Consensus guidelines for the perioperative management of patients undergoing endoscopic retrograde cholangiopancreatography

Deep sedation without tracheal intubation (monitored anaesthesia care) and general anaesthesia with tracheal intubation are commonly used anaesthesia techniques for endoscopic retrograde cholangiopancreatography (ERCP). There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be
considered depending on the nature and severity of the patient’s underlying disease, comorbidities, and procedural risks.
An international group of expert anaesthesiologists and gastroenterologists created clinically relevant questions
regarding the merits and risks of monitored anaesthesia care vs general anaesthesia in specific clinical scenarios for
planning optimal anaesthetic approaches for ERCP. Using a modified Delphi approach, the group created practical recommendations for anaesthesiologists, with the aim of reducing the incidence of perioperative adverse outcomes while
maximising healthcare resource utilisation. In the majority of clinical scenarios analysed, our expert recommendations
favour monitored anaesthesia care over general anaesthesia. Patients with increased risk of pulmonary aspiration and
those undergoing prolonged procedures of high complexity were thought to benefit from general anaesthesia with
tracheal intubation. Patient age and ASA physical status were not considered to be factors for choosing between
monitored anaesthesia care and general anaesthesia. Monitored anaesthesia care is the favoured anaesthesia plan for
ERCP. An individual risk-benefit analysis that takes into account provider and institutional experience, patient
comorbidities, and procedural risks is also needed.