Experience of propofol sedation in a UK ERCP practice: lessons for service provision

Capturing the incidence of patient agitation amongst conscious sedation ERCPs and the impact on therapeutic outcomes

BACKGROUND

Completing advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) under conscious sedation is challenging. International recommendations favor enhanced sedation (e.g. propofol) for ERCP. Conscious sedation can result in sedation-related failure (SRF) and agitation for some patients, limiting therapeutic efficacy.

AIM

The aim of this study is to establish the risk of SRF and the impact on therapeutic success under conscious sedation practice in a single tertiary referral center.

METHODS

A retrospective review of a prospectively maintained ERCP database, analyzing sedation, procedural success, and complications.

RESULTS

Over 19 months, 807 conscious sedation ERCPs were recorded. Median midazolam dose was 5 mg (range 1-14 mg) and median fentanyl dose was 75 µg (0-200 µg). Sedation reversal was required in 0.1% of cases (1/807). Overall ductal cannulation rate was 92%. Severe agitation was recorded in 11% (86/807) of conscious sedation ERCP reports with SRF present in 3% (22/807). Patient agitation resulted in significantly lower cannulation (81% vs 92%, P = 0.002) and successful clearance rates (49% vs 85%, P = 0.002) versus non-agitated cases. Complication and pancreatitis rates were unaffected. Highest rates of SRF and agitation were identified in female patients, patients aged <50 years old, and post-operative biliary leak indications.

CONCLUSION

Over 10% of conscious sedation ERCPs are compromised by sedation issues, resulting in procedure abandonment or significantly diminished therapeutic success. General anesthetic ERCP is beneficial in facilitating biliary access, removing the risk of agitation and providing stability to aid cannulation. Female patients, patients aged <50 years, and post-operative biliary leak ERCPs appear as the priority cases for enhanced sedation support.

Effectiveness of single loading dose of dexmedetomidine combined with propofol for deep sedation of endoscopic retrograde cholangiopancreatography (ERCP) in elderly patients: a prospective randomized study

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure and requires deep sedation. Deep sedation with dexmedetomidine for the respiratory drive preserved has become popular in recent years. However, the use of dexmedetomidine in elderly patients is controversial because its adverse events are more common. The objective of this study was to investigate the effectiveness of a single loading dose of dexmedetomidine combined with propofol for deep sedation of ERCP in elderly patients.

Methods

In this prospective randomized trial, 49 elderly patients undergoing ERCP were randomly allocated to the dexmedetomidine (DEX) or propofol (PRO) groups. The single loading dose of dexmedetomidine was set at 0.5 μg/kg at the start of anesthesia induction and loading for 10 min. The primary outcome was the cumulative dose of propofol. Secondary outcomes included time to awake, the frequency of airway interventions, and hemodynamics.

Results

The intraoperative cumulative dose of propofol was lower in the DEX group (111.0 ± 12.6 μg/kg/min) than the PRO group (143.7 ± 23.4 μg/kg/min) (P < 0.001). There was no statistically significant difference in the time to awake between the two groups. The incidence of artificial airway interventions and hypotension in the PRO group (36%, 60%) were significantly higher than those in the DEX group (4.2%, 16.7%) (P = 0.011, P = 0.003, respectively). In addition, the occurrence of bradycardia increased significantly in the DEX group (58.3%) compared with the PRO group (12%) (P < 0.001).

Conclusions

The single loading dose of dexmedetomidine combined with propofol can reduce propofol consumption and artificial airway intervention and provide better hemodynamic stability than propofol for deep sedation in elderly patients during ERCP.

Trial registration

www.chictr.org.cn (Registration number ChiCTR1900028069, Registration date 10/12/2019).

Choice of sedation in endoscopic retrograde cholangiopancreatography: is monitored anesthesia care as safe as general anesthesia? A systematic review and meta-analysis

Background

Monitored anesthesia care (MAC) and general anesthesia (GA) are the 2 most common methods of sedation used for endoscopic retrograde cholangiopancreatography (ERCP). We performed a systematic review and meta-analysis to compare the overall safety between MAC vs. GA in ERCP.

Methods

We conducted a comprehensive search of electronic databases to identify studies reporting the use of MAC or GA as a choice of sedation for ERCP. The primary outcome was to compare the overall rate of sedation-related adverse events in MAC vs. GA groups. The secondary endpoint was to investigate the total duration of the procedure, recovery time, ERCP cannulation rates, and conversion rate of MAC to GA. The meta-analysis was performed using a Der Simonian and Laird random-effects model.

Results

A total of 21 studies reporting on 11,592 patients were included. The overall sedation-related side-effects were similar in the GA (12.76%, 95% confidence interval [CI] 5.80-21.73; I²=95%) and MAC (12.08%, 95%CI 5.38-20.89; I²=99%) groups (P=0.956). Hypoxia, arrhythmias, hypotension, aspiration and other sedation-related side-effects were similar between the 2 groups. The mean duration of the procedure was longer in the MAC group, but the mean recovery time was shorter. Significant heterogeneity was noted in our meta-analysis.

Conclusions

In our meta-analysis, the overall sedation-related side-effects were similar between the MAC and GA groups. MAC could be used as a safer alternative to GA when performing ERCP. However, large multicenter randomized control trials are needed to further validate our findings.

Anesthesia-administered sedation for endoscopic retrograde cholangiopancreatography: monitored anesthesia care or general endotracheal anesthesia?

