Sedation-related complications during anesthesiologist-administered sedation for endoscopic retrograde cholangiopancreatography: a prospective study

Abstract

Background: Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) require adequate sedation or general anesthesia. To date, there is lack of consensus regarding who should administer sedation in these patients. Several studies have investigated the safety and efficacy of non-anesthesiologist-administered sedation for ERCP; however, data regarding anesthesiologist-administered sedation remain limited. This prospective single-center study investigated the safety and efficacy of anesthesiologist-administered sedation and the rate of successful performed ERCP procedures. Methods: The study included 200 patients who underwent ERCP following anesthesiologist-administered sedation with propofol and remifentanil. Procedural data, oxygen saturation, systolic blood pressure (SBP), heart rate, recovery score, patient and endoscopist satisfaction, as well as 30-day mortality and morbidity data were analyzed. Results: Sedation-related complications occurred in 36 of 200 patients (18%) and included hypotension (SBP < 90 mmHg) and hypoxemia (O 2 saturation < 90%) in 18 patients (9%) each. Most events were minor and did not necessitate discontinuation of the procedure. However, ERCP was terminated in 2 patients (1%) secondary to sedation-related complications. Successful cannulation was performed in all patients. The mean duration of the examination was 25 ± 16 min. Mean recovery time was 14 ± 10 min, and high post-procedural satisfaction was observed in both, patients (mean visual analogue scale [VAS] 9.6 ± 0.8) and endoscopists (mean VAS 9.3 ± 1.3). Conclusion: This study suggests that anesthesiologist-administered sedation is safe in patients undergoing ERCP and is associated with a high rate of successful ERCP, shorter procedure time, and more rapid post-anesthesia recovery, with high patient and endoscopist satisfaction.

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

“…They casually dismissed the 3% incidence of unplanned intubation by stating that "airway access was easily obtained on the rare occasion unplanned intubation was deemed necessary." In a similar prospective study of ERCP under MAC, Zhang et al 7 found that sedation-related complications occurred in 18% of patients, with hypoxemia (defined as oxygen saturation <90% for at least 2 minutes) occurring in 9% of patients, and >33% of patients experiencing multiple hypoxemic episodes. The authors noted that the incidence of hypoxemia in their study was comparable to the hypoxemia rate in other similar studies and, thus, concluded that "sedation by anesthesia personnel for ERCP is safe."…”

“…28,29 However, what may be more concerning to those in the anesthesia profession is the high rate of SRAEs during the procedure, with an incidence reported as high as 21%. 6,7 This begs the questions of who should be administering anesthesia and monitoring the patient during ERCP and what type of anesthesia should be administered. In this "Pro-Con," we argue that a qualified anesthesia professional should administer the anesthesia for ERCP, and that GEA offers significant advantages over MAC.…”

“…The interpretation of data ultimately relies on the lens through which they are viewed. A gastroenterologist may not be alarmed by an unplanned intubation rate of up to 3%, 6 or hypoxemia rates as high as 33%, 7 as long as the patient did not suffer any long-term sequelae.…”

“…Therefore, the time and invasiveness of the intervention are vital inputs to anesthetic choice, and the advantages and disadvantages of each anesthetic technique must be considered (Table 2). No significant difference in overall serious adverse events when comparing MAC versus GEA in healthy, nonobese patients [2][3][4] Avoidance of the potential problems associated with GEA including intubation-related injury, hemodynamic instability, and medication side effects Improved gastrointestinal suite efficiency metrics and shorter patient recovery time 5 Low conversion rate from MAC to GEA of <4% 4 Reliable detection of airway obstruction using end-tidal CO 2 monitoring and astute clinical observation, and rapid improvement with basic airway maneuvers CON side: arguments in favor of GEA for ERCP MAC is associated with unacceptably high rates of SRAEs (~20%), conversion to GEA (~3%), and hypoxemic episodes (~10%-30%) 4,[6][7][8][9][10] The only randomized controlled trial to date comparing GEA to MAC (in high-risk patients) demonstrated significantly higher rates of adverse events in the MAC cohort 10 NORA carries inherent risk, often related to impaired oxygenation and/or ventilation. www.anesthesia-analgesia.org…”

Sedation strategy for retrograde cholangiopancreatography in older patients

“…The authors provided the details of ERCP-and sedation-related adverse events occurring on the day of the procedure or on the day after the procedure, but they did not assess the satisfaction levels of patients, anesthesiologists and endoscopists, as performed in other studies. 4,5 In fact, satisfaction levels with the performance of the overall procedure reported by operators and patients are very important for determining clinical availability of interventions. 6 Furthermore, these variables are very easily measured with a numeric rating scale (0, very unsatisfactory; 10, very satisfactory).…”