his secret region has drunk with mighty mouth the nurture of a distant sky and the cold snows of the East, he breaks up all his wealth of waters and carries his tempests to the sea in seven wide channels o'er the fields."
Statius, Thebaid 9. 404 ff (trans. Mozley) (Roman epic C1st A.D.) :
"[The River] Father Ismenos, reclining in that secret cavern whence winds and clouds do drink and the rain-bringing bow is nourished, and whence comes a fuller harvest to the Tyrian fields . . . uplifted his moss-grown neck and his ice-weighted hair; the tall pine fell from his loosened grasp, and the urn dropped and rolled away. Along the banks the woods and lesser Rivers marvel at him as he thrusts forth his face encrusted with age-long mire; so majestically he rises from the flood, lifting his foamy head and his breast astream with the echoing fall of rivulets from his dark-blue beard . . . So spake he, gnashing his teeth, and gave the sign to his already raging waters: cold [Mount] Cithaeron sends succour from the hills, and bids his ancient snows and stores of frost be moving; to the flood his brother [the River] Asopos unites his secret stores, and supplies streams from wide-open veins [i.e. subterranean channels]. He himself explores the hollow earth's recesses, and tries torpid lakes and pools and lazy fens, and lifting skyward his greedy countenance sucks down the moisture of the clouds and drains dry the air . . . High he stands in the deep river, ad smiting his face and horns entwined with green sedge."
Apuleius, The Golden Ass 5. 25 ff (trans. Walsh) (Roman novel C2nd A.D.) :
"[Psykhe, abandoned by her lover Eros :] She hurled herself headlong down from the bank of a river close by. But that kindly Stream was doubtless keen to pay homage to the god [Eros] who often scorches even the waters, and in fear for his person he at once cast her ashore on his current without injuring her, and set her on its grassy bank."
Tryphiodorus, The Taking of Ilias 322 ff (trans. Mair) (Greek poet C5th A.D.) :
"[The Trojans dragged the Wooden Horse into Troy :] Groaned shady Ida together with her Nymphe-haunted oaks : the eddying waters of the river Xanthos shrieked, and the mouth of Simoeis rang aloud."
Tryphiodorus, The Taking of Ilias 683 ff :
"Xanthos, beholding the fiery doom of the city [of Troy], wept with seaward flowing fountain of lamentation."
Nonnus, Dionysiaca 11. 379 ff (trans. Rouse) (Greek epic C5th A.D.) :
"[The river] Maiandros, lurking in the secret places with his water in the lap of earth--who rolls deep through the earth and drags his crooked stream towards the light, crawling unseen and travelling slantwise underground, until he leaps up quickly and lifts his neck above the ground."
Nonnus, Dionysiaca 12. 123 ff :
"[Dionysos' beloved Ampelos was killed by a wild bull :] Before the unsmiling countenance of Dionysos, full of love and piteous pining, the reedy Lydian Hermos held up his course, and his fastrolling waves which poured on with weatherbeaten throb--he cared no more to flow; Paktolos yellow as saffron with the wealth deep under his flood, stayed his water in mourning, like the image of a sorrowful man; Sangarios the Phrygian stream, in honour of the dead, checked back the course of his banked fountains."
Nonnus, Dionysiaca 19. 158 ff :
"So you also [Seilenos] have changed your shape [i.e. he metamorphosed into a river]. You must no longer seek a barefoot Bakkhante for your bride as before, that Bakkhante of the mountains with flowing locks; you have now for your pleasure the innumerable tribe of Naiades with flowing hair. Seek no longer the snaky wreaths of Lyaios; eels are what you have to do with, the wriggling travail of streams, and instead of serpent there ware fishes with closefitted speckled scales crawling in your streams. And if you have parted from Dionysos and his grapes, I hold you the happier; for you really make the grapes to grow! What more could you want, when you have after Bakkhos now Zeus to feed your streams, the Father of all creation? Instead of your Satyroi you have your regiments of Rivers; instead of the winepress you dance on the back of murmuring Okeanos. Even in the waters you are like what you were; it is proper that Seilenos, once proud of his horned forehead, as a River should have the horned shape of a bull."
Nonnus, Dionysiaca 23. 76 ff :
"[The River] Hydaspes covered the dead [i.e. the Indians slain by Dionysos and his army] with his reluctant flood, and became their tomb. Then one [Indian] within the River cried out his last reproach : `You, too, father! Why do you drown your own sons? [He declares that the other Rivers do not drown their people] . . . but you swallow up the lawful sons of your own perishing people--you drown no bastard blood. How dare you mingle with other Rivers, with your Father Okeanos himself and Tethys your mother, rolling down a flood of gore in bloody streams?'"
Nonnus, Dionysiaca 41. 264 ff :
"She [the goddess Harmonia] embroidered also the Potamoi (Rivers) in a green picture [of the earth], shaped each with a human face and bull's horn; and at the outer fringe of the wellspun robe she made Okeanos run all round the world in a loop."
For MORE poetical descriptions from Nonnus see HYDASPES
Ovid, Metamorphoses 7. 192 ff (trans. Melville) (Roman epic C1st B.C. to C1st A.D.) :
"[The witch] Medea . . . in the deep stillness of the midnight hour . . . To the stars she stretched her arms, and thrice she turned about and thrice bedewed her locks with water, thrice a wailing cry she gave, then kneeling on the stony ground, `O Nox [Nyx the night], Mother of Mysteries, and all ye golden Astra (Stars) who with Luna [Selene the moon] succeed the fires of day, and thou, divine triceps (three-formed) Hecate, who . . . dost fortify the arts of magic, and thou, kindly Tellus [Gaia the Earth], who dost for magic potent herbs provide . . . Lacus (Lakes) and Amnes (streams) . . . be with me now! By your enabling power, at my behest, broad rivers to their source flow back, their banks aghast.'"
