6 - Sedación en CPRE

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6

Sedation in ERCP
Catherine D. Tobin and Gregory A. Coté

Unlike routine endoscopic procedures, endoscopic retrograde cholan- movement to achieve technical success. In a study serially assessing
giopancreatography (ERCP) combines several unique challenges. Despite sedation depth during ERCP, 85% of patients met criteria for deep
defined indications, the complexity and length of each procedure are sedation during a segment of the procedure.2 Consequently, the ASA
often difficult to predict because of unforeseen challenges with can- recommends that the sedation provider be adequately trained in rescue
nulation and subsequent therapy. Patients are usually in the prone maneuvers commensurate with one level of sedation higher than the
position to maintain a stable, short endoscope position. In addition, intended target. Therefore patients targeted for deep sedation should be
the prone position and overlying fluoroscopy unit make airway monitor- managed by a provider who is trained in the administration of general
ing and interventions difficult, particularly with an acute decline in the anesthesia.3 This would include management in bag mask ventilation,
patient’s respiratory status. Furthermore, many indications for ERCP laryngeal mask airway placement, and endotracheal intubation. The
are associated with a functional or mechanical gastric outlet obstruction, Centers for Medicaid & Medicare Services (CMS) have endorsed this
increasing the risk for periprocedural aspiration. Finally, the obesity recommendation, releasing a clarification letter to their policy on
epidemic and the rising prevalence of overt and subclinical obstructive hospital anesthesia services in 2010 after the major gastrointestinal
sleep apnea (OSA) result in a high-risk patient population for sedation- (GI) societies in the United States made a concerted effort to endorse
related adverse events (AEs). For these reasons, the endoscopist must nonanesthesiologist-administered propofol for low-risk patients undergo-
be meticulous in assessing preprocedure risk to determine the optimal ing standard endoscopy.4,5
approach to sedation for ERCP. This chapter will discuss (1) the The current options for sedation in ERCP can be simplified into
approaches to sedation during ERCP, including the rationales for two categories: endoscopist-administered sedation and anesthesiologist-
anesthesia-administered sedation and empirical endotracheal intubation; administered sedation. Computerized sedation systems that incorporate
(2) risk assessment for sedation-related AEs; and (3) methods for real-time patient feedback have been evaluated for standard endoscopic
attenuating this risk. procedures but have not been investigated for patients undergoing ERCP.6
Because propofol can be administered only by anesthesia providers in
the United States, endoscopist-administered sedation implies moderate
DEFINING THE CONTINUUM OF SEDATION sedation using conventional agents such as the combination of a
Sedation is typically characterized using the American Society of benzodiazepine (e.g., midazolam) and an opiate (e.g., fentanyl or
Anesthesiologists (ASA) Continuum of Sedation, which defines four meperidine). Of note, benzodiazepine can be reversed by flumazenil
discrete levels of sedation (Table 6.1).1 Depth is most frequently and opioids by naloxone in the event of oversedation. Anesthesiologists
defined by patient responsiveness to voice, light tactile stimulation, and may choose between general anesthesia with endotracheal intubation
painful stimulation during the procedure. However, the corresponding at the onset of the procedure and general anesthesia with use of a nasal
cardiopulmonary sequelae of this degree of awareness do not directly cannula and having the patient breathe spontaneously during the
translate into the probability of sedation-related AEs. In moderate procedure. In the latter scenario, patients are typically sedated using a
(also known as “conscious”) sedation, patients may be sleeping but propofol-based regimen, with a goal of achieving deep sedation or
will have purposeful response to tactile stimuli, yet may not respond general anesthesia. Endoscopists increasingly prefer anesthesia-
to voice. In patients who are deeply sedated, this response occurs only administered sedation for all endoscopic procedures. The growing role
after repeated or painful stimuli. Patients who do not respond to of propofol in endoscopic practice is reflected in epidemiologic data
painful stimuli even if they are breathing on their own are by defini- demonstrating a consistent increase in anesthesia-administered sedation.7,8
tion under general anesthesia. Monitored anesthesia care (MAC) is a The overuse of anesthesia services for colonoscopy is under increased
term often used when talking about sedation. MAC does not describe scrutiny.9 With a greater emphasis on cost-effectiveness in health care,
the level of sedation; it just means that a trained anesthesia provider judicious use of anesthesia will mandate an improved preprocedure
was involved in the care and the administration of drugs. In reality, risk assessment; this is particularly important in ERCP, where the potential
a patient’s level of sedation rarely meets only one of these definitions for sedation-related complications is highest.
during the course of endoscopy, and these levels actually represent a Initially approved for the induction and maintenance of anesthesia,
continuum. The amount of sedation administered to achieve moderate propofol (2,6-diisopropylphenol) has become an increasingly popular
sedation often inadvertently leads to deep sedation.2 Similarly, patients sedative for endoscopic procedures because of its rapid onset of action
who are targeted for deep sedation often meet criteria for general (30 to 45 seconds) and short duration of effect (4 to 8 minutes).10,11 In
anesthesia. the United States, propofol is currently restricted to anesthesiologists
Many patients undergoing ERCP often require deep sedation, as and some emergency medicine physicians because of its relative potency,
opposed to the light or moderate sedation that is usually adequate lack of an antagonist, and potential for rapid change in the depth of
for colonoscopy or esophagogastroduodenoscopy. ERCP procedures sedation from moderate sedation to general anesthesia. Nevertheless,
are typically longer in duration and require less spontaneous patient in a meta-analysis of 12 trials of propofol sedation during routine