PURPOSE OF REVIEW

The decision to undertake monitored anesthesia care (MAC) or general endotracheal anesthesia (GEA) for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is influenced by many factors. These include locoregional practice preferences, procedure complexity, patient position, and comorbidities. We aim to review the data regarding anesthesia-administered sedation for ERCP and identify the impact of airway management on procedure success, adverse event rates and endoscopy unit efficiency.

RECENT FINDINGS

Several studies have consistently identified patients at high risk for sedation-related adverse events during ERCP. This group includes those with higher American Society of Anesthesiologists class and (BMI). ERCP is commonly performed in the prone position, which can make the placement of an emergent advanced airway challenging. Although this may be alleviated by performing ERCP in the supine position, this technique is more technically cumbersome for the endoscopist. Data regarding the impact of routine GEA on endoscopy unit efficiency remain controversial.

SUMMARY

Pursuing MAC or GEA for patients undergoing ERCP is best-approached on an individual basis. Patients at high risk for sedation-related adverse events likely benefit from GEA. Larger, multicenter randomized controlled trials will aid significantly in better delineating which sedation approach is best for an individual patient.

Type of sedation and the need for unplanned interventions during ERCP: analysis of the clinical outcomes research initiative national endoscopic database (CORI-NED)

BACKGROUND AND AIMS

Recent studies suggest that sedation provided by anaesthesia professionals may be less protective against serious adverse events than previously believed, however, data are lacking regarding endoscopic retrograde cholangiopancreatography (ERCP). Using the clinical outcomes research initiative national endoscopic database (CORI-NED), we aimed to assess whether mode of sedation was associated with rates of unplanned interventions (UIs) during ERCP.

PATIENTS AND METHODS

All subjects from CORI-NED undergoing ERCP from 2004 to 2014 were identified and stratified into three groups based on the initial mode of anaesthesia: endoscopist-directed sedation (EDS), monitored anaesthesia care without an endotracheal tube (MAC-WET) and general endotracheal anaesthesia (GEA). The primary outcome was UIs. To assess the impact of sedation mode on UIs, multivariable logistic regression models were created adjusting for demographic, physician and procedure-level variables.

DESIGN

Population-based study.

RESULTS

26 698 ERCPs were analysed (7588 EDS, 8395 MAC-WET, 10 715 GEA). UIs occurred in 320 ERCPs (1.2%). EDS was associated with a higher risk of UIs compared with sedation administered by an anaesthesia professional (OR 1.86, 95% CI 1.44 to 2.42). Additional factors associated with a higher risk of UIs included ASA class IV compared with class II (OR 3.18, 95% CI 2.00 to 5.06) and ERCPs done in community (OR 1.41, 1.04 to 1.91) and health maintenance organisations (OR 3.75, 2.01 to 6.99) hospitals.

CONCLUSION

EDS is associated with a higher risk of UIs during ERCP compared with sedation administered by an anaesthesia professional. Higher ASA class and procedures performed in non-university hospitals were also associated with a higher risk of UIs. This study suggests that, when available, sedation using an anaesthesia professional should be utilised for ERCP.

Day case 'treat and transfer' ERCP service under general anaesthesia

OBJECTIVE

General anaesthesia (GA) has been increasingly used for advanced endoscopic procedures in particular endoscopic retrograde cholangiopancreatography (ERCP). Given the increasing pressure on many hospitals, the delivery of such service on a regular basis may not always be possible. We established a new day case 'GA ERCP' service. We describe our experience in evaluating the safety and overall feasibility of this new service.

DESIGN

Prospective database has been interrogated for the period from March 2015 to December 2016. We documented patients' demographics, ERCP indications, American Society of Anesthesiologists (ASA) status, Cotton grade and complications.

RESULTS

67 patients were referred to endoscopy unit at King's College Hospital (KCH), for urgent day case GA ERCP from nine referring hospitals. The main indications were failed ERCP under sedation 47.8% (32/67), and unavailability of ERCP locally 41.8% (28/67). A total of 64 patients were actually transferred to KCH; 57.8% (37/64) women with a median age 55.8 years (range 23-90). 78.1% (50/64) of patients had a virgin papilla, with 39% (25/64) were ASA ≥3. The Cotton grade was ≥ 3 in 50% (32/64) patients. ERCP was completed successfully in 87.5% (56/64). For patients with previous failed ERCP, repeat ERCP under GA was successful in 75% (24/32). All patients were safely discharged back to their referring hospitals after the short observation period post-ERCP.

CONCLUSIONS

Urgent inpatient transfers between hospitals for performing ERCP under GA as a day case is safe and feasible. The new GA ERCP pathway can be replicated by other UK centres.

Updated guideline on the management of common bile duct stones (CBDS)

Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.

Endoscopic management of biliary stone disease

The management of bile duct stone disease is the most common indication for endoscopic retrograde cholangio-pancreatography (ERCP). The majority of cases may be resolved using standard approaches including endoscopic sphincterotomy and balloon stone extraction. Recent advances in the management of large or challenging stones has come from the clear evidence for the role of endoscopic papillary large balloon dilatation (EPLBD)/sphincteroplasty and the development of cholangioscopically directed lithotripsy. Perhaps the greatest improvement in endoscopic stone management will be achieved through the implementation of plans for more formalised training, reflection and audit of ERCP performance indicators and network-wide coordination of ERCP services.