Ovid, Heroides 6. 85 ff (trans. Showerman) (Roman poetry C1st B.C. to C1st A.D.) :
"She [the witch Medea] is one to strive to draw down from its course the unwilling moon, and to hide in darkness the horses of the sun; she curbs the waters and stays the down-winding streams (flumina); she moves from their places the woods and the living rocks."
Valerius Flaccus, Argonautica 6. 442 ff (trans. Mozley) (Roman epic C1st A.D.) :
"Medea . . . than whom is none more potent at the nightly altars [i.e. witchcraft] . . . she changes the aspect of the fields and the track of the Rivers."
Homer, Iliad 23. 141 ff (trans. Lattimore) (Greek epic C8th B.C.) :
"He [Akhilleus] stood apart from the pyre [of Patroklos] and cut off a lock of fair hair which he had grown long to give to the river Sperkheios, and gazing out over the wide wine-blue water, he spoke forth : `Sperkheios, it was in vain that Peleus my father vowed to you that there, when I had won home to the beloved land of my fathers, I would cut my hair for you and make you a grand and holy sacrifice of fifty rams consecrate to the waters of your springs, where is your holy ground and your smoking altar. So the old man vowed, but you did not accomplish his purpose. Now, since I do not return to the beloved land of my fathers, I would give my hair into the keeping of the hero Patroklos.'"
Hesiod, Theogony 337 ff (trans. Evelyn-White) (Greek epic C8th or 7th B.C.) :
"She [Tethys] brought forth also a race apart of daughters [the Okeanides], who with Lord Apollon and the Potamoi (Rivers) have the young in their keeping all over the earth, since this right from Zeus is given them."
Aeschylus, Libation Bearers 7 ff (trans. Weir Smyth) (Greek tragedy C5th B.C.) :
"I bring a lock to Inakhos in requital for his care [i.e. as the protector of youth].'"
Aeschylus, Suppliant Women 1022 ff :
"Let the theme of our praise be this city of the Pelasgians [Argos], and no longer let the homage of our [the immigrants to Argos from Egypt] hymns be paid to Neilos' [the Nile's] floods where they seek the sea, but to the rivers (potamoi) that pour their gentle draught through the land and increase the birth of children, soothing its soil with their fertilizing streams."
Pausanias, Description of Greece 1. 37. 3 (trans. Jones) (Greek travelogue C2nd A.D.) :
"By the river [Kephisos in Athens] is a statue of Mnesimakhe, and a votive statue of her son cutting his hair as a gift for Kephisos. That this habit has existed from ancient times among all the Greeks may be inferred from the poetry of Homer, who makes Peleus vow that on the safe return of Akhilleus from Troy he will cut off the young man's hair as a gift for the Sperkheios."
Pausanias, Description of Greece 8. 20. 2 :
"Leukippos [mythical Eleian hero] was growing his hair long for the river Alpheios."
[N.B. Youths dedicated the uncut locks of their childhood to the local river-god.]
Philostratus the Elder, Imagines 1. 7 (trans. Fairbanks) (Greek rhetorician C3rd A.D.) :
"Memnon [of Aithiopia], the son of Eos . . . Notice how long is the crop of curls, which he grew, no doubt, that he might dedicate them to Neilos (the Nile); for . . . the sources of it belong to Aithiopia."
Nonnus, Dionysiaca 3. 345 ff (trans. Rouse) (Greek epic C5th A.D.) :
"He [Dardanos first king of Troy] has given the firstling crop of his hair to Phrygian Simoeis." [N.B. At his coming-of-age, the Greek youth would cut his unshorn locks and dedicate it to the local river-god.]
Nonnus, Dionysiaca 47. 490 ff (trans. Rouse) (Greek epic C5th A.D.) :
"[The Argive river] Asterion, where the young men so often cut the flower of their bared brows as firstfruits of growing age."
Homer, Odyssey 5. 452 ff (trans. Shewring) (Greek epic C8th B.C.) :
"[After Odysseus' raft was destroyed in a storm, he was carried by the waves to the Phaiakian's isle :] And when in his swimming he [Odysseus] came abreast of a flowing river, where he thought the ground best to land on, being clear of rocks and sheltered from winds besides, he hailed the outflowing stream as a god and prayed to him in his heart thus : `Hear me, Lord, whosoever you may be. I find in you an answer to all my prayers, as I seek a refuge from the sea and from the threatenings of Poseidon. Do not even the Deathless Ones owe compassion to a mortal who comes to them as a wanderer and a suppliant? Such a man am I, approaching your stream, approaching your knees, after much distress. Have pity upon me, Lord; a suppliant is what I claim to be.'
So he prayed, and the god forthwith checked his stream and held back his waves; he stilled the waters before Odysseus and brought him safe to the river's mouth."
Hesiod, Works and Days 737 ff (trans. Evelyn-White) (Greek epic C8th or 7th B.C.) :
"Never cross the sweet-flowing water of ever-rolling rivers (potamoi) afoot until you have prayed, gazing into the soft flood, and washed your hands in the clear, lovely water. Whoever crosses a river with hands unwashed of wickedness, the gods are angry with him and bring trouble upon him afterwards."
Hesiod, Works and Days 750 ff :
"Never make water [i.e. urinate] in the mouths of rivers which flow to the sea, nor yet in springs; but be careful to avoid this. And do not ease yourself in them : it is not well to do this."
Aeschylus, Fragment 68 Mysians (from Photius, Lexicon 344) :
"Hail, thou first priest of Kaikos' stream, by thy healing prayers mayest thou preserve thy lords!"
Strabo, Geography 5. 2. 5 (trans. Jones) (Greek geographer C1st B.C. to C1st A.D.) :
"Pisa [in Italia] is situated at the confluence of two rivers, the Arnos and the Ausar . . . And the following fable is told : when these Rivers first began to flow down from the mountains, and their course was being hindered by the natives for fear that they would unite in one stream and deluge the country, the Rivers promised not to deluge it and kept their pledge."