49
50 SECTION I General Topics

TABLE 6.1 ASA Continuum of Sedation1


Minimal Sedation/ Moderate Sedation/Analgesia
Anxiolysis (“Conscious” Sedation) Deep Sedation/Analgesia General Anesthesia
Responsiveness Normal response to Purposeful response to verbal or light Purposeful response after repeated Unarousable even with
verbal stimulation tactile stimulation or painful stimulation* painful stimulus
Airway Unaffected No intervention required Intervention may be required Intervention often required
Spontaneous Unaffected Adequate May be inadequate Frequently inadequate
ventilation
Cardiovascular Unaffected Usually maintained Usually maintained May be impaired
function

ASA, American Society of Anesthesiologists.


*Reflex withdrawal from a painful stimulus is not considered a purposeful response.
Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to
produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals
administering moderate sedation/analgesia (“conscious” sedation) should be able to rescue patients who enter a state of deep sedation/
analgesia, whereas those administering deep sedation/analgesia should be able to rescue patients who enter a state of general anesthesia.
Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and
advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (e.g.,
hypoventilation, hypoxia, and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue a
procedure at an unintended level of sedation (adapted from ASA guidelines with approval).1

TABLE 6.2 ASA Physical Status Classification System17


Class Definition
1 A normal healthy patient (i.e., healthy, nonsmoking, no or minimal alcohol use)
2 A patient with mild systemic disease (examples include [but are not limited to] current smoker, social alcohol drinker, pregnancy, obesity [30 < BMI <
40], well-controlled DM or HTN, mild lung disease)
3 A patient with severe systemic disease (examples include [but are not limited to] poorly controlled DM or HTN, COPD, morbid obesity [BMI ≥40], active
hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis,
premature infant PCA <60 weeks, and history [>3 months] of MI, CVA, TIA, or CAD/stents)
4 A patient with severe systemic disease that is a constant threat to life (examples include [but are not limited to] recent (<3 months) MI, CVA, TIA, or
CAD/stents; ongoing cardiac ischemia or severe valve dysfunction; severe reduction of ejection fraction; sepsis; DIC; ARD or ESRD; and not undergoing
regularly scheduled dialysis)
5 A moribund patient who is not expected to survive without the operation (examples include [but are not limited to] ruptured abdominal/thoracic aneurysm,
massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology, or multiple organ/system dysfunction)
6 A declared brain-dead patient whose organs are being removed for donor purposes

ARD, Acute renal disease; ASA, American Society of Anesthesiologists; BMI, body mass index; CAD, coronary artery disease; COPD, chronic
obstructive lung disease; CVA, cerebral vascular accident; DIC, disseminated intravascular coagulation; DM, diabetes mellitus; ESRD, end-stage
renal disease; HTN, hypertension; MI, myocardial ischemia; PCA, postconceptual age; TIA, transient ischemia attack.
An addition of “E” denotes emergency surgery. An “E” is noted after the ASA number (e.g., ASA 3E). (An emergency is defined as existing
when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.)

