ERCP Anesthesia Type
ERCP should be performed using monitored anesthesia care (MAC) with propofol-based deep sedation for most patients, as this is the current standard of practice and is associated with higher procedural success rates, better patient satisfaction, and improved tolerance compared to traditional conscious sedation. 1, 2, 3
Primary Anesthesia Approach
Monitored anesthesia care (MAC) is favored over general anesthesia with tracheal intubation for the majority of ERCP procedures. 1, 3 This represents the consensus recommendation from international expert guidelines published in 2023, which used rigorous Delphi methodology to synthesize expert opinion across multiple clinical scenarios. 1, 3
MAC Technique Details
Propofol-based enhanced sedation administered by an anesthetist is now standard practice in most Western European and North American ERCP services, replacing traditional conscious sedation with benzodiazepines and opioids. 2
MAC provides superior outcomes compared to traditional conscious sedation: 14% of ERCPs performed under conscious sedation with midazolam and opioids are poorly tolerated, leading to procedural failure and patient distress. 2
Propofol sedation requires administration by an anesthetist in UK practice due to lack of support for non-anesthetist administration, though some studies have evaluated non-anesthesia personnel administration. 2, 4
When General Anesthesia Is Indicated
General anesthesia with tracheal intubation should be used for specific high-risk scenarios:
Patients with increased risk of pulmonary aspiration require airway protection with endotracheal intubation. 3
Prolonged procedures of high complexity, including cases with intrahepatic ductal stones or anticipated long duration, benefit from general anesthesia. 2, 3
Patients who cannot tolerate conscious sedation (such as those with substance abuse history or severe anxiety) may require general anesthesia. 5
Important Distinction
Patient age and ASA physical status alone are NOT considered factors for choosing between MAC and general anesthesia - the decision should be based on aspiration risk and procedural complexity. 3
Traditional Conscious Sedation (Now Less Common)
While historically used, traditional conscious sedation with midazolam and opioids has significant limitations:
33% of patients require >5.5 mg midazolam, and approximately 8% require naloxone reversal. 2
Midazolam plus meperidine provides better patient comfort than midazolam alone when conscious sedation is used, though both are inferior to propofol-based MAC. 6
Dexmedetomidine shows promise as an alternative to midazolam with lower gag response rates (23% vs 97%) and faster recovery, though this remains less commonly used than propofol. 7
Critical Safety Requirements
Facilities providing propofol sedation must meet minimum requirements as outlined in British Society of Gastroenterology guidance in conjunction with the Royal College of Anaesthetists, with appropriately resourced facilities and trained clinicians. 2
Strict NPO status is mandatory: solid food must be discontinued at least 6 hours before ERCP, and clear liquids 2-4 hours before, because deep sedation or general anesthesia compromises airway protection. 2
Common Pitfall to Avoid
Do not assume that older patients or those with higher ASA status automatically require general anesthesia - the evidence shows MAC is safe and effective across age groups and ASA classifications when aspiration risk is not elevated. 3 The key decision points are aspiration risk and procedural complexity, not patient demographics.