Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography: a comparative systematic review and meta-analysis

Comparison of intratracheal intubation or not during endoscopic retrograde cholangiopancreatography: a meta-analysis and systematic review

OBJECTIVES

In endoscopic retrograde cholangiopancreatography anesthesia, both intubation and non-intubation techniques have their own advantages and disadvantages. However, whether either approach is associated with postoperative and anesthesia-related adverse events remains controversial.

METHODS

We searched the literature in PubMed, Web of Science, Cochrane Library, Scopus, Ovid and Embase databases up to October 2024. All studies comparing intubated vs. non-intubation anesthesia for endoscopic retrograde cholangiopancreatography were included. The main outcome measures were sedation-related adverse events and death. Data were combined using risk ratio with 95% confidence intervals. The study protocol was prospectively registered with PROSPERO (CRD42024608807).

RESULTS

We finally included 8 studies with a total of 21,433 patients. Endotracheal intubation was associated with a lower risk of sedation-related adverse events (RR: 2.85, 95% CI 1.33-6.09, p = 0.007). However, the risks of death (RR: 0.59, 95% CI 0.36-0.96, p = 0.03) and intraoperative hypotension (RR: 0.43, 95% CI 0.26-0.69, p = 0.0006) were lower without intubation. In the trial-sequence analysis, the trial-sequence monitoring boundary is crossed, indicating conclusive evidence of a statistically significant effect.

CONCLUSIONS

Our findings suggest that endotracheal intubation during endoscopic retrograde cholangiopancreatography is associated with a lower risk of sedation-related adverse events but a higher risk of mortality and intraoperative hypotension compared to non-intubation. However, these associations do not establish direct causality and should be interpreted with caution. Further high-quality randomized controlled trials are needed to validate these findings. Clinicians should adopt a patient-centered approach, carefully balancing the potential benefits and risks of intubation to optimize airway management strategies in endoscopic retrograde cholangiopancreatography.

Assessing Sedation Depth with PSI in Elderly ERCP Patients: A Prospective Cohort Study

Background

Adequate sedation is important for elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Patient state index (PSI) via the SedLine® system has been utilized for real-time monitoring of anesthesia depth in surgical patients. We aimed to assess the correlation between PSI and Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores in elderly patients undergoing ERCP.

Methods

This prospective cohort study included 57 elderly patients scheduled for ERCP procedures. Patients received target-controlled infusion of propofol, titrated to the sedation level of MOAA/S scores of 1 and 2. The MOAA/S scores and PSI values were recorded during sedation and recovery. We also documented procedure and recovery time, oversedation (PSI < 25 for at least 10 min and EEG burst suppression), adverse events, and fatigue scores (0-10, higher scores indicating more fatigue).

Results

All patients completed this study (mean age of 73 years and 63% male), with a mean procedure time of 53 min and recovery time of 37 min. Five patients (8.8%) experienced PSI < 25 for at least 10 min, and three of them (5.3%) showed EEG burst suppression. No patients developed desaturation or intra-procedural awareness. Hypotension and abdominal pain were uncommon. Nine patients (15.8%) experienced mild dizziness or nausea. The median (IQR) fatigue score was 3 (2-4) at recovery room discharge. A significant correlation was observed between the MOAA/S scores and PSI values (Spearman correlation coefficient ρ = 0.742, P < 0.001). When patients were at the MOAA/S scores of 1 and 2, the median PSI was 50 (95% CI: 48 to 52).

Conclusion

PSI provides a useful and real-time monitoring of sedation for elderly patients undergoing ERCP. Our results showed a significant correlation between the PSI values and MOAA/S scores and suggested a PSI value of 50 with a range of 48 to 52 for maintaining adequate sedation.

Trial Registration

Chinese Clinical Trial Registry (ChiCTR2400079859).

Comparative Efficacy and Safety of Anesthetic and Sedative Regimens for Endoscopic Retrograde Cholangiopancreatography: A Network Meta-Analysis

INTRODUCTION

This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures.

METHODS

A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios.

RESULTS

42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol.

CONCLUSION

This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.

INTRODUCTION

This study evaluates the efficacy and safety of various anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography (ERCP) procedures.

METHODS

A systematic search was conducted across PubMed, Web of Science, Scopus, and Embase to identify randomized controlled trials (RCTs) published until March 2024. Primary outcomes included procedure time, patient satisfaction, oxygen saturation (SpO2), incidence of SpO2 below 90%, and adverse events. The analysis was performed using R software, analyzing continuous outcomes with mean differences and dichotomous outcomes with risk ratios.

RESULTS

42 RCTs were included. Combination therapies such as remifentanil plus tramadol and propofol plus midazolam plus pethidine demonstrated significantly shorter procedure times. Propofol plus oxycodone yielded higher patient satisfaction. Oxygenation results indicated that propofol plus fentanyl, oxycodone, and ketamine improved SpO2. Propofol plus oxycodone (RR <0.01), dexmedetomidine plus fentanyl (RR <0.01), propofol plus nalbuphine (RR = 0.01), Mg sulfate plus propofol (RR = 0.01), and propofol plus fentanyl (RR = 0.02) showed a significant lower rate of patients with SpO2 below 90% compared to propofol. Midazolam plus pethidine plus dexmedetomidine (RR = 0.01), propofol plus oxycodone (RR = 0.09), and dexmedetomidine plus fentanyl (RR = 0.2) exhibited lower rates of adverse events compared to propofol.