endoscopy, endoscopic ultrasonography (EUS), and ERCP, the overall ischemia, and need for airway rescue maneuvers or reversal agents.
rate of cardiopulmonary AEs was lower than that of standard combination Mortality data related to sedation in endoscopy are sparse, particularly
opiate–benzodiazepine regimens.12 in ERCP. The risk of death is probably close to 0.03% for patients
There are several unique characteristics of ERCP compared with undergoing standard endoscopy using conventional sedation regimens.14
other endoscopic procedures that may accentuate the benefits of propofol. Fewer studies track the frequency of airway rescue maneuvers, such as
Specifically, ERCPs tend to be longer in duration and require sustained a chin lift, nasal trumpet insertion, and transient positive pressure (i.e.,
patient cooperation in order to achieve technical success.13 Longer bag-mask) ventilation.15 These may be performed as a preventive
procedures require higher cumulative doses of benzodiazepines and maneuver in anticipation of hypoxemia or apnea and reflect the
opiates to maintain moderate sedation, which translates into longer importance of having a sedation provider experienced in airway rescue.
recovery times. Rates of conversion from nasal cannula to endotracheal intubation
during administration of intravenous propofol during ERCP are less
DEFINING SEDATION-RELATED COMPLICATIONS defined, although a study of 528 patients undergoing ERCP with MAC
reported a 3% incidence of unplanned endotracheal intubation.16 In a
(ADVERSE EVENTS) cohort study that included all endoscopic procedures performed during
Adverse events (AEs) specifically related to sedation are usually classified a 5-year period, patients with a higher ASA class17 (Table 6.2) and those
in the literature by objective criteria such as oxygen desaturation, undergoing ERCP were more likely to require reversal agents such as
aspiration, laryngospasm, apnea, hypotension, arrhythmia, myocardial flumazenil or naloxone.18
CHAPTER 6 Sedation in ERCP 51

