Skip to main content
SpringerLink
Log in

Anesthesia for ERCP

  • Chapter
  • First Online:
Anesthesiology

Abstract

With over 500,000 endoscopic retrograde cholangiopancreatography (ERCP) performed every year in the USA alone, the anesthesia aspects warrant a new appraisal. Along with increasing numbers, the complexity of the procedures and morbidity of the patient population has increased. Yet, the anesthesia/sedation methods are poorly standardized and the physio-anatomical factors are not always taken into account. The current review is an attempt to discuss the myriad of variables that need to be understood and applied to provide safe sedation for ERCP. Along with relevant anatomy and physiology of pancreatiocobiliary tree, the systemic effects of ongoing pathology are highlighted. Importance of preoperative evaluation and the specific areas of relevance for safe ERCP sedation are discussed. While planning for the ERCP rooms, due consideration should be given to aspects like type and location of monitoring systems, use of mobile anesthesia carts, type of airway equipment, anesthesia work station and breathing systems. Authors preferred technique and a brief discussion of post procedural sedation issues are mentioned. Table 19.1 provides a summary of anesthesia considerations in patients undergoing ERCP.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 139.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 179.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Silviera ML, Seamon MJ, Porshinsky B, Prosciak MP, Doraiswamy VA, Wang CF, et al. Complications related to endoscopic retrograde cholangiopancreatography: a comprehensive clinical review. J Gastrointestin Liver Dis. 2009;18(1):73–82.

    PubMed  Google Scholar 

  2. Puig I, Calvet X, Baylina M, Isava Á, Sort P, Llaó J, et al. How and when should NSAIDs be used for preventing post-ERCP pancreatitis? A systematic review and meta-analysis. PloS One. 2014;9(3):e92922.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Tieu AH, Kumbhari V, Jakhete N, Onyimba F, Patel Y, Shin EJ, et al. Diagnostic and therapeutic utility of SpyGlass (®) peroral cholangioscopy in intraductal biliary disease: single-center, retrospective, cohort study. Dig Endosc. 2015;27(4):479–85.

    Article  PubMed  Google Scholar 

  4. Siiki A, Rinta-Kiikka I, Koivisto T, Vasama K, Sand J, Laukkarinen J. Spyglass single-operator peroral cholangioscopy seems promising in the evaluation of primary sclerosing cholangitis-related biliary strictures. Scand J Gastroenterol. 2014;49(11):1385–90.

    PubMed  Google Scholar 

  5. Goudra B, Singh PM. ERCP: the unresolved question of endotracheal intubation. Dig Dis Sci. 2013;59(3):513–9.

    Article  PubMed  Google Scholar 

  6. Branch null. ERCP-induced pancreatitis. Curr Treat Options Gastroenterol. 2000;3(5):363–70.

    Article  CAS  PubMed  Google Scholar 

  7. Nemes B, Gámán G, Doros A. Biliary complications after liver transplantation. Expert Rev Gastroenterol Hepatol. 2015;9(4):447–66.

    Article  CAS  PubMed  Google Scholar 

  8. Sampaziotis F, Elias J, Gelson WTH, Gimson AE, Griffiths WJH, Woodward J, et al. A retrospective study assessing fully covered metal stents as first-line management for malignant biliary strictures. Eur J Gastroenterol Hepatol. 2015;27(11):1347–53.

    Article  CAS  PubMed  Google Scholar 

  9. Buxbaum J, Roth N, Motamedi N, Lee T, Leonor P, Salem M, et al. Anesthetist-directed sedation favors success of advanced endoscopic procedures. Am J Gastroenterol. 2016;112(2):290–6.

    Article  PubMed  Google Scholar 

  10. Bowie JD. What is the upper limit of normal for the common bile duct on ultrasound: how much do you want it to be? Am J Gastroenterol. 2000;95(4):897–900.

    Article  CAS  PubMed  Google Scholar 

  11. Hadidi A. Pancreatic duct diameter: sonographic measurement in normal subjects. J Clin Ultrasound. 1983;11(1):17–22.

    Article  CAS  PubMed  Google Scholar 

  12. Westphal JF, Brogard JM. Biliary tract infections: a guide to drug treatment. Drugs. 1999;57(1):81–91.

    Article  CAS  PubMed  Google Scholar 

  13. Motte S, Deviere J, Dumonceau JM, Serruys E, Thys JP, Cremer M. Risk factors for septicemia following endoscopic biliary stenting. Gastroenterology. 1991;101(5):1374–81.