Pausanias, Description of Greece 9. 30. 8 (trans. Jones) (Greek travelogue C2nd A.D.) :
"The people of Dion (Dium) [in Thrake] say that at first this River [Baphyras] flowed on land throughout its course. But, they go on to say, the women who killed Orpheus wished to wash off in it the blood-stains, and thereat the River sank underground, so as not to lend its waters to cleanse manslaughter."
See the CULT OF THE RIVER-GODS page


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This book is about my life and the struggles I have experienced and how that has changed how I create my art. It also displays my artwork over the several mediums I have experimented with in the last few years. Please take the time to check out my story most importantly because it tells about God's amazing love!
I grew up in Lexington, Kentucky and went to Lafayette High school graduated in 1999 and then attended College at Berea in Berea, Kentucky. I then transferred to the University of Kentucky in the Fall of 2002 and finished my BA in Studio Art in 2005. My concentration of art mainly falls in the painting, printmaking and drawing realm. I created a book that I uploaded to Blurb.com which features a portfolio of my undergraduate work. My artwork is very abstract, while also remained very tightly drawn in a very realistic manner. Very illustrative with bright colors and my signature "curls". My art is mainly focused on showing the how God can transform anyone. It is approached in a very abstract manner. A way that invites and doesn't push away. I achieve this by making my work about my thoughts and feelings in a very cathartic manner that allows the viewer to ask questions and to let a conversation begin.
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THIS WEEK: The No. 4 Stanford men's volleyball team (18-7, 15-7 MPSF) closes out the regular season on the road at No. 6 UC Irvine (17-9, 14-8 MPSF) on Friday, April 11 and at UC San Diego (3-22, 1-21 MPSF) on Saturday, April 12. Both matches are scheduled for 7 p.m.
CATCH THE CARDINAL: Live stats for the matches can be found on the men's volleyball schedule page on GoStanford.com. Live video links will also be available on Stanford's schedule page for both matches.
SCOUTING UC IRVINE: UC Irvine (17-9, 14-8 MPSF) enters the weekend having won eight its past nine matches. The Anteaters are hitting .308 as a team and putting down 1.38 service aces per set. UCI is led by junior opposite Zack La Cavera's 3.51 kills and 1.15 digs per set. Senior outside hitter Jeremy Dejno adds 3.15 kills per set, while senior middle blocker Collin Mehring averages 1.51 kills and 1.08 blocks on a .456 hitting percentage. Junior libero Michael Brinkley anchors the defense with 2.48 digs per set.
SCOUTING UC SAN DIEGO: The Tritons (3-22, 1-21 MPSF) are coming off a sweep over UC Merced last week at home. UCSD is hitting .203 as a team while allowing opponents to hit .380. Senior Mike Brunsting leads the Tritons with 205.5 points on the season, averaging 2.24 kills, 3.08 assists and 1.68 digs per set. Junior setter Garrett Dempsey leads the squad with 8.46 assists per set and adds 1.17 digs per set.
SOCIAL MEDIA: Fans will have access to unique behind-the-scenes content on the team this season by liking Stanford Men's Volleyball on Facebook or following the team on Twitter (@StanfordMVB) and Instagram (@therealstanfordmvb).
LAST TIME OUT: Stanford continued to roll last week, sweeping Pacific and Cal Baptist to push its winning streak to nine matches. Senior outside hitter Brian Cook led the team with 3.17 kills per set on a .300 hitting percentage in the two matches. Sophomore middle Conrad Kaminski added 2.50 kills and 1.17 blocks per set on a .789 attack percentage (15-19).
IN THE POLL: Stanford remained at No. 4 in the latest AVCA Division I-II Men's Coaches Poll after sweeping Pacific and Cal Baptist last week. The Cardinal is one of nine MPSF teams ranked in the top 15 with all nine appearing in the top 10.
STATISTICAL RANKINGS: The following is Stanford's team and individual rankings among the nation's top-25.
Hitting Percentage: .336, 2nd
Kills per set: 13.65, 3rd (Brian Cook 3.63, 20th)
Assists per set: 12.87, 3rd (James Shaw 10.99, 9th)
Digs per set: 9.84, 5th (Grant Delgado 2.56, 9th)
Aces per set: 1.46, 5th
Points per set: (Brian Cook 4.17, 25th)
SENIOR STATEMENTS: Senior outside hitters Brian Cook and Steven Irvin pace the Cardinal this season with 3.63 and 3.31 kills per set, respectively. Cook has led the Cardinal in the kill column 16 times, while Irvin is hitting above .300 for the first time in his career.
POSTSEASON BERTH: Stanford's win over Cal Baptist last week clinched an MPSF Tournament berth for the Cardinal. Stanford has now appeared in the postseason for seven consecutive seasons.
RETURNING ALL-AMERICANS: The Cardinal boasts three returning All-Americans on its roster this seaosn. Senior outside hitter Brian Cook earned AVCA First Team All-America honors as a junior, averaging a team-best 4.01 kills per set. Senior outside hitter Steven Irvin nabbed second team honors from the AVCA in 2013, while sophomore setter James Shaw was a third team pick by Volleyball Magazine as a rookie.
HEAD COACH JOHN KOSTY: Stanford head coach John Kosty is in his eighth season at the helm of the Cardinal program and his 24th overall on staff. He is 139-89 in his career and guided Stanford to the 2010 NCAA national championship. The Cardinal has produced a first team AVCA All-America selection in each of the past six seasons under Kosty.


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Hi there! My name is Dawn Crothers. I have a passion for the gorgeous details found in vintage furnishings that are rare today–velvet tufted sofas with carved wood trim, white farm tables with a chippy patina, gold rimmed tea cups, intricate floral patterned plates, and crochet-trimmed cotton napkins. To me, attention to these details is what can transform an event from ordinary to extraordinary. That's what I'm here to do!
