Deep sedation for endoscopic retrograde cholangiopacreatography

Abstract

Sedation and analgesia comprise an important element of unpleasant and often prolonged endoscopic retro grade cholangiopacreatography (ERCP), contributing, however, to better patient tolerance and compliance and to the reduction of injuries during the procedure due to inappropriate cooperation. Although most of the studies used a moderate level of sedation, the lite rature has revealed the superiority of deep sedation and general anesthesia in performing ERCP. The anes thesiologist's presence is mandatory in these cases. A moderate sedation level for ERCP seems to be adequate for octogenarians. The sedative agent of choice for sedation in ERCP seems to be propofol due to its fast distribution and fast elimination time without a cumu lative effect after infusion, resulting in shorter recovery time. Its therapeutic spectrum, however, is much nar rower and therefore careful monitoring is much more demanding in order to differentiate between moderate, deep sedation and general anesthesia. Apart from con ventional monitoring, capnography and Bispectral index or Narcotrend monitoring of the level of sedation seem to be useful in titrating sedatives in ERCP.

The dexmedetomidine "augmented" sedato analgesic cocktail: An effective approach for sedation in prolonged endoscopic retrograde cholangio-pancreatography

“…Deep sedation evolved as a better choice to get a good success rate. [ 2 ] Propofol commonly, and also midazolam, fentanyl, ketamine, droperidol and number of other drugs had been used for this purpose either alone or in combination. Combinations of drugs may help to reduce dose of an individual agent.…”

Outpatient endoscopic retrograde cholangiopancreatography: Safety and efficacy of anesthetic management with a natural airway in 653 consecutive procedures

“…Apart from requiring higher anesthetic doses that raise direct costs, this approach also increases risks and duration of the procedure with no apparent change in patient outcome or procedural safety. Theoretically, unlike other procedures done under sedation or general anesthesia, carbon dioxide insufflation of the stomach and intestines during ERCP in prone position can predispose to higher risk of aspiration[1] and vagally mediated hypotension. [2] Previous literature on monitored anesthesia care under sedation advocates the use of endotracheal intubation with general anesthesia in high risk (higher American Society of Anesthesiologists (ASA) grade and obese) patients, however, our experience of maintaining natural open airway over the years has proved to be safe and efficient both for procedural success and safety.…”

Is Dexmedetomidine a Poor Surrogate to Propofol for Procedural Sedation During Endoscopic Retrograde Cholangio-Pancreatography (Ercp)

“…Propofol after evaluation in a variety of sedative regimens has been shown to provide superior quality sedation with the advantage of better patient cooperation and shorter recovery time 14,15 . Specifically, studies for ERCP under deep sedation used Propofol alone or in combination with sedatives [1][2][3][4][12][13][14][15] .…”