What is the recommended anesthesia plan for an average adult undergoing endoscopic retrograde cholangiopancreatography (ERCP) without significant comorbidities?

Anesthesia for ERCP

For an average adult without significant comorbidities undergoing ERCP, monitored anesthesia care (MAC) with propofol-based deep sedation is the recommended approach, as it provides superior procedural success, patient satisfaction, and safety compared to traditional conscious sedation, while avoiding the risks associated with general anesthesia in most cases. 1, 2

Primary Anesthetic Approach: Propofol-Based MAC

Propofol administered by an anesthetist should be the standard sedation technique for ERCP, as this approach is associated with:

• Higher procedural success rates compared to traditional benzodiazepine/opioid sedation 1
• Better patient tolerance, with only 4% sedation failures versus 14% with conscious sedation 1, 3
• Rapid recovery times, with most patients achieving Aldrete scores ≥9 within minutes 3
• Excellent patient and physician satisfaction scores 1

Propofol Dosing Strategy

Target-controlled infusion (TCI) of propofol provides optimal sedation control, with initial plasma concentrations of 1.0-4.0 µg/mL titrated to maintain patient cooperation while ensuring adequate sedation 4:

• Start with lower targets (1.0-2.0 µg/mL) and titrate upward based on patient response 4
• Maintain moderate sedation (OAA/S level 3) throughout the procedure 3
• Expect total propofol doses of 70-350 mg for average ERCP procedures 4

Adjunctive Analgesia

Combine propofol with an opioid for optimal pain control and reduced propofol requirements 5:

• Fentanyl 50-100 µg bolus is the preferred opioid, providing stable analgesia and improved oxygenation (SpO2) compared to propofol alone 4, 5
• Propofol plus fentanyl combinations show significantly lower rates of SpO2 <90% (RR = 0.02) compared to propofol monotherapy 5
• Alternative: Propofol plus oxycodone demonstrates the highest patient satisfaction scores and lowest desaturation rates (RR <0.01) 5

When to Choose General Anesthesia Instead

General anesthesia with endotracheal intubation should be reserved for specific high-risk scenarios 2:

• Increased aspiration risk: patients with gastroparesis, bowel obstruction, or recent oral intake 2
• Prolonged or highly complex procedures: anticipated duration >90 minutes, intrahepatic ductal stones, or multiple interventions 1, 2
• Failed MAC: if adequate sedation cannot be achieved or airway management becomes problematic 2

Patient age and ASA physical status alone are NOT indications for general anesthesia over MAC 2

Critical Safety Monitoring

Continuous monitoring must include 6, 1:

• Pulse oximetry with immediate oxygen supplementation available 6
• Capnography to detect respiratory depression early 6
• Blood pressure and heart rate monitoring 6
• Level of consciousness assessment using standardized scales (OAA/S or similar) 6, 3

Common Pitfalls and Management

Respiratory depression is the primary concern with propofol-based MAC 4, 3:

• Transient oxygen desaturation (SpO2 <90%) occurs in approximately 8% of cases, typically lasting 16-56 seconds 4
• Transient apnea episodes occur but are usually brief (1-37 seconds) 4
• Have airway management equipment immediately available: oral/nasal airways, bag-mask ventilation, and intubation supplies 7
• Reduce propofol infusion rate if respiratory depression occurs rather than immediately converting to general anesthesia 3

Avoid traditional conscious sedation with benzodiazepines and opioids as the primary technique, as this approach results in:

• 14% poorly tolerated procedures requiring conversion or termination 1
• 33% of patients requiring >5.5 mg midazolam, leading to prolonged recovery 1
• 8% requiring naloxone reversal 1
• Significantly longer recovery times compared to propofol-based techniques 3

Pre-Procedural Requirements

Strict NPO guidelines must be followed 1:

• Solid foods discontinued at least 6 hours before ERCP 1
• Clear liquids permitted up to 2-4 hours before procedure 1

Anticoagulation management for high bleeding risk procedures 1:

• Warfarin discontinued 5 days prior with INR <1.5 confirmed 1
• DOACs discontinued at least 48 hours before ERCP 1

Post-Procedural Care

Monitor patients until return to baseline mental status 6:

• Propofol's rapid offset allows most patients to achieve full recovery (Aldrete score ≥12) within 1 minute 4
• Continue vital sign monitoring and consciousness assessment using standardized scales 6
• Early oral feeding within 24 hours is recommended rather than prolonged NPO status 1

Administer intravenous ketorolac for post-procedure analgesia, as it provides effective pain control and reduces post-ERCP pancreatitis risk 1

Facility and Personnel Requirements

Propofol administration requires appropriate resources 1:

• Must be administered by qualified anesthesia personnel (anesthesiologist or nurse anesthetist) 1, 3
• Facilities must meet minimum standards per gastroenterology and anesthesia society guidelines 1
• Immediate access to advanced airway management equipment and personnel 7