An international group of anesthesiologists and gastroenterologists published new consensus guidelines that favor deep sedation without tracheal intubation (monitored anesthesia care [MAC]) over general anesthesia for most patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).
Before the guidelines were developed, a large retrospective analysis performed by the primary investigator, Matthias Eikermann, MD, recommended MAC for patients undergoing ERCP.
“At the same time, there are small studies from other institutions with end points that we didn’t find very relevant, just oxygen desaturation during the case, which were in favor of general anesthesia,” said Eikermann, the Francis F. Foldes Professor and Chair in the Department of Anesthesiology at Montefiore Health System, in New York City. “We decided it was a good time to bring experts together from all over the world to systematically address, ‘What are the really important questions?’ and ‘How we can approach a consensus around those?’”
The guidelines, which were published as a special article in the British Journal of Anaesthesia (2023;130[6]:763-772) discuss the merits and risks of each approach and provide practical recommendations for anesthesiologists to reduce adverse outcomes while optimizing healthcare resource utilization.
The panel of 12 international experts used a modified Delphi process to develop the guidelines. Multiple iterations of live meetings and online questionnaires were performed until a consensus (=75% agreement) was reached. At the end of the review process, the panel developed consensus statements on three main topics related to the choice of general anesthesia with tracheal intubation versus MAC. The three main topics were 1) the risk for intraoperative or postoperative respiratory adverse events, 2) the risk for intraoperative and postoperative cardiovascular adverse events, and 3) procedural risks and quality metrics.
For each of the three topics, the panel provided a review of the available evidence and a recommendation for best practices to optimize ERCP outcomes. For most cases, the panel agreed that MAC was the preferred approach.
“This remains a controversial topic, but the weight of evidence is really pushing towards favoring MAC anesthesia for most patients,” said study author Tyler Berzin, MD, an associate professor of medicine at Harvard Medical School, in Boston. “Not only are patients’ outcomes equivalent or better for MAC anesthesia in most scenarios, but the MAC approach generally is more efficient and less burdensome on hospital staff and resources.”
Concerning respiratory events, the guidelines acknowledge that while the risks for intraprocedural hypoxemia, hypercapnia and apnea are greater with MAC than with general anesthesia, these events may not lead to postoperative complications if effectively treated by the anesthetist.
“Anesthesiologists are still somewhat stuck looking at oxygen desaturation as a relevant outcome. In pulmonary and critical care and ARDS [acute respiratory distress syndrome] research, it was shown a long time ago that this is not really an outcome that matters,” Eikermann said. “Intraoperative desaturation can be easily treated by the anesthesiologist—that’s what they do for a living.”
The expert panel also concluded that the risks for cardiovascular adverse events such as hypotension and reduced cardiac output are greater with general anesthesia than with MAC, which favors MAC for most patients.
Eikermann noted that the panel focused on what they considered more relevant quality and efficiency outcomes, including ICU admission, ability to discharge patients to go home after the procedure and what approaches help the system perform more cases.
“There is a big difference between monitored anesthesia care, which we think should be the first choice in the majority of cases, and general anesthesia and endotracheal intubation, which takes more time, has a longer recovery time and has more strict requirements for postoperative recovery,” he said.
When considering procedural risks and quality metrics, the panel favors MAC for short, low-complexity procedures, but acknowledges that clinical scenarios will favor general anesthesia.
“While in the majority of cases, MAC is the favored strategy, some patients really should be intubated. Ultimately, the guidelines that we wrote provide some criteria for that. At the end of the day, it is a team decision,” Eikermann said, noting that the guidelines encourage communication between anesthesiologists and gastroenterologists.
“Gastroenterologists rely on our expert anesthesia colleagues to select the safest anesthesia approach for any procedure, and ERCP usually involves some multidisciplinary decision making in this regard,” Berzin said. “For the most part, given the benefits of efficiency and quicker patient recovery, I think most gastroenterologists and advanced endoscopists will be happy with the trend towards MAC utilization for ERCP.”
Eikermann believes that the field is split, with very strong opinions on either side for the best approach.
“There are centers who do 100% endotracheal intubation and think that it’s not safe to do MAC. And there are other centers, typically high-volume centers, with the experience that it can be safely done without endotracheal intubation,” he said. “I think many people will be surprised or will reject the guideline based on the local culture. I encourage those people to open up a little bit, think about the relevant end points and look at the recent literature on this. Give it a second thought.”
—By Jenna Bassett, PhD
Berzin and Eikermann reported no relevant financial disclosures.