September 19, 2018
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General endotracheal anesthesia preferred for high-risk patients undergoing ERCP

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Patients at higher risk for sedation-related adverse events could benefit from undergoing endoscopic retrograde cholangiopancreatography with general endotracheal anesthesia rather than monitored anesthesia, according to research published in Gastrointestinal Endoscopy.

Vladimir M. Kushnir, MD, of the division of gastroenterology at Washington University School of Medicine, St. Louis, Missouri, and colleagues wrote that although the ASGE recommends anesthesia-administered sedation to be considered in all complex endoscopic procedures, there is no current standard of care regarding the type of anesthesia and airway management during ERCP.

“[Monitored anesthesia care (MAC)] is often used in patients deemed low risk for sedation-related adverse events,” they wrote. “However, in patients with risk factors for adverse events, practice patterns vary.”

Kushnir and colleagues enrolled consecutive patients undergoing ERCP at a single center into the study. Researchers randomly assigned patients who met the inclusion criteria — STOP-BANG score of no more than 3, abdominal ascites, BMI of at least 35 kg/m2, chronic lung disease, ASA class less than 3, Mallampati class 4 airway, moderate to heavy alcohol use — to undergo the procedure with either MAC (n = 99) or general endotracheal anesthesia (GEA; n = 101). The primary endpoint of the study was incidence of sedation-related adverse events (SRAEs), including hypoxemia, use of airway maneuvers, hypotension requiring vasopressors, sedation-related procedure interruption, cardiac arrhythmia, cannulation success, in-room time and immediate adverse events.

Kushnir and colleagues found that composite SRAEs were significantly higher in the MAC group compared with the GEA group (51.5% vs. 9.9%; P < .001). The difference in SRAEs was mainly due to the frequent need for airway maneuvers among patients in the MAC group, they wrote.

The procedure was interrupted in 10.1% of patients in the MAC group to change to GEA because of respiratory instability refractory to airway maneuvers or because of retained gastric contents.

These findings came without any significant difference in technical success, procedure time, patient recovery time or endoscopy unit metrics.

“The results of this study suggest that GEA is the preferred mode of anesthesia in patients undergoing ERCP who are at high risk for SRAEs, especially in an efficient endoscopy unit with experienced anesthesia providers,” the researchers wrote. “A larger, multicenter, [randomized control trial] could provide more generalizable results, especially regarding unit efficiency, while also systematically assessing patient satisfaction regarding the type of anesthesia performed.” – by Alex Young

Disclosures: The authors report no relevant financial disclosures.