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Anesthesia-administered sedation for endoscopic retrograde cholangiopancreatography

monitored anesthesia care or general endotracheal anesthesia?

Smith, Zachary L.a; Das, Koushik K.b; Kushnir, Vladimir M.b

Current Opinion in Anesthesiology: August 2019 - Volume 32 - Issue 4 - p 531–537
doi: 10.1097/ACO.0000000000000741

Purpose of review The decision to undertake monitored anesthesia care (MAC) or general endotracheal anesthesia (GEA) for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is influenced by many factors. These include locoregional practice preferences, procedure complexity, patient position, and comorbidities. We aim to review the data regarding anesthesia-administered sedation for ERCP and identify the impact of airway management on procedure success, adverse event rates and endoscopy unit efficiency.

Recent findings Several studies have consistently identified patients at high risk for sedation-related adverse events during ERCP. This group includes those with higher American Society of Anesthesiologists class and (BMI). ERCP is commonly performed in the prone position, which can make the placement of an emergent advanced airway challenging. Although this may be alleviated by performing ERCP in the supine position, this technique is more technically cumbersome for the endoscopist. Data regarding the impact of routine GEA on endoscopy unit efficiency remain controversial.

Summary Pursuing MAC or GEA for patients undergoing ERCP is best-approached on an individual basis. Patients at high risk for sedation-related adverse events likely benefit from GEA. Larger, multicenter randomized controlled trials will aid significantly in better delineating which sedation approach is best for an individual patient.

aDivision of Gastroenterology and Liver Disease, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, Ohio

bDivision of Gastroenterology, Washington University School of Medicine, Saint Louis, Missouri, USA

Correspondence to Zachary L. Smith, DO, University Hospitals Digestive Health Institute, 11100 Euclid Ave, Wearn 2nd Floor, Cleveland, OH 44106, USA. Tel: +1 216 844 6172; fax: +1 216 844 7480; e-mail:

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