    Article  CAS  PubMed  Google Scholar 

  14. Bae S, Kim T, Kim M-C, Chong YP, Kim S-H, Sung H, et al. Clinical characteristics and outcomes of spontaneous bacterial peritonitis caused by Enterobacter species versus Escherichia coli: a matched case-control study. BMC Infect Dis. 2016;16:252.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Palabiyiko I, Tekeli E, Aysev D, Sirlak M, Kaymakci S, Ozturk S. ERCP related sepsis. Am J Infect Dis. 2005;1(2):87–9.

    Article  Google Scholar 

  16. Cotton PB, Eisen G, Romagnuolo J, Vargo J, Baron T, Tarnasky P, et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc. 2011;73(5):868–74.

    Article  PubMed  Google Scholar 

  17. Shiffman ML, Sugerman HJ, Kellum JM, Moore EW. Changes in gallbladder bile composition following gallstone formation and weight reduction. Gastroenterology. 1992;103(1):214–21.

    Article  CAS  PubMed  Google Scholar 

  18. Iorgulescu A, Turcu F, Iordache N. ERCP after bariatric surgery—literature review and case report. J Med Life. 2014;7(3):339–42.

    PubMed  PubMed Central  CAS  Google Scholar 

  19. Donepudi S, Chavalitdhamrong D, Pu L, Draganov PV. Air embolism complicating gastrointestinal endoscopy: a systematic review. World J Gastrointest Endosc. 2013;5(8):359–65.

    Article  PubMed  PubMed Central  Google Scholar 

  20. ASGE Standards of Practice Committee, Anderson MA, Fisher L, Jain R, Evans JA, Appalaneni V, et al. Complications of ERCP. Gastrointest Endosc. 2012;75(3):467–73.

    Article  Google Scholar 

  21. Lynch CR, Khandekar S, Lynch SM, Disario JA. Sublingual L-hyoscyamine for duodenal antimotility during ERCP: a prospective randomized double-blinded study. Gastrointest Endosc. 2007;66(4):748–52.

    Article  PubMed  Google Scholar 

  22. Ozaslan E, Karakelle N, Ozaslan NG. Hyoscine-N-butylbromide induced ventricular tachycardia during ERCP. J Anaesthesiol Clin Pharmacol. 2014;30(1):118–9.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Vallakati A, Reddy M, Olayee M, Lakkireddy D. Cardiac arrest from asystole during endoscopic retrograde cholangiopancreatography: a rare but fatal complication. J Atr Fibrillation. 2013;6(4):47–9.

    Google Scholar 

  24. Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol. 2001;96(4):1266–72.

    Article  CAS  PubMed  Google Scholar 

  25. Radnay PA, Duncalf D, Novakovic M, Lesser ML. Common bile duct pressure changes after fentanyl, morphine, meperidine, butorphanol, and naloxone. Anesth Analg. 1984;63(4):441–4.

    Article  CAS  PubMed  Google Scholar 

  26. Wu S-D, Zhang Z-H, Jin J-Z, Kong J, Wang W, Zhang Q, et al. Effects of narcotic analgesic drugs on human Oddi’s sphincter motility. World J Gastroenterol WJG. 2004;10(19):2901–4.

    Article  CAS  PubMed  Google Scholar 

  27. Enestvedt BK, Eisen GM, Holub J, Lieberman DA. Is ASA classification useful in risk stratification for endoscopic procedures? Gastrointest Endosc [Internet]. 2013 Mar [cited 2016 Jun 3];77(3). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3816502/.

  28. Sankar A, Johnson SR, Beattie WS, Tait G, Wijeysundera DN. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. Br J Anaesth. 2014;113(3):424–32.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med. 2015;373(23):2258–69.

    Article  CAS  PubMed  Google Scholar 

  30. Day LW, Lin L, Somsouk M. Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis. Endosc Int Open. 2014;2(1):E28–36.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7):1004–21.

    Article  CAS  PubMed  Google Scholar 

  32. ASGE Standards of Practice Committee, Levy MJ, Anderson MA, Baron TH, Banerjee S, Dominitz JA, et al. Position statement on routine laboratory testing before endoscopic procedures. Gastrointest Endosc. 2008;68(5):827–32.

