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

Sedation for ERCP in Average-Risk Adults

Propofol-based monitored anesthesia care (MAC) administered by an anesthesiologist is the recommended sedation approach for average-risk adults undergoing ERCP, using target-controlled infusion with plasma concentrations of 1.0-2.0 µg/mL combined with fentanyl 50-100 µg for analgesia. 1, 2

Primary Sedation Strategy

Propofol-Based MAC (Preferred Approach)

For average-risk patients (ASA class I-II), propofol sedation administered by trained personnel provides safe, effective sedation with high procedural success rates and superior patient satisfaction compared to traditional benzodiazepine/opioid combinations. 3, 1

• Target-controlled infusion (TCI) of propofol at plasma concentrations of 1.0-2.0 µg/mL provides optimal sedation control with rapid titration capability. 1, 2
• Total propofol exposure typically ranges 70-350 mg for a standard ERCP procedure (mean approximately 200-465 mg depending on procedural complexity). 1, 2, 4
• Add fentanyl 50-100 µg as a bolus for analgesia, since propofol has no intrinsic analgesic properties. 1, 5, 2

Administration Personnel

Propofol for ERCP should be administered by an anesthesiologist or trained non-anesthesiologist personnel following established protocols, with the safety profile of non-anesthesiologist-administered propofol (NAAP) being equivalent to standard sedation for low-risk patients. 3, 4

• The worldwide safety experience with NAAP exceeds 460,000 patients, with extraordinarily low rates of serious adverse events in ASA class I-II patients. 3
• For ERCP specifically, NAAP appears equivalent in safety to standard sedation, though the experience base is smaller than for routine endoscopy. 3
• NAAP is more cost-effective than standard sedation for ERCP and improves practice efficiency. 3

Essential Monitoring Requirements

Continuous monitoring of heart rate, blood pressure, and pulse oximetry is mandatory throughout propofol administration, with supplemental oxygen provided to all patients. 1, 5

• Processed EEG monitoring (BIS or Entropy) targeting BIS 40-60 is mandatory when using target-controlled infusion to prevent both awareness and excessive anesthetic depth. 6
• Transient oxygen desaturation (SpO₂ <90%) occurs in approximately 5-8% of cases, typically lasting 16-56 seconds and self-limiting. 1, 5

When to Consider General Anesthesia Instead

General endotracheal anesthesia (GEA) should be strongly considered for high-risk patients rather than MAC, as it significantly reduces sedation-related adverse events. 7, 8

High-Risk Criteria Requiring GEA:

• STOP-BANG score ≥3 (obstructive sleep apnea risk) 7
• Body mass index ≥35 7
• ASA class >III 7
• Mallampati class 4 airway 7
• Abdominal ascites or chronic lung disease 7

In high-risk patients, GEA reduces composite sedation-related adverse events from 51.5% with MAC to 9.9% with GEA, primarily by eliminating the need for repeated airway maneuvers. 7

Even in average-risk patients (ASA ≤III), GEA reduces sedation-related adverse events from 35% with MAC to 9% with GEA, without prolonging procedure time or affecting success rates. 8

Critical Safety Considerations

Dosing Pitfalls to Avoid

Never administer propofol as bolus dosing during maintenance phase, as this causes hemodynamic instability. 6

Do not exceed effect-site concentrations of 1.5 µg/mL during conscious sedation, as this dramatically increases oversedation and hypoventilation risk, especially with concurrent opioids. 6

Propofol infusion rates of 10 mg/kg/h (≈167 µg/kg/min) produce markedly greater respiratory depression with higher apnea incidence—these rates are inappropriate for ERCP sedation. 5

Respiratory Management

Brief apnea episodes (1-37 seconds) may occur but are typically self-limited; bag-mask ventilation should be immediately available. 3, 1

The need for airway intervention is greater during ERCP than colonoscopy due to the prone/semi-prone positioning and procedural complexity. 3

Recovery Profile

Due to propofol's rapid offset, the majority of patients achieve full recovery (Aldrete score ≥12) within 1 minute after procedure completion, with mean discharge time of approximately 31 minutes. 1, 2

Alternative: Traditional Conscious Sedation

Traditional conscious sedation with midazolam and opioids is generally well-tolerated but has significant limitations, with 14% of ERCPs being poorly tolerated, leading to procedural failure. 1

• ERCP complexity often necessitates higher benzodiazepine doses than routine endoscopy, with 33% of patients requiring >5.5 mg midazolam and 8% requiring naloxone reversal. 1
• Most ERCP services in Western Europe and North America have transitioned to propofol-based sedation as standard practice due to superior outcomes. 1

Cost-Effectiveness Considerations

NAAP is more cost-effective than standard sedation for ERCP, while anesthesiologist-administered sedation costs $150-$1500+ more per case depending on local conditions. 3

However, the improved procedural success, patient satisfaction, and reduced complications with propofol-based techniques justify the additional cost in most clinical settings. 3, 1