classification system is another bedside tool to gauge risk, with scores


RISK ASSESSMENT
of 3 or greater being associated with a higher probability of sedation-
A thorough preprocedure assessment of patient risk before ERCP can related complications (see Table 6.2).8 One must consider that when a
be challenging, particularly for patients with urgent or emergent indica- patient is at higher risk for sedation-related complications, use of the
tions. ASA guidelines acknowledge the dearth of publications confirming anesthesia team may be needed because of endotracheal intubation or
the value of the preprocedure assessment in reducing sedation-related airway management.
AEs, but expert consultants strongly agree that this is a vital precursor In addition to patient factors, the endoscopist should also consider
for all procedures requiring sedation. Identifying risk factors for sedation- the indication for ERCP and estimated procedure length when choosing
related complications should help the endoscopist determine the need the optimal sedation strategy. Although anticipating the complexity of
for an anesthesiologist. The endoscopist should always conduct a focused ERCP is often challenging, specific indications such as stent removal
history to assess for significant organ dysfunction (with a particular and stent exchange in a patient with prior sphincterotomy are almost
emphasis on the cardiopulmonary system), cervical spine disease, OSA, always of short duration; these patients may not be critically ill and
fasting interval, and prior substance abuse. Because more than 30% of often undergo the procedure in the ambulatory setting. In these
Americans are overweight or obese, the incidence of subclinical sleep cases, the threshold to use anesthesia assistance or adjunct medica-
apnea may be 10% or greater.19,20 A bedside assessment for OSA risk, tions to supplement a standard combination regimen is much lower.
such as the STOP-BANG instrument, can identify patients who are at Situations that may be advisable to incorporate the anesthesia team
higher risk for needing active airway management during the proce- include end-stage liver disease patients with cirrhosis and massive
dure.21,22 In this questionnaire, the patient is asked about snoring (S), ascites, patients on high-dose chronic opioids, high preprocedure
feeling tired (T), observed apnea (O), high blood pressure (P), body baseline pain, and sepsis. These patients may be at risk for aspiration,
mass index >35 kg/m2 (B), age above 50 years (A), neck circumference airway obstruction, hypotension requiring vasopressors, or higher dose
>16 inches (N), and male gender (G). The physical assessment should opioids than normal. For drainage of a large pancreatic fluid collection
include a routine examination of the heart and lungs along with a (e.g., pseudocyst), we prefer to perform empiric endotracheal intu-
dedicated examination of the airway, head, and neck. Particular features bation because of the anticipated influx of pancreatic juice into the
that portend a more complex airway include a macrognathia, trismus, stomach.
short chin–sternal notch distance, and large uvula. The Mallampati
score (0 to 4)23 is a validated bedside tool to assess airway risk. A summary
of selected features associated with sedation-related AEs and difficult
ANESTHESIOLOGIST-ADMINISTERED SEDATION
airway assessments to evaluate on preprocedure history and physical With an estimated 1 death per 200,000 to 300,000 anesthetics admin-
examination is in Table 6.3.15 Although vague, the ASA physical status istered, the safety profile of general anesthesia is excellent24; however,
there are limited data regarding the safety of anesthesiologist-administered
sedation specifically during ERCP.13,16,25,26 For patients in the prone
position undergoing ERCP, some anesthesiologists are reluctant to deliver
MAC by intravenous sedation without a secured airway because it is
TABLE 6.3 Factors Associated With difficult to maintain a patent airway, to monitor respirations, and to
Sedation-Related Complications gain access to the airway in an emergency. Although monitoring chest
Physical Scoring wall excursions is more difficult in ERCP with the overlying fluoroscopy
History Examination Instruments equipment, the prone position is not an independent predictor of
sedation-related complications and in fact may confer some protection
Previous problems with Short neck with ASA Physical Status
against aspiration versus patients who are supine.15,27 There is a perceived
sedation/anesthesia limited neck Classification
higher risk of aspiration when the patient is supine as opposed to prone
extension system
when not intubated endotracheally. The left lateral decubitus position
Cardiac disease (e.g., Decreased Mallampati score
may confer less risk of aspiration than supine, but this confounds the
aortic stenosis) hyoid-mental
acquisition of fluoroscopic images. Airway obstruction occurs less often
distance (<3 cm
in the prone position than in the supine position because the tongue
in adults)
rests off the hard palate. When administered by an experienced provider,
Pulmonary disease Trismus Body-mass index
anesthesiologist-administered intravenous propofol without an endo-
Obstructive sleep apnea Macroglossia STOP-BANG (bedside
tracheal tube has a favorable safety profile for sedation during ERCP
(consider use of a tool to assess risk
and other advanced endoscopic procedures.15,16 Lastly, the experience
bedside screening of Obstructive
of and consistent staffing with the same anesthesia providers minimizes
instrument) Sleep Apnea)
the risk of hypoxemia during deep sedation and reduces facility costs
Difficulties with Tonsillar
as a result of room efficiency.28
positive-pressure hypertrophy
The decision to perform empiric endotracheal intubation before
ventilation or
commencing ERCP is made on a case-by-case basis. Endotracheal
endotracheal
intubation is preferred for patients at high risk for aspiration, airway
intubation
obstruction, and oxygen desaturation. Patients with OSA and obesity
Advanced rheumatologic Micrognathia
should be intubated because of a high likelihood of desaturation from
disease
upper airway obstruction. Risk factors for aspiration include patients
Advanced osteoarthritic Obesity
with delayed gastric emptying and patients with gastric outlet obstruction;
cervical spine disease
examples would include patients using opioids, late-term pregnancy,
Edentulous
diabetic gastroparesis, obesity, and nonfasting state (Table 6.4). Fasting
Full beard
recommendations are guidelines and do not assure complete gastric
ASA, American Society of Anesthesiologists. emptying. Certain disease states, such as diabetic and nondiabetic
52 SECTION I General Topics

TABLE 6.4 Fasting Guidelines TABLE 6.5 Modified Observer’s


Recommended by ASA29 Assessment of Alertness/Sedation
Minimum Fasting
(MOAA/S)44
Meal Time (hr) Examples Correlation With ASA
Clear liquids 2 Black coffee, tea, apple juice, Score Definition Continuum of Sedation
nonpulp juice 5 Responsive and alert Minimal sedation
Breast milk 4 4 Lethargic, but responsive to Moderate sedation
Infant formula 6 normal verbal command
Nonhuman milk 6 3 Responsive to loud verbal
Light meal 6 Dry toast and clear liquid command
2 Responsive to shaking only Deep sedation
ASA, American Society of Anesthesiologists.
1 Unresponsive to shaking