CONCLUSION

This study provides comprehensive evidence to guide clinical decision-making and optimize anesthetic management for ERCP procedures.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

Safety and efficacy of remifentanil-propofol combination on "muscle relaxant-free" general anesthesia for therapeutic endoscopic retrograde cholangiopancreatography: a randomized controlled trial

OBJECTIVE

To prospectively evaluate the safety and efficacy of a "muscle relaxant-free" general anesthesia using a combination of remifentanil and propofol, compared to propofol-based monitored anesthesia care and conventional general anesthesia during therapeutic endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

From September to December 2019, 360 patients scheduled for elective ERCP at the Endoscopy Center of the First Affiliated Hospital of Nanjing Medical University were randomly assigned to three different groups: Group MAC (propofol-based monitored anesthesia care, n=120), Group GA1 (general anesthesia with neuromuscular blocking agents, n=120), or Group GA2 (remifentanil-propofol combination-based muscle relaxant-free general anesthesia, n=120).

RESULTS

The results showed that there was a significant difference in intraprocedural cardiopulmonary adverse events among the three groups (Group MAC, 37.5%; Group GA1, 19.2%; Group GA2, 17.5%; P < 0.001). Total time (from patient entry into the Endoscopy Center to departure) and room time (from patient entry into the endoscopy suit to departure) were shorter in Group GA2 and Group MAC compared to Group GA1 (P < 0.001). Additionally, endoscopist satisfaction levels were significantly higher in Group GA1 and Group GA2 compared to Group MAC (P < 0.001).

CONCLUSION

The study found that administering propofol-remifentanil combination for "muscle relaxant-free" general anesthesia during therapeutic ERCP was safe and effective. This approach offered greater safety and endoscopist satisfaction than propofol-based monitored anesthesia care, as well as shorter total time and room time than conventional general anesthesia.

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.

A randomized, controlled clinical trial comparing remimazolam to propofol when combined with alfentanil for sedation during ERCP procedures

STUDY OBJECTIVE

In many countries, the combination of propofol and opioid is used as the preferred sedative regime during ERCP. However, the most serious risks of propofol sedation are oxygen deficiency and hypotension. Compared to midazolam, remimazolam has a faster onset and offset of hypnotic effect, as well as cardiorespiratory stability, and to achieve widespread acceptance for procedural sedation, remimazolam must replace propofol which is the most commonly used for procedural sedation. The objective of this study was to compare the safety and efficacy profiles of the remimazolam and propofol when combined with alfentanil for sedation during ERCP procedures.

DESIGN

A randomized, controlled, single-center trial.

SETTING

The Endoscopic Centre of Tianjin Nankai Hospital, China.

PATIENTS

518 patients undergoing elective ERCP under deep sedation.

INTERVENTIONS

Patients scheduled for ERCP were randomly assigned to be sedated with either a combination of remimazolam-alfentanil or propofol-alfentanil.

MEASUREMENTS

The primary outcome was the prevalence of hypoxia, which was defined as SpO₂ < 90% for >10 s. Other outcomes were the need for airway maneuver, procedure, and sedation-related outcomes and side effects (e.g., nausea, vomiting, and cardiovascular adverse events).

MAIN RESULTS

A total of 518 patients underwent randomization. Of these, 250 were assigned to the remimazolam group and 255 to the propofol group. During ERCP, 9.6% of patients in the remimazolam group showed hypoxia, while in the propofol group, 15.7% showed hypoxia (p = 0.04). The need for airway maneuvering due to hypoxia was significantly greater in the propofol group (p = 0.04). Furthermore, patients sedated with remimazolam had a lower percentage of hypotension than patients sedated with propofol (p < 0.001). Patients receiving remimazolam sedation expressed higher satisfaction scores and were recommended the same sedation for the next ERCP. The procedure time in the remimazolam group was much longer than in the propofol group due to the complexity of the patient's disease, which resulted in a longer sedation time.

CONCLUSION

During elective ERCP, patients administered with remimazolam showed fewer respiratory depression events under deep sedation with hemodynamic advantages over propofol when administered in combination with alfentanil.

The effective doses of remimazolam besylate in the procedural sedation of endoscopic retrograde cholangiopancreatography

This study aimed to determine the values of the half-effective dose (ED50) and 95% effective dose (ED95) of remimazolam besylate used in the procedural sedation of endoscopic retrograde cholangiopancreatography (ERCP). Sixty patients who fulfilled the inclusion and exclusion criteria of this study were selected. Sufentanil was administered intravenously and remimazolam besylate was administered 2 min later. ERCP treatment was feasible when the modified alertness/sedation (MOAA/S) score was ≤2. If choking or movement occurred during duodenoscope placement, it was considered as a positive reaction. The dose was increased in the next patient; otherwise, it was considered as a negative reaction, and the dose was reduced in the next patient. The ED50 and ED95 values and 95% confidence interval (CI) of remimazolam besylate were calculated by Probit regression analysis. All 60 patients completed the trial. The ED50 and ED95 values of remimazolam besylate were 0.196 and 0.239 mg/kg, respectively, for the procedural sedation of ERCP. The time of MOAA/S score ≤ 2 was (82.58 ± 21.70) s, and the mean time of awakening was (9.03 ± 5.64) min. Transient hypotension was observed in two patients without medical intervention. The ED50 and ED95 values of remimazolam besylate used in the procedural sedation of ERCP were 0.196 and 0.239 mg/kg, and the dose of the medications has definite efficacy and good safety.