Anaesthesia for ERCP

endoscopy ercp positioning radiation shared airway Nov 04, 2024

Dark, crowded and a long way from home… 🕶️🛤️🏠

Endoscopic retrograde cholangiopancreatography (ERCP) is the ‘gold standard’ 🏆 for imaging of the biliary tree. Most patients will now undergo ERCP for therapeutic procedures, as diagnostic imaging can be performed via other, less invasive methods.

👉🏻 What is it? 

ERCP is a combined endoscopic and radiological procedure performed to treat obstruction of the biliary tree from stones, malignancy, or strictures. The patient is either sedated or anaesthetised, and placed in a semi-prone position. An endoscope is passed into the duodenum, where the ampulla of Vater is located. The biliary tree is cannulated under direct vision, and X-ray with contrast is used to guide stone retrieval, stent placement, or balloon dilation.

👉🏻 What does the anaesthetic team need to know? 

🔺 Positioning

The “swimmer’s” position is used to optimise the endoscopist and radiographer’s access to the surgical site. It creates risk for the anaesthetic team because there is limited access to the airway, there is risk of nerve/corneal injury, and there are limited sites for cannulation. In the event of cardiac arrest or airway problems, the patient may need to be rapidly returned to the supine position. Communication and vigilance are key to protecting the patient. 

🔺 Shared airway

This is another example of shared airway upper endoscopy, with the added complexity of access and positioning should your team need to perform airway rescue. If sedation without a secure airway is used, your team must always be prepared to intubate or manage complications such as laryngospasm or aspiration. 

🔺 Access to patient

Access to the patient is often limited by the orientation of the room and the X-ray machine. 

🔺 Radiation

A well-fitting lead gown and thyroid protector is essential for anyone in the room. Be mindful of the risk of spending too much time next to the source of radiation, especially if you’re attending to the airway. 

🔺 Patient comorbidities

Biliary sepsis, cancer, and pancreatitis are just some of the indications for ERCP. Thorough preoperative assessment and planning is essential for safe anaesthesia in this patient group. 

✅ Build knowledge

✅ Improve safety

References:

Henriksson AM, Thakrar SV. Anaesthesia and sedation for endoscopic retrograde cholangiopancreatography. BJA Educ. 2022 Oct;22(10):372-375. doi: 10.1016/j.bjae.2022.04.002. Epub 2022 Jul 19. PMID: 36132880; PMCID: PMC9482865.

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