6 - Sedación en CPRE
6 - Sedación en CPRE
6 - Sedación en CPRE
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
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
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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