Anaesthesia for endoscopy and ERCP

Meet the patient

A 78-year-old with ascending cholangitis is wheeled to the endoscopy suite at 22:00 for urgent ERCP. She is septic, not reliably fasted, in atrial fibrillation and heart failure, and she will lie semi-prone. The trainee suggests "just a little propofol sedation to get the list moving." The fellowship answer is a structured triage — and in this woman, that triage is general anaesthesia with a cuffed tracheal tube, not deep sedation — per the sedation-recommendations review's triage framing and the prone-ERCP series' exclusion-criteria discipline.^[4][7]

The two questions that decide every endoscopy case are two trainee skipped: can I rescue this airway in the dark, prone, far from theatre? and what happens to her oxygenation and blood pressure if the depth I choose abolishes her reflexes? Hold those two and the triage writes itself — desaturation is the commonest adverse event in the prone non-intubated series.^[7]

References7ShowHide

1. [1]Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery Circulation, 1999.PMID 10477528
2. [2]Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial Lancet, 2008.PMID 18479744
3. [3]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
4. [4]Dossa F, Megetto O, Yakubu M, et al. Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations. BMC Gastroenterol, 2021.PMID 33413147
5. [5]Sheahan CG, Mathews DM Monitoring and delivery of sedation. Br J Anaesth, 2014.PMID 25498581
6. [6]De Vico P, Biasucci DG, Aversano L, et al. Feasibility and safety of deep sedation with propofol and remifentanil in spontaneous breathing during endoscopic retrograde cholangiopancreatography: an observational prospective study. BMC Anesthesiol, 2023.PMID 37542218
7. [7]Melis V, Aldo C, Dioscoridi L, et al. Non-intubated general anesthesia in prone position for advanced biliopancreatic therapeutic endoscopy: A single tertiary referral center experience. Saudi J Anaesth, 2022.PMID 35431757