    Article  Google Scholar 

  33. Egan RJ, Nicholls J, Walker S, Mellor K, Young WT, Stechman MJ. Routine coagulation screening is an unnecessary step prior to ERCP in patients without biochemical evidence of jaundice: a cross-centre study. Int J Surg Lond Engl. 2014;12(11):1216–20.

    Article  Google Scholar 

  34. Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol. 2011;27(2):174–9.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF, Beal SL, Cohen SN, et al. The usefulness of preoperative laboratory screening. JAMA. 1985;253(24):3576–81.

    Article  CAS  PubMed  Google Scholar 

  36. Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG, American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522–38.

    Article  Google Scholar 

  37. Berzin TM, Sanaka S, Barnett SR, Sundar E, Sepe PS, Jakubowski M, et al. A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation. Gastrointest Endosc. 2011;73(4):710–7.

    Article  PubMed  Google Scholar 

  38. Yang JF, Farooq P, Zwilling K, Patel D, Siddiqui AA. Efficacy and safety of propofol-mediated sedation for outpatient endoscopic retrograde cholangiopancreatography (ERCP). Dig Dis Sci. 2016;61(6):1686–91.

    Article  CAS  PubMed  Google Scholar 

  39. Goudra BG, Singh PM, Penugonda LC, Speck RM, Sinha AC. Significantly reduced hypoxemic events in morbidly obese patients undergoing gastrointestinal endoscopy: predictors and practice effect. J Anaesthesiol Clin Pharmacol [Internet]. [cited 2016 Jun 3]. http://www.joacp.org/article.asp?issn=0970-9185;year=2014;volume=30;issue=1;spage=71;epage=77;aulast=Goudra

  40. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261–6.

    Article  CAS  PubMed  Google Scholar 

  41. Goudra B, Nuzat A, Singh PM, Gouda GB, Carlin A, Manjunath AK. Cardiac arrests in patients undergoing gastrointestinal endoscopy: a retrospective analysis of 73,029 procedures. Saudi J Gastroenterol. 2015;21:400–11.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol. 2010;23(4):523–31.

    Article  PubMed  Google Scholar 

  43. MacRae MG. Closed claims studies in anesthesia: a literature review and implications for practice. AANA J. 2007;75(4):267–75.

    PubMed  Google Scholar 

  44. Goudra B, Nuzat A, Singh PM, Borle A, Carlin A, Gouda G. Association between type of sedation and the adverse events associated with gastrointestinal endoscopy: an analysis of 5 years’ data from a Tertiary Center in the USA. Clin Endosc. 2016;50(2):161–9.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Goudra BG, Singh PM, Sinha AC. Anesthesia for ERCP: impact of anesthesiologist’s experience on outcome and cost. Anesthesiol Res Pract [Internet]. 2013 May 28 [cited 2013 Jun 7];2013. http://www.hindawi.com/journals/arp/2013/570518/abs/.

  46. Tringali A, Mutignani M, Milano A, Perri V, Costamagna G. No difference between supine and prone position for ERCP in conscious sedated patients: a prospective randomized study. Endoscopy. 2008;40(2):93–7.

    Article  CAS  PubMed  Google Scholar 

  47. Vuyk J. Pharmacokinetic and pharmacodynamic interactions between opioids and propofol. J Clin Anesth. 1997;9(6 Suppl):23S–6S.

    Article  CAS  PubMed  Google Scholar 

  48. Vuyk J. TCI: supplementation and drug interactions. Anaesthesia. 1998;53(Suppl 1):35–41.

    Article  CAS  PubMed  Google Scholar 

  49. Goudra B, Singh PM, Gouda G, Borle A, Carlin A, Yadwad A. Propofol and non-propofol based sedation for outpatient colonoscopy-prospective comparison of depth of sedation using an EEG based SEDLine monitor. J Clin Monit Comput. 2015;30(5):551–7.

    Article  PubMed  Google Scholar 

  50. Standards for Basic Anesthetic Monitoring. Committee of origin: standards and practice parameters (approved by the ASA House of Delegates on October 21, 1986, last amended on October 20, 2010, and last affirmed on October 28, 2015).

    Google Scholar 

  51. Weaver J. The latest ASA mandate: CO2 monitoring for moderate and deep sedation. Anesth Prog. 2011;58(3):111–2.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Statement on Nonoperating Room Anesthetizing Locations. Committee of origin: standards and practice parameters (approved by the ASA House of Delegates on October 19, and last amended on October 16, 2013).