ASA, American Society of Anesthesiologists.

gastroparesis, may delay emptying, and one should consider extending


the recommended timelines.29 MONITORING
Other considerations for empiric endotracheal intubation include
patients who have recently undergone surgery, severe pain at baseline, The ASA and Joint Commission standards require a qualified individual,
and anticipated very long or high-risk procedure. Finally, certain other than the person performing the procedure, be present to monitor
pulmonary conditions that often mandate empiric endotracheal intuba- the patient throughout the procedure.1,35 For patients targeted for
tion include patients with a home oxygen requirement and pulmonary moderate sedation, the individual administering sedation may execute
hypertension of any etiology, the latter to avoid hypercarbia, which focused, interruptible tasks during the procedure; when deep sedation
would worsen the pulmonary vascular resistance. Cardiac conditions is intended, the individual must have no other responsibilities and be
such as presence of coronary stents, history of myocardial ischemia, trained in the administration of general anesthesia.
and cardiomyopathy do not mandate empiric endotracheal intubation, Standard monitoring equipment for all patients should include
unless the patient is at risk for hypoxemia for reasons outlined ealier. continuous pulse oximetry, 3-lead or 5-lead electrocardiography,
A laryngeal mask airway could minimize the risk of upper airway and a noninvasive blood pressure cuff.36 In addition, capnography is
obstruction but does not mitigate the risk of aspiration.30 now recommended by the ASA for all patients targeted for moderate
sedation or greater. Carbon dioxide monitoring via a transcutane-
NONANESTHESIOLOGIST (ENDOSCOPIST)– ous electrode37 or capnography38,39 has been studied in ERCP in an
effort to recognize hypopnea or apnea before the onset of hypoxemia.
ADMINISTERED SEDATION Capnography represents end-tidal carbon dioxide (ETCO2) and is a
In most facilities, ASA practice guidelines for sedation administered by real-time monitor of every inhalation and exhalation. Normal ETCO2
nonanesthesiologists are used as the standard for local practices such is 35 to 45 mm Hg, and watching the curve is more important than
as preprocedure evaluation and duration of fasting.1 The ASA periodically the number when it is used to monitor sedation. If apnea or airway
releases guidelines for institutions that are responsible for granting obstruction develops, ETCO2 will drop immediately, yet pulse oximetry
privileges to administer sedation.3,31 Endoscopist-directed sedation in may take minutes to reflect hypoxemia caused by apnea/hypopnea.
ERCP generally refers to the use of a combination of benzodiazepines Therefore, when using capnography, one can react faster to address the
and opiates targeted for moderate sedation. Advantages of this combina- etiology of airway problems before they have permanent and dangerous
tion include the ability to administer reversal agents in the event of a outcomes. A meta-analysis of five studies that included a variety of
sedation-related AE, amnestic effect, and sustained analgesia during procedures, including endoscopy, found that the use of capnography
the postprocedure recovery period (typically several hours). In cases increased the detection rate of respiratory depression.40 Capnography
where these agents cannot provide adequate depth or duration of sedation reduces the incidence of severe hypoxemia or apnea in patients using a
to complete the procedure, the addition of antihistamines (e.g., propofol-based regimen or a standard combination of benzodiazepine
diphenhydramine or promethazine) and droperidol, among others, may and opiate. In healthy individuals, the benefit of capnography during
be used.32–34 Use of antihistamines increases the likelihood of requiring standard endoscopic procedures in healthy individuals using moderate
reversal agents by potentiating the risk of apnea. Although still used in sedation is questionable.41,42 Still, economic models based on existing
some endoscopy units, droperidol has fallen out of favor because of data suggest that it may be cost-effective.43 Given the complexities of
QT interval prolongation and potential for ventricular arrhythmia. That sedation specific to ERCP, universal use of capnography should be
being said, conventional agents are limited by their slower onset of strongly considered.
action compared with propofol-based regimens, difficulty in titration A quantitative measure of sedation depth is the Modified Observer’s
during prolonged ERCP, and limited efficacy. This is compounded by Assessment of Alertness/Sedation (MOAA/S) score (Table 6.5).44 This
a higher risk of AEs among patients using opiate medications before scale from 1 to 5 reflects patient responsiveness alone, and no studies
the procedure, which is particularly common in patients undergoing to date have evaluated the impact of frequent measurements (e.g.,
ERCP. This is because of obstructive pathology of the pancreatobiliary every 2 minutes) of the MOAA/S score on sedation-related outcomes.
tree (e.g., stones, tumors) causing pain at the time of clinical presentation. Because frequent assessments of patient alertness are already compulsory
ERCP technical success rate is significantly higher when patients are in ERCP, the utility of MOAA/S is probably limited to research as a
sedated using general anesthesia compared with moderate sedation tool for quickly measuring sedation depth but not as an instrument
regimens as a result of improved sedation.13 Hence, there is a growing for titrating sedation per se. Nevertheless, this is a reminder of the
trend in the use of propofol-based sedation in ERCP. importance of frequent interval assessments throughout the procedure to
CHAPTER 6 Sedation in ERCP 53