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It is my hope that you'll allow me to make life's special occasions into events that you and your guests will never forget.


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MEDINA — The humidity at Pleasant Valley Country Club on Monday afternoon had little effect on four local golfers.
Brunswick's Joey Bachman and Medina's Amanda Rom won their respective age divisions and Seville's Alyssa Drehs and Hinckley Township's Alicia Porvasnik shared the title in the 10-12 bracket as the Southwest Junior Golf Tour had its final regular-season event.
The tour will hold a three-day Match Play Championship at Pine Hills Golf Club starting today, before all golfers compete in the Founders Cup Tour Championship next Monday at Medina Country Club.
Bachman edged Matt Frey of Broadview Heights by a single shot en route to finishing with a 3-over-par 75, while Rom chalked up the victory thanks to a round of 85. He outlasted fellow Medina resident Madison Loftis by four strokes.
Drehs and Porvasnik fired identical 52s to share bragging rights in nine-hole competition.
Hinckley Township's Chad Dubiel was second in the 12-13 age group and Justin Roth of Brunswick placed in a tie for runner-up in 14-15.


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van Beek, Elke J.A.H.; Leroy, Piet L.J.M.
Pediatric Sedation Unit, Maastricht University Medical Centre, Maastricht, The Netherlands.
Address correspondence and reprint requests to Piet L.J.M. Leroy, Department of Pediatrics, Maastricht University Medical Centre, PB 5800, 6202 AZ Maastricht, The Netherlands (e-mail: email@example.com).
Received 29 March, 2011
Accepted 19 September, 2011
Drs van Beek and Leroy participated equally in this study.
The authors report no conflicts of interest.
Objective: The aim of the study was to assess, by a review of published evidence, the safest and most effective way to provide procedural sedation (PS) in children undergoing gastrointestinal endoscopy (GIE).
Methods: The databases MEDLINE, Cochrane Library, and Embase were used. Search terms "endoscopy, gastrointestinal" or "endoscopy, digestive system" were combined with "sedation," "conscious sedation," "moderate sedation," "deep sedation," and "hypnotics and sedatives." The final review was restricted to studies reporting specifically on safety (incidences of adverse events) and/or effectiveness (time characteristics, need for supplemental sedation, need for restraint, procedural success, provider satisfaction, and patient comfort) of PS for GIE in children younger than 18 years.
Results: The search yielded 182 references and the final selection included 11 randomized controlled trials (RCTs) and 15 non-RCTs. Six sedation categories were identified: propofol, opioid/benzodiazepine, premedication, ketamine-, sevoflurane-, and midazolam-based. Only a few RCTs have compared different categories. Opioid/benzodiazepine- and propofol-based PS have a similar safety profile and a low incidence of major adverse events. Propofol-based sedation turned out to be the most effective regimen, with effectiveness comparable to general anesthesia. The addition of midazolam, fentanyl, remifentanil, and/or ketamine to propofol may increase the effectiveness without creating more adverse events. Data on midazolam-, ketamine- and sevoflurane-based sedation were generally too limited to draw conclusions.
Conclusions: Despite a lack of RCTs containing all aspects of effectiveness and safety, the present evidence indicates propofol-based PS to be the best practice for PS in children undergoing GIE. Propofol can be safely administered by specifically trained nonanesthesiologists.
Gastrointestinal endoscopy (GIE) is a well-established procedure for diagnosis and treatment in pediatric gastroenterology. Despite local anesthesia, reassurance, and distraction techniques, most children are unable to undergo GIE without being physically restrained (1,2). In addition, the recall of an unpleasant GIE generates a more negative attitude toward future endoscopies (3). Therefore, children undergoing GIE will need anesthesia or procedural sedation (PS) to guarantee optimum comfort and cooperation. PS can be defined as the use of sedative, analgesic, or dissociative drugs to relieve anxiety and pain associated with diagnostic and therapeutic procedures, while maintaining spontaneous ventilation (4,5). PS covers a large spectrum of sedatives and involves a wide range of sedation levels (Table 1). Mild sedation, formerly called anxiolysis, is typically the result of 1 standard dose of midazolam or by the breathing of 50% nitrous oxide (6). Moderate sedation, formerly called conscious sedation, is often used incorrectly to describe a state that is probably more like deep sedation; reflex withdrawal to a painful stimulus alone should not be considered as arousable (7). The term deep sedation has been under discussion in some professional groups because it may be indistinguishable from anesthesia. Although this point may be overstated, it has led to the recommendation that the same personnel, equipment, and facilities must manage both deep sedation and anesthesia. Some have proposed other descriptions of deep sedation/anesthesia: the terms light anesthesia or minimal anesthesia may be more appropriate to describe a technique in which the patient seems unconscious, although any appreciable stimulation is likely to rouse them (8,9).
PS provided in a context of inadequate training, competence, or safety precautions is associated with a greater likelihood of potentially fatal complications (4,10). PS by untrained individuals also bares the risk of ineffective sedation, possibly leading to unsuccessful and/or uncomfortable procedures. Pediatric gastroenterologists differ in their opinions on the effectiveness of PS, and many prefer anesthesiologists' assistance (11). Depending on local anesthesiology resources, traditions, and personal experience, endoscopists have adopted different PS techniques (12,13). This diversity of sedation practices is, at least partially, the consequence of a lack of consensus on the safest and most effective regimen. By systematically reviewing the literature, we aimed to answer the following clinical question: what is the safest and most effective way to provide PS in children undergoing GIE?