    Google Scholar 

  53. Goudra BG, Singh PM, Penugonda LC, Speck RM, Sinha AC. Significantly reduced hypoxemic events in morbidly obese patients undergoing gastrointestinal endoscopy: predictors and practice effect. J Anaesthesiol Clin Pharmacol. 2014;30(1):71–7.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Goudra B, Alvarez A, Singh PM. Practical considerations in the development of a nonoperating room anesthesia practice. Curr Opin Anaesthesiol. 2016;30(1):71–7.

    Google Scholar 

  55. Perbtani YB, Summerlee RJ, Yang D, An Q, Suarez A, Williamson JB, et al. Impact of endotracheal intubation on interventional endoscopy unit efficiency metrics at a tertiary Academic Medical Center. Am J Gastroenterol. 2016 Jun;111(6):800–7.

    Article  PubMed  Google Scholar 

  56. Goudra B, Singh P, Sinha A. Outpatient endoscopic retrograde cholangiopancreatography: safety and efficacy of anesthetic management with a natural airway in 653 consecutive procedures. Saudi J Anaesth. 2013;7(3):259–65.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Akhondzadeh R, Ghomeishi A, Nesioonpour S, Nourizade S. A comparison between the effects of propofol-fentanyl with propofol-ketamine for sedation in patients undergoing endoscopic retrograde cholangiopancreatography outside the operating room. Biomed J. 2016;39(2):145–9.

    Article  PubMed  Google Scholar 

  58. Goyal R, Hasnain S, Mittal S, Shreevastava S. A randomized, controlled trial to compare the efficacy and safety profile of a dexmedetomidine-ketamine combination with a propofol-fentanyl combination for ERCP. Gastrointest Endosc. 2016;83(5):928–33.

    Article  PubMed  Google Scholar 

  59. Srikanth MS, Kahlstrom R, Oh KH, Fox SR, Fox ER, Fox KM. Topical benzocaine (Hurricaine) induced methemoglobinemia during endoscopic procedures in gastric bypass patients. Obes Surg. 2005;15(4):584–90.

    Article  PubMed  Google Scholar 

  60. Baron TH, Kozarek RA, Carr-Locke DL. ERCP. Philadelphia: Elsevier Health Sciences; 2012.

    Google Scholar 

  61. Schmitz A, Schmidt AR, Buehler PK, Schraner T, Frühauf M, Weiss M, et al. Gastric ultrasound as a preoperative bedside test for residual gastric contents volume in children. Paediatr Anaesth. 2016;26(12):1157–64.

    Article  PubMed  Google Scholar 

  62. Bouvet L, Chassard D. [Contribution of ultrasonography for the preoperative assessment of gastric contents]. Ann Fr Anesth Reanim. 2014;33(4):240–7.

    Google Scholar 

  63. Amer S, Horsley-Silva JL, Menias CO, Pannala R. Endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy. Abdom Imaging. 2015;40(8):2921–31.

    Article  PubMed  Google Scholar 

Download references

Conflicts of Interest

Funding and Conflicts of interest—none.

Author information

Authors and Affiliations

  1. Hospital University Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA

    Basavana G. Goudra M.D., F.R.C.A., F.C.A.R.C.S.I.

  2. Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India

    Preet Mohinder Singh M.D., D.N.B.

Authors
  1. Basavana G. Goudra M.D., F.R.C.A., F.C.A.R.C.S.I.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Preet Mohinder Singh M.D., D.N.B.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Basavana G. Goudra M.D., F.R.C.A., F.C.A.R.C.S.I. .

Editor information

Editors and Affiliations

  1. Hospital University Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA

    Basavana G. Goudra

  2. Department of Anesthesiology, Emory University, Atlanta, Georgia, USA

    Michael Duggan

  3. Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

    Vidya Chidambaran

  4. University Hospitals Birmingham, Birmingham, United Kingdom

    Hari Prasad Krovvidi Venkata

  5. Emory University Hospital, Atlanta, Georgia, USA

    Elizabeth Duggan

  6. University of Alabama at Birmingham, Birmingham, Alabama, USA

    Mark Powell

  7. All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India

    Preet Mohinder Singh

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Goudra, B.G., Singh, P.M. (2018). Anesthesia for ERCP. In: Goudra, B., et al. Anesthesiology. Springer, Cham. https://doi.org/10.1007/978-3-319-74766-8_19

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-74766-8_19

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-74765-1

  • Online ISBN: 978-3-319-74766-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation