Pro-Con Debate: Monitored Anesthesia Care Versus General Endotracheal Anesthesia for Endoscopic Retrograde Cholangiopancreatography

Abstract

Over the past several decades, anesthesia has experienced a significant growth in nonoperating room anesthesia. Gastrointestinal suites represent the largest volume location for off-site anesthesia procedures, which include complex endoscopy procedures like endoscopic retrograde cholangiopancreatography (ERCP). These challenging patients and procedures necessitate a shared airway and are typically performed in the prone or semiprone position on a dedicated procedural table. In this Pro-Con commentary article, the Pro side supports the use of monitored anesthesia care (MAC), citing fewer hemodynamic perturbations, decreased side effects from inhalational agents, faster cognitive recovery, and quicker procedural times leading to improved center efficiency (ie, quicker time to discharge). Meanwhile, the Con side favors general endotracheal anesthesia (GEA) to reduce the infrequent, but well-recognized, critical events due to impaired oxygenation and/or ventilation known to occur during MAC in this setting. They also argue that procedural interruptions are more frequent during MAC as anesthesia professionals need to rescue patients from apnea with various airway maneuvers. Thus, the risk of hypoxemic episodes is minimized using GEA for ERCP . Unfortunately, neither position is supported by large randomized controlled trials. The consensus opinion of the authors is that anesthesia for ERCP should be provided by a qualified anesthesia professional who weighs the risks and benefits of each technique for a given patient and clinical circumstance. This Pro-Con article highlights the many challenges anesthesia professionals face during ERCPs and encourages thoughtful, individualized anesthetic plans over knee-jerk decisions. Both sides agree that an anesthetic technique administered by a qualified anesthesia professional is favored over an endoscopist-directed sedation approach.

Comparing Patient Comfort During Bronchoscopy Under Conscious Sedation and Monitored Anesthesia Care: A Prospective, Observational, Controlled Study

“…In conclusion, this study and current literature provide evidence supporting the use of both CS and MAC in bronchoscopy, emphasizing the need for individualized patient care. While MAC offers deeper sedation, it does not significantly improve patient comfort compared to CS [ 19 ]. Both methods are safe and effective, with the choice between them depending on specific patient and procedural factors.…”

Endoscopic Endotracheal Intubation for ERCP In the Era of COVID: An Approach To Minimize Risk of Transmission of Infectious Diseases

“…Elective asleep endoscopic intubations have been utilized for procedures in patients without known difficult airways for multiple patient and procedure-specific reasons and we have examined the use of this approach in patients undergoing ERCP [5]. There is a need for improved airway management in endoscopic procedures and an endoscopic endotracheal intubation for ERCP procedures carries several advantages and may fulfil this need, as described previously [3,11]. Intubation is accomplished briskly (<1 minute), the patient is anesthetized, muting the aerosol-generating cough reflex, the patient's mouth is directed down and away from the intubating physician, and distance between patient and physician can be maintained at four feet during the entire intubation process [5].…”

Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy

“…Additional monitoring, such as invasive pressure measurement, can be used in long-term therapeutic endoscopic procedures, depending on the patient’s comorbidities. In the event of complications and emergencies, equipment must be available to convert to general anesthesia [ 59 , 60 ].…”