The literature was searched in the databases MEDLINE, Cochrane Library, and Embase. The search terms "endoscopy, gastrointestinal" or "endoscopy, digestive system" were combined with the terms "sedation," "conscious sedation," "moderate sedation," "deep sedation," and "hypnotics and sedatives." The search was restricted to articles including human subjects ages 0 to 18 years and published between January 1995 and January 2011. Additional records were searched in bibliographies of published studies, review articles, editorials, and guidelines. In the first step, articles addressing a mainly adult population were excluded. Next, both authors reviewed independently the full text of the remaining articles. Authors were not blinded for either the Journal or authors. Exclusion criteria were studies not reporting on the safety or effectiveness of PS, studies focusing on non-GIE procedures, studies on specific endoscopy procedures (eg, endoscopic retrograde cholangiopancreatography) or specific research populations (eg, critically ill children), review articles, editorials, policy statements, guidelines, and case reports. Disagreements were discussed and solved among authors. The final review was restricted to studies that reported specifically on "safety" and/or "effectiveness" of PS for GIE in children. Safety was assessed using incidences of adverse events: hypoxia, hypoventilation or apnea, laryngeal spasm, bradycardia, hypotension, vomiting, complications with fatal outcome or permanent sequelae, and the need for rescue interventions. Effectiveness was assessed using time characteristics (induction, recovery, and total sedation time), the need for supplemental sedation, procedural success, provider satisfaction, and patient comfort (stress or pain scores, recall, parent or patient satisfaction). We defined that an optimally effective PS technique should achieve near 100% predictable procedural success and timing, minimal induction and recovery times, and optimal patient comfort (absence of procedural pain, anxiety, or the need for restraint) (2).
To answer the clinical question, results from randomized controlled trials (RCTs) were used at first. If these sources remained inconclusive, then the results of non-RCTs were used to formulate a deliberate answer. Non-RCTs were classified as B1 for "comparative-prospective," B2 for "comparative-retrospective," and C for "noncomparative" studies.
The results of the literature search and selection process are summarized in Figure 1. The final selection included 25 articles, reporting on 26 studies (11 RCTs and 15 non-RCTs). One article included the results from a retrospective comparative study and an RCT (14). RCTs are summarized in an evidence table, listing details on methodology, results, limitations, and conclusions (Table 2). Non-RCT studies are summarized in Table 3. Esophagogastroduodenoscopy (EGD) was the most frequent GIE. Depending on the investigated sedative(s), RCTs can be divided into 3 categories: propofol-based, opioid + benzodiazepine combination, and studies on premedication. Non-RCT literature yielded 3 additional categories, that is, ketamine-, sevoflurane-, and midazolam-based protocols. Results are ordered according to the number of reported procedures. Studies on premedication are reported separately.
Six RCTs (N = 561 procedures) and 4 non-RCTs (N = 3322 procedures) examined the safety and/or effectiveness of propofol-based PS. The majority of published propofol sedations (3420/3883; 88.1%) were performed by nonanesthesiologists, that is, pediatric intensivists (14,15) or specifically trained pediatricians (4,16).
Propofol-based PS is safe. Mild respiratory events occur frequently and major complications may happen rarely, but adverse events do not occur more frequently compared with other sedation regimens. On a total of 3883 reported propofol-based sedations, major respiratory complications like total airway obstruction, deep hypoxia, or apnea occurred 11 times (0.3%). No cases of intubation, resuscitation, permanent sequelae, or death were reported. In the largest study (Larsen et al (15); N = 2332), the incidence was only 0.04%, but the retrospective design may have caused underreporting. In all of the studies, patients routinely received additional oxygen. Overall, the incidence of adverse events is not higher compared with other sedative regimens included in this systematic review. Minor respiratory events, such as temporary desaturation or hypoventilation, occurred more frequently (up to 24% in Kaddu et al's study), particularly in infants younger than 1 year (incidence 35% compared with 12.5% in children older than 10 years; P < 0.02) (15). Three of the 6 children needing assisted ventilation in the study by Barbi et al (4) (N = 811 procedures) were also younger than 1 year. The other 3 and all 14 children with laryngospasm (overall incidence 1.7%) were younger than 4 years. Disma et al (12) reported an incidence of laryngospasm of 3.75% in children sedated with propofol alone. Adding midazolam or fentanyl to propofol resulted in no cases of laryngospasm. Clinically relevant hypotension, hypoperfusion, or bradycardia has not been reported.
Propofol-based PS is greatly effective. None of the retrieved articles reported in itself on all aspects of effectiveness as defined in the methodology section of this systematic review. The reported incidences of incomplete or failed procedure ranged from 0% (14) over 0.05% (15) to 0.4% (4,15). Kaddu et al (17) showed that deep sedation with propofol is an equivalent alternative for general anesthesia (GA). The time to achieve adequate sedation, the mean procedure time, and the recovery time were significantly shorter in children sedated with propofol, compared with the combined sedation with meperidine + midazolam (14). Only 3 studies assessed patient comfort or the need for restraint as outcome parameters for effectiveness. Paspatis et al (18) reported an incidence of extreme discomfort of 14.2% if propofol was used alone. Premedication with oral midazolam improved significantly the level of patient comfort during the procedure (0% extreme discomfort). Khoshoo et al (14) showed that propofol + midazolam was associated with the need for restraint in only 3% of cases, compared with 57% in the meperidine + midazolam group (P < 0.01). Total absence of recall was observed more frequently in the propofol + midazolam group (88% vs 55%; P < 0.05). Elitsur et al (19) reported the absence of pain and recall in 96% of patients. Propofol injection pain was reported to occur in 53% of cases, despite the addition of lidocaine to propofol (4).
The addition of ketamine, midazolam, or fentanyl to propofol-based PS may have beneficial effects on PS quality. Tosun et al (20) compared propofol + ketamine with propofol + fentanyl. Both combinations provided equally effective sedation and similar low incidences of mild respiratory events. The use of ketamine was associated with a better tolerance of endoscope insertion but higher incidences of cough, vomiting, dizziness, and diplopia. A low dose of ketamine before propofol is more effective in reducing propofol infusion pain, compared with a lidocaine–propofol mixture (16). Disma et al (12) showed that the addition of either fentanyl or midazolam caused less adverse events compared with propofol alone. This effect was mainly caused by a lower incidence of coughs and laryngeal spasms. No differences were seen between these 2 additional medication regimes regarding effectiveness or adverse events. Both Disma et al and Elitsur et al (12,19) showed that adding midazolam or fentanyl significantly lowers the necessary dose of propofol.
The effectiveness and/or safety of opioid + benzodiazepine-based sedation were studied in 3 RCTs (N = 94 procedures) and 6 non-RCTs (N = 2326 procedures). The administrating professionals were intensivists (14), gastroenterologists/endoscopists (21–24), or were not reported (13,25,26).
Opioid + benzodiazepine-based sedation is safe. Mild respiratory events occur frequently and major complications may happen rarely. Of a total of 2420 opioid + benzodiazepine-based sedations, major respiratory complications such as apnea, total airway obstruction, or deep desaturation occurred only 5 times (0.2%). In all of the studies, patients received oxygen routinely, except for the studies by Fishbein et al, Chuang et al, and Gilger at al (21,22,26).
Khoshoo et al (14) showed that the use of meperidine + midazolam was associated with a higher need for supplemental oxygen and ventilatory support, compared with the use of propofol + midazolam (17% vs 7% and 7% vs 3%, respectively; P < 0.05 for both differences). Ali et al (25) showed in a small RCT that fentanyl + midazolam and meperidine + midazolam are equally safe. Chuang et al (21) came to the same conclusion in their retrospective comparative study. Fishbein et al (26) compared intravenous (IV) meperidine + midazolam with the combination of intranasal midazolam and IV meperidine. Both regimens were equally safe and none of the patients experienced major adverse events. In their prospective study on IV fentanyl + midazolam, Mamula et al (13) reported 9% respiratory adverse events (8% transient desaturation, 1% prolonged desaturation, 0.2% apnea), 11% mild cardiovascular adverse events (3% hypertension, 8% hypotension), 0.6% rash, 1% agitation, and 5% vomiting. The following rescue interventions were reported: 9.5% extra oxygen therapy, 1.3% tactile stimulation, 0.4% jaw thrust, 0.2% bag and mask ventilation, and 1.6% IV fluid bolus. In a smaller prospective study, Squires et al (24) compared PS using meperidine + midazolam with general inhalational anesthesia. No major adverse events or desaturations were reported. Gilger et al (22) compared retrospectively meperidine + midazolam with meperidine + midazolam + ketamine and midazolam + ketamine. Mild respiratory adverse events, especially desaturations, occurred most frequently in the meperidine + midazolam group (30.7% vs 10.9% [P < 0.001] and 0.6% [P < 0.001], respectively).
The evidence indicates that effectiveness of opioid + benzodiazepine-based PS is suboptimal, especially regarding time characteristics and the need for restraint. None of the retrieved articles reported in itself on all aspects of effectiveness as defined in the methodology section of this systematic review. In their comparative study between propofol + midazolam and meperidine + midazolam, Khoshoo et al (14) reported equally high procedural success rates (±100%); however, the time to achieve adequate sedation, the mean procedure time, and the recovery time were significantly longer if midazolam + meperidine was used. Furthermore, restraint was significantly needed more in the meperidine + midazolam group, suggesting suboptimal effectiveness of this regimen. Fishbein et al (26) reported high incidences of major negative behavior during EGD in children sedated with IV midazolam + meperidine (19/20) or intranasal midazolam + IV meperidine (18/20). The intensity of negative behavior was significantly lower in the group receiving intranasal midazolam premedication. Ali et al (25) could not show any significant difference in effectiveness between fentanyl- and meperidine-based PS, but patient comfort was not an outcome parameter in their study. In the Mamula et al study (13) on fentanyl + midazolam, 11% of the colonoscopies were incomplete because of inadequate sedation. Gremse et al (23) found similar figures in their study on meperidine + midazolam. Gilger et al (22) showed that, compared with ketamine + midazolam, the use of meperidine + midazolam resulted more frequently in inadequate sedation (8.6% vs 3.1%), although the difference was not significant (P = 0.07). Finally, a prospective comparison between meperidine + midazolam and GA showed a lower procedural failure rate (0% vs 4.8%), lower need for restraint (0% vs 13%), and less direct and indirect indications of discomfort in the GA group (24).
Three non-RCT trials (N = 1056 procedures) have examined the safety and/or effectiveness of ketamine. In 2 studies, gastroenterologists administered ketamine (22,27). Aggarwal et al (28) did not report the administrating professional.
Ketamine-based PS is probably safe, but data are limited. Especially in EGD, ketamine is associated with a high chance of laryngeal spasm. Compared with meperidine + midazolam, Gilger et al (22) reported less desaturation in the ketamine + midazolam group. Aggarwal et al (28) found no particular major adverse events or complications, but it is unclear how vital parameters were assessed. A retrospective study by Green et al (27) reported in more detail on adverse events (Table 2). All of the patients routinely received oxygen therapy. Laryngeal spasm occurred in 9.5% of EGDs. The only significant independent predictor of laryngospasm in a multivariate analysis was age: 13.9% in preschool-age (6 years or older) children and 3.6% in school-age (older than 6 years) children (difference 10.3%, 95% CI 5.5%–14.9%).
Ketamine-based PS is probably effective, but data are limited. Reliable data on patient comfort and the need for restraint are missing. According to Gilger et al (22), inadequate sedation occurs less frequently in ketamine + midazolam sedation compared with meperidine + midazolam. Incidences of failed sedation ranged from 0% to 1.1% (27,29); however, data on patient comfort, the need for restraint, or the ease of the procedure are missing.
One RCT (N = 61 procedures) and 2 non-RCTs (N = 275 procedures) have studied the safety and/or effectiveness of midazolam alone. Either anesthesiologists (30,31) or pediatricians (32) administered midazolam.
Data are too limited to draw conclusions on the safety of midazolam-based PS. Rafeey et al (31) compared oral and IV midazolam. Major adverse events did not occur. The mean oxygen saturation was lower in the IV group. Verhage et al (32) reported an overall incidence of adverse events of 3%. Nature and severity of events were not reported. Flumazenil was needed in 2.7% of cases. In a small comparative study, Lamireau et al (30) compared IV midazolam with halothane anesthesia. Desaturation below 90% occurred significantly more frequently in the midazolam group (50% vs 0%; P < 0.001). Midazolam-based PS is probably ineffective, but data are limited.
Lamireau et al (30) found that incomplete procedures and complete procedures under difficult conditions occurred significantly more frequently in patients sedated with IV midazolam compared with halothane anesthesia (50% vs 0% and 38.9% vs 0%, respectively). Rafeey et al and Verhage et al (31,32) reported procedural success rates of approximately 100%; however, both studies failed to report reliable data on patient comfort, adequacy of sedation, and ease of procedure. The significant increase in heart rate and blood pressure during endoscopy, as registered by Rafeey et al, suggests that midazolam is ineffective in reducing patient discomfort.
In a retrospective study, Montes and Bohn (33) compared inhaled sevoflurane (N = 67 procedures), administered by an anesthesiologist using an oropharyngeal tube, with 2 sedative regimens administered by pediatric intensivists: propofol alone (N = 114 procedures) and a combination of midazolam and/or fentanyl and/or ketamine and/or propofol (N = 67 procedures).
Sevoflurane-based PS may be safe, but data are limited. No severe adverse events were reported. Respiratory adverse events occurred rarely at similar incidences in the 3 groups. The incidence of hypotension was 0% in the sevoflurane group versus 13.2% and 7.5% in the other groups. None of these hypotensive episodes was considered relevant. Data are too limited to draw conclusions on the effectiveness of sevoflurane-based PS. Compared with the IV regimens, sevoflurane was characterized by a shorter recovery time, earlier discharge, and lower costs. The present study did not report on patient comfort, need for restraint, or overall procedural success; neither did it specify whether and how sevoflurane pollution in the ambient air was avoided (33).
Three RCTs (N = 107 procedures) specifically analyzed the safety and/or effectiveness of midazolam premedication. One RCT (N = 50 procedures) analyzed atropine premedication.
Midazolam premedication is probably safe for children undergoing PS for GIE, but data are limited. None of the studies recorded differences in safety between premedication and non–premedication groups.
Premedication with midazolam has positive effects on patient comfort. There is good evidence that oral midazolam premedication preceding a propofol- or an opioid-based PS improves significantly the ease and comfort of both IV catheter placement and separating the child from the parents. It also increases the level of patient comfort during the procedure (18,34). Following an opioid-based PS, the degree of partial or total amnesia is higher, compared with placebo, if oral midazolam premedication is given (83% vs 55%; P < 0.05) (34). In propofol-based PS, the addition of oral midazolam premedication lowers the propofol dose during the procedure but increases the recovery time (18). Fishbein et al (26) showed that premedication with intranasal midazolam before IV meperidine effectively reduces the intensity of negative behaviors; however, no effect was seen on the total number of negative behaviors. Furthermore, the intranasal administration itself was associated with negative behavior in 50% of cases.
Atropine premedication probably does not increase the safety or effectiveness of PS in children undergoing GIE, but data are limited. Hofley et al (35) compared atropine premedication with placebo in a small group of children sedated with fentanyl + midazolam or meperidine + midazolam. They concluded that atropine did not increase PS safety and provided no appreciable benefits on oral secretions, gastric motility, vomiting, facial flushing, or diphoria.
The available evidence suggests that propofol-based PS is the most effective regimen for PS during GIE in children (Table 4). Propofol guarantees an excellent level of procedural success, optimal timing, and maximal patient comfort, in particular if propofol is preceded by midazolam premedication. The addition to propofol of IV midazolam, fentanyl, or remifentanil may increase the effectiveness without generating more adverse events, provided that sedation is performed by trained PS practitioners under certain quality and safety conditions. Compared with GA, propofol-based PS seems to be an equally effective technique for selected cases of diagnosis and therapy. It must be noted, however, that there is a considerable risk that deep sedation with propofol may result in an actual sedative state close or similar to GA for a limited period of time with an increased risk. In a prospective study of children sedated with propofol by nonanesthesiologists, 90% of children reached a level of "anesthesia" albeit briefly (36). Nevertheless, this systematic review's search category was "sedation" and not "anesthesia," so that irrespective of the actual sedation level, practitioners believed that they were sedating and not anesthetizing.
Propofol infusion–related pain can be prevented with a low dose of ketamine, which is, in children, a more effective approach compared with adding lidocaine to propofol. Opioid + benzodiazepine-based PS also results in high procedural success rates; however, the longer time needed to achieve sedation, the longer recovery time, and the significantly lower levels of patient comfort are substantial drawbacks compared with propofol-based PS. There is some evidence that the relatively high incidence of incomplete colonoscopies in opioid + benziodiazepine-based PS (up to 10%) is caused by ineffective sedation. We could find no study comparing the effectiveness of propofol and ketamine for GIE in children. The available evidence on ketamine suggests less inadequate sedation, compared with meperidine + midazolam; however, none of the articles reported data on patient comfort, the need for restraint, or the ease of the procedure. It is plausible that IV midazolam alone is not an effective way to provide PS for GIE in children; however, oral midazolam premedication preceding a propofol-based or an opioid-based PS improves significantly the ease and comfort of both IV catheter placement and separation of the child from the parents. It also increases the level of patient comfort during the procedure.
Comparing the safety outcome of propofol-based PS with the more traditional opioid + benzodiazepine-based PS does not reveal striking differences. Mild and transient hypoxia is reported as the most frequent adverse event in both strategies. Major respiratory adverse events, such as deep hypoxia, hypoventilation, apnea, and airway obstruction, seem to occur rarely but at similar rates. As a consequence, both regimens require the same safety precautions. In adult medicine, 3 recent meta-analyses did not show significant differences between propofol-based and traditional PS for hypoxemia and hypotension, except for fewer cardiorespiratory complications with propofol during colonoscopy (37–39). Khoshoo et al published the only available RCT comparing the safety of propofol-based versus opioid + benzodiazepine–based PS in children. In the propofol group, oxygen therapy and ventilatory support were significantly less needed. There is some evidence that laryngospasm occurs in about 9% of children sedated with ketamine for EGD (27), compared with 1.7% to 3.7% if propofol is used alone (4,12) and 0% if propofol is combined with midazolam or fentanyl (12). Therefore, it may be prudent to advise not to use ketamine for upper GIE and to add midazolam or fentanyl to a propofol PS.
The fact that, apart from 1 article (4), none of the studies made use of capnography monitoring may have caused underestimation of the real incidences of airway obstruction and hypoventilation. The relevance of capnography for early detecting imminent respiratory events during PS is well established (40–42). Its application during GIE was reviewed recently (43).
The similar low rate of adverse events in the different sedation regimens is not surprising. It has been shown that PS-related safety is determined by the circumstances, applied safety precautions, and professional skills rather than by specific pharmacological characteristics (10). In most studies included in this systematic review, competent and skilled professionals performed PS in accordance with widely accepted safety guidelines. Adherence to PS safety guidelines reduces the occurrence of PS-related adverse events (36,44,45).
The present review suggests the superior effectiveness of propofol compared with the more traditionally used opioid + benzodiazepine combination. The latter is generally considered safe in a nonanesthesiologist's hands, whereas the administration of the anesthetic propofol is usually restricted for safety reasons to anesthesiologists only. This distinction is remarkable given the results of this systematic review, showing a similar safety profile for both regimens. Furthermore, the vast majority of included propofol sedations were performed by nonanesthesiologists. Because of limited anesthesiology resources, propofol is being administered worldwide by nonanesthesiologists (specially trained nurses or endoscopists) for GIE in selected adult patients (46). An evidence-based guideline on this topic was published recently (47). Excellent evidence exists demonstrating that well-trained nonanesthesiologists may provide propofol sedation safely in children, including for gastrointestinal procedures (48). It has also been shown that within the setting of adequate training and strict safety measures, no differences exist in rates of major complications among different specialists (ie, anesthesiologists and nonanesthesiologists) (49). Appropriate safety precautions, monitoring, and professional skills, rather than professional title, are determinants for the safe and effective use of propofol for PS (50).
The present study has several limitations. At first, few RCTs compared different pharmacological techniques. The fact that different studies used different outcome measures or different definitions for safety and effectiveness is another important limitation. An objective or validated assessment of the more subjective measures such as satisfaction, ease of procedure, or patient comfort is missing in most studies. Consequently, it is presently impossible to summarize the available evidence in meta-analyses or to draw solid conclusions on best practices. Nevertheless, we believe that it is possible to draw prudent conclusions and to formulate practical recommendations. Because most of the studies reviewed included both upper and lower GIE, we choose not to differentiate between them. It is likely that optimal sedation characteristics and issues on safety and effectiveness are not the same for both procedures; however, we believe that the main conclusions would probably remain the same. Psychological distraction techniques may be useful adjuncts or partial alternatives for PS. We deliberately choose not to include these nonpharmacological methods in this systematic review. Finally, in individual patients, the optimal PS strategy may deviate from the conclusions of this systematic review. Although the benzodiazepine + opioid combination is not as good as propofol-based PS, it may be suitable for some children if they can tolerate moderate sedation. Also, unsedated endoscopy in selected greatly motivated children has been reported (51). In this respect, it is remarkable that in the Barbi et al (4) study among children older than 14 years, 26.6% preferred to have no sedation at all during upper GIE.
The limitations of this systematic review clearly identify a gap of scientific knowledge on this topic. Only well-designed, procedure-specific RCTs comparing validated outcome measures on effectiveness and safety between different sedative regimens in large numbers of children may yield a definite answer on our clinical question; however, given the results of this systematic review in general and the findings on patient comfort in particular, one may question whether setting up such trials is still ethically justifiable.
Despite the methodological limitations, the evidence gathered in this systematic review indicates propofol-based PS as the best practice for PS in children undergoing GIE. The addition to propofol of IV midazolam, fentanyl, or remifentanil may increase its safety and effectiveness. Oral midazolam premedication leads to a lower mean dose of propofol, less painful and easier IV access, easier separation from the parents, and greater patient comfort during endoscopy. A low dose of ketamine is effective in reducing propofol infusion pain. Propofol is likely to lead to an unconscious state in many children. Although this may not be unsafe, it does mean that it is not strictly sedation. Practitioners should be trained to manage this depth of sedation (ie, anesthesia) and parents and children warned that this may happen. Conversely, children who expect to be oblivious to the GIE during sedation with propofol should be told that they may be sedated (not anesthetized) and that they may recall some details of the procedure. Propofol can be safely administered to children by specifically trained nonanesthesiologists who provide PS in adherence to established safety guidelines. In the absence of these professionals and settings, it is advisable to refer children who need to undergo a GIE to an anesthesiologist for propofol-based PS or anesthesia.
This article has been cited 2 time(s).
children; effectiveness; gastrointestinal endoscopy; procedural sedation; safety
Copyright 2012 by ESPGHAN and NASPGHAN
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