FIG 6.1 Example of room configuration. Note lead shield and aprons FIG 6.2 Jaw thrust in the prone position. This image depicts an anesthesia
worn by staff, patient monitor, and emergency bag-mask ventilation provider performing a jaw thrust on a patient undergoing ERCP in the
device all in clear site. The anesthesia provider is in close proximity to prone position. The patient is receiving oxygen through a nasal cannula,
the patient’s airway and monitors. which is also being used to monitor end-tidal CO2.

recognize imminent sedation-related complications before the onset of a equipment, including a lead apron, thyroid shield, and glasses. If possible,
severe AE. the person administering sedation should try to position himself or
Automated responsiveness monitors (ARMs) are useful for patients herself behind a radiation shield.
targeted for monitored sedation, where responsiveness should be pre-
served throughout the procedure. An ARM is a computer-generated
auditory or tactile stimulus that requires the patient to react (e.g., press
CONCLUSIONS
a button) within a defined interval.45 This technology is effective in ERCP is an increasingly complex therapeutic procedure that is performed
computerized titration of propofol in standard endoscopy and reduces on patients with high baseline morbidity. Sedation in ERCP should be
the frequency of sedation-related complications compared with standard individualized because the risk of sedation-related complications depends
combination regimens.6,46–48 Computerized titration of sedation in ERCP on a variety of patient-specific and procedure-specific factors. There is
has not been studied; because patients are more frequently targeted to a trend toward greater utilization of anesthesiology-administered sedation
deep sedation, the utility of ARMs may be limited. However, further in ERCP and all endoscopy in the United States, although systemic
study is needed in ERCP and other interventional endoscopic procedures. pressure to control health care costs may obligate endoscopists to have
a higher threshold for anesthesia-administered sedation in the future.
Future research and policy are expected to expand the use of propofol-
ROOM SETUP AND CONSIDERATIONS FOR SAFETY based sedation regimens in all endoscopic procedures, perhaps enhanced
The room setup and configuration are extremely important (Fig. 6.1). by automated response monitors. Although these changes are expected
The person administering sedation needs to be able to see the patient to primarily affect standard endoscopic procedures initially, physicians
monitor and patient simultaneously. A jaw thrust maneuver is often performing ERCP should still be intimately familiar with this procedure’s
required while continuing to monitor vital signs (Fig. 6.2). It is important unique sedation risk profile. No matter the approach to sedation in
to also have a bag valve mask within arm’s reach. Furthermore, a stretcher ERCP, preprocedure recognition of high-risk patients and comfort with
needs to be close by in the event of an emergency requiring the patient airway rescue maneuvers are paramount.
to be repositioned supine, such as for endotracheal intubation in the
setting of refractory airway obstruction or cardiopulmonary arrest. The complete reference list for this chapter can be found online at
Radiation protection for the person administering sedation should www.expertconsult.com.
be emphasized (see Chapter 3). It is important to wear personal protective
CHAPTER 6 Sedation in ERCP 53.e1

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