BJAEducation,22(10):372e375(2022)

doi:10.1016/j.bjae.2022.04.002
AdvanceAccessPublicationDate:19July2022

Matrix codes:
1A02,2A08,3A
07

E S S E N TI A L NO T E S

Anaesthesia and sedation for endoscopic

retrogradecholangiopancreatography
A.M.Henriksson1,*andS.V.Thakrar2
1
ChelseaandWestminsterHospital,ChelseaandWestminsterNHSTrust,London,UKand 2Hammersmith
Hospital,QueenCharlotte’sandChelseaHospital,ImperialCollegeHealthcareTrust,London,UK
*Correspondingauthor:anna.henriksson@nhs.net

Keywords:Cholangiopancreatography,endoscopicretrograde;conscioussedation;deepsedation;generalanaesthesia;pati
entselection;riskfactors

Endoscopicretrogradecholangiopancreatography(ERCP)wasin
troduced in 1968 and is now the ‘gold standard’ for
imagingofthebiliarytree.Thesubsequentdevelopmentofnon-
invasive diagnostic procedures such as magnetic
resonancecholangiopancreatography (MRCP) and endoscopic
ultraso-
nography(EUS),meansthatERCPisnowlargelyreservedforthera
peutic rather than diagnostic
indications.1Endoscopicretrogradecholangiopancreatograph
yoffersarangeofpossible interventions for patients, including
those deemed attoo high risk for surgery. The complexity of
ERCP
andcomorbiditiesofpatientscanpresentchallengestotheanaest
hetist,whicharediscussedbelow.
WhatisERCP?
Endoscopic retrograde cholangiopancreatography is com-
bined endoscopy and fluoroscopy serving as a diagnostic
andtherapeutic tool for a range of pancreatobiliary conditions.
Anendoscopeisadvancedintothesecondpartoftheduodenum,
Anna Maria Henriksson BSc (Hons) MRCP FRCA is a
specialtyregistrarwithaninterestinhepatobiliarysurgeryandexperien
ceinundertakingdeepsedationandgeneralanaesthesia(GA)forvarious
endoscopylists(adultandpaediatric)aspartofhertrainingacrosstheNo
rthWestThamesDeanery.
SonaliVThakrarBSc(Hons)MRCPFRCAisaconsultanthep-
atobiliaryanaesthetistatatertiaryreferralcentreforhep-
atopancreaticobiliary disease specialising in balloon enteroscopy
andspyglasscholangioscopy.Shewaspreviouslyaclinical
researchfellowinhepatobiliarysurgeryincludinglivertransplantation.
where the opening of ampulla of Vater (AV) is found. Cannu-
lation of the biliary and pancreatic ducts allows for contrast
tobe injected and visualised under X-ray guidance.
Therapeuticinterventions such as stone retrieval, lithotripsy,
stent inser-
tion,balloondilationandsphincterotomymaybecarriedout.
IndicationsforERCP
Themainindicationsare1:
● choledocholithiasisinpatientsunfitforsurgeryorwhohaveh
adcholecystectomy
● patientswithpancreatitisandcholangitisrequiringemergen
cydrainage
● inoperablemalignancycausingobstructivejaundice
● sphincterofOddidysfunctionandbiliarymanometry
● postoperativecomplicationssuchasbileleaksorbiliary
strictures
Endoscopic retrograde cholangiopancreatography can
beperformedinconjunctionwithEUSandcholangioscopytoaidab
lation,tissuesamplinganddirectvisualisationofthebil-
iopancreaticducts.Thisexpansioninavailableindications
has correlated with an increase in the number of ERCPs per-
formed,whichhasincreasedby10%between2017and2019intheU
K.2
Considerationsfortheanaesthetist
Environment
Endoscopic retrograde cholangiopancreatography is
usuallycarriedoutinanendoscopysuite,remotefrommaintheat
res,inaroomthatneedstoaccommodatestaff,endoscopystack,

Accepted:13April2022
©2022BritishJournalofAnaesthesia.PublishedbyElsevierLtd.Allrightsreserved.ForPermissions,
pleaseemail:permissions@elsevier.com
372
 Table1Summaryofsedation-relatedandprocedure-relatedadverseeventsassociatedwithERCP.COPD,chronicobstructivepulmonarydisease;ERCP,endoscopicretrogradechol-
angiopancreatography;OSA,obstructivesleepapnoea;PA,propofolanaesthesia.

ERCP ilişkili komplikasyonlar

Komplikasyonlar İnsidans Hasta ilişkili risk faktörler Anestezi veya prosedürle ilgili risk
faktörler
Sedasyonla ilgili Entübe edilmemiş hastada hava yolu kapanması, 3.5-13.3% KOAH Aşırı Sedasyon
advers olaylar hava yolu manevraları gerektiren OSAS Hedef kontrollü propofol infüzyonu yerine bolus
yapılması
BMI ≥30 Prosedür süresi >1 saat
ASA ≥3 Aşırı Sedasyon
Hipoksi (O2Sats<85%) 6.7-15% Bilinen veya şüphelenilen zor hava yolu
KOAH Hedef kontrollü propofol infüzyonu yerine bolus yapılması
OSAS

Akut hastalığın şiddeti Prosedür süresi >1 saat

BMI ≥30
ASA ≥3
Aspirasyon <1% Ileus Korumasız hava yolu
Asit Prosedür süresi >1 saat
Alkolizm
Sedasyondan GA'ya geçiş 4.7-10% OSAS Aşırı Sedasyon
KOAH Prosedür süresi >1 saat
BMI ≥30
ASA ≥3
Vazopressör ilaç gerektiren hipotansiyon 4.1-44.2% Kardiyovasküler hastalık Genel Anestezi
Akut hastalığın şiddeti Hedef kontrollü propofol infüzyonu yerine bolus yapılması
İlleri yaş

ASA ≥3 Prosedür süresi >1 saat

Aritmi 2.5-14% Kardiyovasküler hastalık Hipoksi
Akut hastalığın şiddeti Sempatik uyarım
BJAEducation

Antikolinerjik ilaçlar

Procedure-related Post-ERCPpancreatitis 3e10% Historyofpost-ERCPpancreatitis Difficultcannulation

adverseevents7 Historyofacutepancreatitis Pancreaticductdilation
Normalbilirubin serumlevels Pancreaticductcontrastinjection
SphincterofOddidysfunction Biliarysphincterotomy
■
Female
Volume22,Number10,2022

Youngage
Haemorrhage 0.3e2% Coagulopathy Bleedingvisibleduringprocedure

AnaesthesiaandsedationforERCP
Activecholangitis Operatorinexperience
Anticoagulationwithin3daysofERCP
Pancreatobiliaryorduodenalperforation 0.1e0.6% Alteredanatomy Difficultcannulation
SphincterofOddidysfunction Biliarysphincterotomy
Cholangiocarcinoma Biliarystricturedilation
Primarysclerosingcholangitis Patient’smovementduringprocedure
Olderage
Post-ERCPcholangitis 0.5e3% Bacteraemia Percutaneousendoscopicprocedure
Malignantstricturestenting
Incompletebiliarydrainage
Incompletestoneclearancein
choledochlithiasis
Omissionofprophylacticantibioticsin
patientswithbiliaryobstruction
3

Post-ERCPcholecystitis <0.5% Cholelithiasis Stentblockingcysticduct

Tumourofcysticductorifice
Venousairembolus None <2.4% Directcholangioscopy
Stentplacement
Biliarysphincterotomy
Ductdilation
AnaesthesiaandsedationforERCP

anaestheticandX-
receiving propofol anaesthesia.4Hypotension may in
raymachines.Consequently,thereislimitedaccesstothepatient
turncontributetotheoccurrenceofotherAEssuchasacutekidneyi
,whoisonanon-tiltingtableandsometimespositionedprone.
njury,longerhospitalstaysandhighermortality.4
Careful patient selection taking into account the risk fac-
Safetystandards tors for sedation-related AEs and the complexity of the pro-
cedure is key in selecting the approach to anaesthesia
Essential monitoring includes pulse oximeter, blood
andreducingcomplications.
pressure,electrocardiography and capnography for any patient
who issedated. A skilled anaesthetic assistant, WHO checklist
and adedicatedpost-procedurerecoveryareaaremandatory. 3 Positioning
Prone positioning allows for easier cannulation of the
Preoperativeassessment AV.Although the supine position is more comfortable for
thepatient and easier for the anaesthetist, it means the endo-
Thorough preoperative assessment is crucial before ERCP.
scopist faces away from the patient, making it
Aretrospective study over 10 yrs (n¼17,538) reported that 63%
technicallymore challenging. Supine or lateral decubitus
ofpatientshaveASAscoreof≥3,withcommoncomorbidities
positioning ispreferred in patients with obesity, ascites, or
including ischaemic heart disease (20.3%), metastatic
who are criticallyill.
disease(18.3%),diabetes(17.6%),chronicobstructivepulmonary
dis-ease (COPD; 12.8%), renal disease (9.0%), congestive
heartfailure(7.7%)andatrialfibrillation(6.8%). 4,5 Analgesia
Endoscopicretrogradecholangiopancreatographycanbepainf
ERCP:Sedationorgeneralanaesthesia? ul.Multimodalanalgesiaincludingparacetamol,NSAIDsandopi
oidsareoftengiven.Althoughtherehavebeensomeconcerns
Endoscopists have traditionally delivered conscious over opioids causing contraction of sphincter
sedation,oftenwithmidazolamandfentanyl,during ofOddi,theyarenotcontraindicated.
whichpatientsrespond to verbal commands or tactile stimuli.
However,
withtheevolutionofERCP,proceduredurationanddiscomforthas Antispasmodics
increasedandconscioussedationhasbeenreportedtobeinadequat Duodenal peristalsis makes cannulation of the biliary
e in up to 14% of patients. 6Poor tolerance by ductsdifficult. Glucagon or hyoscine butylbromide can be
thepatientincreasesfailureratesandtheriskof procedure- given
relatedcomplications. toreduceperistalsis.Hyoscinebutylbromideisusedmostcommon
Endoscopicretrogradecholangiopancreatographyisincrea ly;itisantimuscarinicand anticholinergic andshould be used
singly performed under deep sedation with with caution in patients with cardiac diseaseand glaucoma.
propofolanaesthesia,inwhichpatientsloseresponsetoverbalsti
mulibut do not require tracheal intubation and continue
sponta-neous ventilation. Propofol has a rapid onset and Conclusions
offset, andits hypnotic properties improve comfort and As the number of ERCPs undertaken increases and the pos-
amnesia. sibilitiesforinterventionexpand,therequirementforanaes-
Thisleadstofasterrecovery,improvedERCPsuccessandincrease thetists’involvementgrows.Theprocedureanditsenvironment
dsatisfaction.3 , patients’ characteristics and possible compli-cations can
Thereportedratesofsedation- all present challenges. A good understanding
relatedadverseevents(AEs)duringERCPvariesbetween2%and2 oftheprocedureandacomprehensivepreoperativeassessmenti
6%5,7(Table1).Theriskof sedation-related AEs is linearly s imperative in managing the risks of anaesthesia and opti-
associated with the dura-tion of the procedure, with the odds misingoutcomes.
ratio increasing from 1.8to 7.9 in procedures lasting less than
10 min compared withthoselastingmorethan1h.8
Thereisnosignificantdifferenceinsedation- Declarationofinterests
relatedAEsbetween anaesthetist-delivered conscious
Theauthorsdeclarethattheyhavenoconflictsofinterest.
sedation and pro-pofol anaesthesia for ERCP.7However,
endoscopist-deliveredsedation has a higher incidence of
oversedation requiringreversal, hypotension and incomplete References
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