What is the optimal anesthetic plan for a 73‑year‑old, 52‑kg male with sepsis secondary to obstructive jaundice and ascending cholangitis, acute‑on‑chronic kidney injury (eGFR 21 mL/min/1.73 m²), non‑ST‑segment elevation myocardial infarction, coagulopathy (INR ≈ 1.9, platelets 125 ×10⁹/L), who is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP)?

Anesthetic Management for High-Risk ERCP in Septic Patient with Multi-Organ Dysfunction

Recommended Anesthetic Technique

For this critically ill 73-year-old patient with sepsis, acute-on-chronic kidney injury (eGFR 21), recent NSTEMI, and coagulopathy undergoing ERCP, proceed with total intravenous anesthesia using propofol target-controlled infusion combined with low-dose remifentanil, with immediate availability of vasopressors and invasive arterial monitoring established before induction. 1, 2

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Rationale for TIVA Over Volatile Anesthetics

• Propofol-based TIVA is specifically recommended for ERCP procedures because it provides superior procedural success rates, better patient tolerance, and rapid emergence with fast return of airway reflexes compared to traditional sedation or volatile anesthetics. 3, 2
• General anesthesia or deep propofol sedation is the standard of care for ERCP in most Western centers, with controlled airway protection essential given the prone/semi-prone positioning and risk of aspiration during active cholangitis. 3, 2
• Your proposed ketamine-remifentanil combination has limited evidence for ERCP specifically, though ketamine has been used successfully in high-risk abdominal surgery patients with renal failure. 4

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Specific Drug Dosing Protocol

Propofol Dosing (Preferred Primary Hypnotic)

• Calculate propofol dose based on lean body weight (approximately 47 kg for this 52 kg patient with likely sarcopenia from chronic illness), using 2.3–2.8 mg/kg LBW for induction. 1
• Target effect-site concentration of 2.0–3.0 µg/mL for induction, then titrate down to 1.5–2.5 µg/mL for maintenance using TCI. 1
• Avoid bolus dosing during maintenance to prevent hemodynamic instability in this septic, volume-depleted patient. 1

Remifentanil Dosing

• Target effect-site concentration of 1–2 ng/mL (lower end of range given hemodynamic instability and recent NSTEMI). 1
• Remifentanil is ideal for renal failure as it undergoes plasma esterase metabolism independent of kidney function, with no prolonged recovery even in end-stage renal disease. 5

Alternative: Low-Dose Ketamine Supplementation

• If using ketamine as adjunct, limit to 0.5–1.0 mg/kg bolus followed by 1.0–2.0 mg/kg/hr infusion to preserve hemodynamic stability while reducing propofol requirements. 6, 4
• Ketamine may provide cardiovascular stability in septic shock but increases secretions and may complicate airway management during ERCP. 4

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Critical Pre-Induction Preparation

Hemodynamic Optimization

• Establish invasive arterial blood pressure monitoring BEFORE induction with transducer at tragus level, as this patient has septic shock requiring vasopressor support. 1
• Have vasopressors drawn up and immediately available (norepinephrine preferred over dopamine in septic shock; consider vasopressin if already on norepinephrine). 3
• Ensure adequate volume resuscitation with isotonic crystalloids before induction, targeting mean arterial pressure >65 mmHg. 3

Coagulopathy Management

• Consider FFP transfusion to target INR <1.5 before ERCP with sphincterotomy, as your INR of 1.88 increases bleeding risk during therapeutic intervention. 3
• Platelet transfusion is recommended if count <50×10⁹/L for ERCP with planned sphincterotomy; your patient's count of 125 is acceptable. 3
• Thromboelastography (TEG) can guide FFP administration more accurately than INR alone in liver disease. 3

