What are the anesthetic considerations for Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures?

Anesthetic Considerations for ERCP

Enhanced sedation with propofol administered by an anesthetist or general anesthesia should be strongly considered for ERCP procedures, as this approach is associated with higher procedural success rates, better patient satisfaction, and improved tolerance compared to traditional conscious sedation with benzodiazepines and opioids. 1

Sedation Options and Selection

Standard Conscious Sedation

• Traditional conscious sedation using intravenous benzodiazepines (midazolam) and opiates is generally well tolerated but has significant limitations 1
• 14% of ERCPs performed under conscious sedation are poorly tolerated, leading to procedural failure and patient distress 1
• The complexity and duration of ERCP often necessitates higher benzodiazepine doses than routine endoscopy, with 33% of patients receiving >5.5 mg midazolam and approximately 8% requiring naloxone 1

Enhanced Sedation with Propofol (Preferred)

• Most ERCP services in Western Europe and North America now use propofol-based enhanced sedation or general anesthesia as standard practice 1
• Propofol-assisted ERCP has been shown to be safe with high rates of procedural success and patient satisfaction 1
• Propofol sedation requires administration by an anesthetist in UK practice, as there is lack of support for non-anesthetist administration 1
• Propofol provides faster recovery times compared to midazolam-based sedation 2

Propofol Combination Regimens

• Propofol-fentanyl combination provides superior analgesia compared to propofol-ketamine 3
• Cocktail sedation containing propofol (1 mg/kg bolus followed by continuous infusion at approximately 6.2 mg/kg/hr) combined with meperidine and midazolam provides faster recovery (9.67 vs 12.89 minutes) and better patient satisfaction compared to conventional sedation 4
• Etomidate offers better hemodynamic and respiratory stability than propofol in ASA I/II patients, with lower rates of transient hypotension (4% vs 16%) and hypoxia (0% vs 18%) 5

General Anesthesia with Endotracheal Intubation

• Reserved for patients with specific anesthetic issues independent of ERCP requirements, including morbid obesity and airway/ventilation problems 1

Specific Indications for Enhanced Sedation

Enhanced sedation or general anesthesia should be specifically considered for:

• Complex cases requiring long procedures (e.g., cholangioscopy-assisted electrohydraulic lithotripsy) 1
• Intrahepatic ductal stones 1
• Cases where lack of enhanced sedation has been correlated with therapeutic failure 1

Pre-Procedural NPO Requirements

• Patients must discontinue solid food intake at least 6 hours before ERCP 6
• Clear liquids may be permitted up to 2-4 hours before the procedure but should be discontinued thereafter 6
• Strict NPO status is critical because ERCP often requires deep sedation or general anesthesia, making airway protection essential 6

Monitoring Requirements

Standard Monitoring

• Continuous monitoring of blood pressure, heart rate, oxygen saturation, and respiratory rate is essential 3, 5
• Capnography should be utilized during sedation 7

Common Pitfall

• Desaturation can occur even with propofol-based sedation (58.3% in cocktail sedation studies), but these episodes are typically mild and correctable with temporary oxygen supplementation without scope removal 4

Anticoagulation Management

For ERCP classified as a high bleeding risk procedure:

• Warfarin should be discontinued 5 days before the procedure with INR checked to ensure <1.5 6
• Direct oral anticoagulants (DOACs) should be discontinued at least 48 hours before the procedure 6
• For high thrombotic risk patients, bridging with low molecular weight heparin may be necessary 6

Post-Procedural Care

Recovery and Feeding

• Early oral feeding within 24 hours is recommended after ERCP rather than prolonged NPO status 6
• Routine extended NPO orders should be avoided as they can lead to nutritional deficits and delayed recovery 6

Pain Management

• Intravenous ketorolac is recommended for post-ERCP pain management as it provides effective analgesia and has the additional benefit of reducing post-ERCP pancreatitis risk 8
• Low-dose IV antispasmodics such as hyoscine butylbromide may help relieve biliary spasm with 70-80% efficacy 8

Complication Prevention

Post-ERCP Pancreatitis Prophylaxis

• Rectal NSAIDs (100 mg indomethacin or diclofenac) should be administered to all patients undergoing ERCP unless contraindicated, as high-quality RCTs have demonstrated benefit in reducing post-ERCP pancreatitis 1
• Post-ERCP pancreatitis occurs in 2-5% of therapeutic ERCPs 1, 8

Antibiotic Prophylaxis

• Prophylactic antibiotics can be safely avoided in the absence of specific risk factors 1
• Antibiotics are indicated for patients with: sclerosing cholangitis, communicating pancreatic cysts, hilar strictures, liver transplantation, cholangioscopy, or failed attempt to drain an opacified bile duct 1

Facility Requirements

• Units providing propofol sedation must meet minimum requirements as outlined in BSG guidance in conjunction with the Royal College of Anaesthetists 1
• Appropriately resourced facilities with trained clinicians are essential to maintain high-quality ERCP services 1