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ERCP Procedure

• After adequate fasting and topical pharyngeal anaesthesia, the patient is sedated (TIVA or GA with airway protection) and positioned—often prone or semi-prone—then a side-viewing duodenoscope is advanced through the mouth into the second portion of the duodenum; under direct vision, the ampulla of Vater is cannulated with a guidewire-tipped catheter, contrast is injected to outline the biliary and/or pancreatic ducts on fluoroscopy, and any indicated therapy—such as sphincterotomy, stone extraction with balloons or baskets, stricture dilation, biopsy, or stent placement—is performed before carefully withdrawing the scope and monitoring for complications like pancreatitis, bleeding, or perforation.

Conduct of Anaesthesia for ERCP

Major Considerations

1. NORA considerations
   • Isolation, unfamiliar environment
2. Pre-optimization and risk stratification
3. GA vs Sedation
4. Shared Airway
5. Prone positioning
6. Fentanyl for analgesia
7. Protect kidneys

Preoperative Preparation

• Risk Stratification & Optimization
  • Assess for obstructive jaundice: look for hematocrit < 30%, indirect bilirubin > 200 µmol/L, malignancy
  • Correct coagulopathy: vitamin K (1–10 mg IM daily ×3 days), fresh frozen plasma as needed
  • Nutritional support: enteral high-protein/high-carbohydrate diet; if intolerant, begin parenteral nutrition 5–7 days pre-op
  • Renal protection: maintain euvolemia, avoid nephrotoxic agents (aminoglycosides, NSAIDs)
• ERCP-Specific Planning
  • Remote-site readiness: ensure full monitoring (ECG, NIBP, SpO₂, capnography) and emergency airway/crash cart availability
  • Positioning rehearsal: anticipate prone or semi-prone setup and secure all lines
• Anaesthesia Mode Selection
  • Apply 2023 consensus criteria:
    • Sedation if short, diagnostic ERCP in experienced hands and patient is haemodynamically stable
    • GA with intubation for prolonged/complex interventions, high aspiration risk, pediatric/high-BMI patients, failed sedation

Intraoperative Management

• Airway & Monitoring
  • Pre-oxygenate for 5 minutes; use capnography throughout
  • Plan for airway control in prone position (consider temporary supine induction or video-guided awake technique if needed)
• Pharmacologic Strategy
  • Induction: propofol (standard dose), etomidate (reduced dose)
  • Muscle Relaxants: avoid succinylcholine; use atracurium or cisatracurium (Hofmann elimination)
  • Inhalational Agents: avoid halothane; use low-dose isoflurane/desflurane with vigilance for hypotension
  • Opioids: reduce total dose by ~50% (↑ endogenous enkephalins); be mindful that morphine may cause transient biliary sphincter spasm
• Fluid & Hemodynamic Management
  • Guide therapy with dynamic indices (SVV, PPV) if available; avoid static CVP/MAP targets alone
  • Maintain euvolemia to prevent interstitial edema and hemodynamic swings
• Adjuncts
  • Topical pharyngeal lidocaine to improve scope tolerance (watch for diminished gag reflex)
  • Prophylactic antiemetics to reduce PONV risk

Postoperative Care

• Recovery & Monitoring
  • Continue full cardiorespiratory monitoring until stable; watch closely for hypoxaemia
  • Monitor for abdominal distension—consider NGT if significant
• Analgesia & Fluids
  • Use small opioid boluses (50% of usual dose) and avoid NSAID
  • Maintain strict fluid balance; use diuretics (furosemide, mannitol) for oliguria
• Nutrition & Mobilization
  • Resume enteral feeds as soon as tolerated; early mobilization to reduce pulmonary complications

Key ERCP-Related Complications

• Post-ERCP Pancreatitis: most common (≈3–10%), manifests with pain and enzyme elevation
• Bleeding: at sphincterotomy site or ductal injury
• Perforation: duodenal or biliary tree—may require surgery or stenting
• Infection: cholangitis or sepsis from instrumentation
• Cardiopulmonary: aspiration pneumonia, respiratory depression, hypoxaemia from sedation
• Others: stent migration, ductal trauma, rare air embolism

Links

• Remote anaesthesia
• Pancreatitis
• ICU and liver disease
• Liver physiology and pathology

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References:

1. Allman K, Wilson I, O’Donnell A. Oxford Handbook of Anaesthesia. Vol. 4. Great Clarendon Street, Oxford, OX2 6DP, United Kingdom: Oxford University Press; 2016.
2. Henriksson, A. and Thakrar, S. (2022). Anaesthesia and sedation for endoscopic retrograde cholangiopancreatography. BJA Education, 22(10), 372-375. https://doi.org/10.1016/j.bjae.2022.04.002
3. Azimaraghi, O., Bilal, M., Amornyotin, S., Arain, M. A., Behrends, M., Berzin, T. M., … & Eikermann, M. (2023). Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography. British Journal of Anaesthesia, 130(6), 763-772. https://doi.org/10.1016/j.bja.2023.03.012

Summaries:

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© 2025 Francois Uys. All Rights Reserved.

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