Airway and Aspiration Risk

• Confirm strict NPO status (solids ≥6 hours, clear liquids ≥2 hours), though this patient's sepsis and ileus increase aspiration risk regardless. 2
• Plan for rapid sequence intubation with cricoid pressure given high aspiration risk from cholangitis, sepsis, and prone positioning requirements. 3
• General anesthesia with endotracheal intubation is mandatory rather than deep sedation, given the combination of sepsis, coagulopathy, and need for airway protection during therapeutic ERCP. 3

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Intra-Procedural Management

Depth of Anesthesia Monitoring

• Target BIS 40–60 throughout maintenance to prevent both awareness and excessive anesthetic depth that could worsen hemodynamic instability. 1
• Processed EEG monitoring (BIS or Entropy) is mandatory for TIVA to guide dosing and prevent awareness. 1

Renal Protection Strategies

• Maintain adequate hydration with isotonic crystalloids to minimize contrast-induced nephropathy risk, though NAC prophylaxis is not recommended. 3
• Avoid nephrotoxic agents and ensure mean arterial pressure >65 mmHg to preserve renal perfusion in this patient with stage 3 AKI (creatinine 3.07, eGFR 21). 3

Antibiotic Coverage

• Administer prophylactic antibiotics covering gram-negative organisms (piperacillin/tazobactam or ceftriaxone) for 48 hours, as this patient has cholangitis and will undergo biliary instrumentation. 3

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ERCP-Specific Considerations

Timing and Indication

• This patient requires urgent ERCP within 24 hours given sepsis secondary to ascending cholangitis with obstructive jaundice (total bilirubin 10.1, direct 7.88). 3, 7
• Endoscopic sphincterotomy with stone extraction is indicated to relieve biliary obstruction and drain infected bile. 3, 7

Post-ERCP Pancreatitis Prophylaxis

• Administer rectal indomethacin 100 mg or diclofenac 100 mg immediately after ERCP unless contraindicated by renal failure or active bleeding. 2
• Intravenous ketorolac provides effective post-ERCP analgesia and reduces pancreatitis risk, though use cautiously given eGFR 21. 2

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Emergence and Recovery Protocol

Extubation Criteria

• Ensure return of airway reflexes and adequate tidal volumes before extubation, with patient fully awake given high aspiration risk. 1
• Extubate in semi-upright position to reduce aspiration risk and improve respiratory mechanics. 1
• Recovery time with propofol-remifentanil TIVA is typically <5 minutes to Aldrete score ≥12, even in renal failure patients. 5, 2

Post-Procedure Monitoring

• Transfer to ICU for continued hemodynamic monitoring and management of sepsis, AKI, and post-ERCP complications. 3
• Early oral feeding within 24 hours is recommended after successful ERCP rather than prolonged NPO. 2

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Critical Contraindications and Red Flags

When NOT to Proceed with ERCP

• Uncontrolled septic shock with multi-organ failure despite maximal resuscitation may represent futility, as TIPSS guidelines note that procedures in patients with advanced multi-organ dysfunction do not alter outcomes. 3
• Severe coagulopathy (INR >2.0) without correction significantly increases bleeding risk during sphincterotomy. 3

Anesthetic Pitfalls to Avoid

• Do NOT use total body weight for propofol dosing in this cachectic patient, as this causes severe overdosing and hypotension. 1
• Do NOT exceed propofol effect-site concentration of 3.5 µg/mL during maintenance, as higher levels dramatically increase hypotension risk in septic patients. 1
• Do NOT use dopamine as first-line vasopressor in septic shock, as norepinephrine is preferred. 3
• Do NOT use conscious sedation for this high-risk ERCP; general anesthesia with airway protection is mandatory. 3, 2

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Alternative Consideration: Deferring ERCP

If hemodynamic instability persists despite aggressive resuscitation (persistent hypotension, lactate >4 mmol/L, worsening multi-organ failure), consider deferring ERCP and placing percutaneous transhepatic biliary drainage as a temporizing measure until the patient is more stable, as the mortality risk of proceeding with ERCP under general anesthesia in profound shock may exceed the benefit. 3