MAC vs GA for ERCP New Guidelines

[pirate_doc]

Anyone see the recent clinical guidelines published in the British Journal of Anesthesia for ERCPs? They state rather pointedly that MAC is the favored anesthetic and should be done for the majority of ERCPs. Complex procedures or specific patient factors may favor GA.

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

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...

pubmed.ncbi.nlm.nih.gov

I'm kind of surprised by this - I can't think of any other surgery that has published "clinical guidelines" stating to do one anesthetic over the other. Also bugs me that they're calling it MAC when it's really GA without an airway. Some of the discussion in it is about utilization of hospital resources and time and that MAC is better for those - I can't help but think this is being heavily pushed by the GI docs because MAC is certainly not less work for an ERCP for the anesthesiologist. They dismiss oxygen desaturations and apnea, events more common in the MAC group, as inconsequential because the anesthesiologist "can manage them."

Admittedly I'm biased because I do ERCPs under GA, and the one time I did MAC the patient aspirated. That was supposed to be a "quick, easy case" per the GI. /narrator It was not.

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[Airway]

https://www.bjanaesthesia.org/article/S0007-0912(23)00135-6/fulltext

 

[Lecithin5]

Lol no thanks. GA 99.9 percent of the time.

 

[UscGhost]

Do Mac for 99% of cases with no issues. Another hospital I go to does under GA.

I don't particularly care. If the GI is skilled and fast, not much issue

 

[Simba1711]

This paper makes no sense. Do what you feel as safe. It’s your license. Doesn’t matter what this paper or gi docs push for. I tube my ercps

 

[TheLoneWolf]

Worked at previous with no machine or vent in the ercp suite so only option was mac. Usually I have them prone, prop bolus, then nasal airway l. Cases were either real quick or long and annoying. No alaris or syringe pumps so physical bonuses. Not ideal setup.

Residency, the GI doc that did ercps was so slick it was literally a 10-15 minute procedure so it was macs with machine in room.

Place I work now it's all GETA and expected by the surgeons.

 

[linkin06]

Half the time, there's a trail of bile as they pull the scope out. I think that shows ET tube should be standard.

 

[aneftp]

Depends on gi doc. My old practice. 2-3 of the gi docs can do ercp in 10-15 minutes and if patients relatively not appearing half dead and not bmi 35 and up (we all know those type of gi inpatients). I could get away with Mac.

But if dude is 250/5 foot 5. Or 200 pound 5 foot 2 lady copd etc. forget. It. General especially with slower gi doc.

 

[pgg]

Did not read the article

LOf'ingL

Nope

 

[Simba1711]

I’m surprised this krap got published. I thought Bja was a somewhat reputable journal. I skimmed through it but this expert panel is biased. Some key things are they argue that
“Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. “ this seems pretty important. Also they argue that osa may not be an independent risk factor for respiratory complications during mac but it might make intubation more difficult favoring mac. The fact that they dismiss apnic events and desaturations because we can manage them is stupid. They are in prone position what we can do is limited.

 

[CD125]

Do GA 99.9% of the time. Could I get away with MAC? Probably. Do I want to? No.

 

[nimbus]

Their international expert panel consisted of 12 people.


In that group,

25% agreed or strongly agreed that patients undergoing deep sedation/MAC need less preop testing than those undergoing GA. 59% of these so called experts agreed (42%) or strongly agreed (17%) that “experienced anesthesiologists usually prefer MAC compared with GA”. 0% disagreed or strongly disagreed with that statement. I know hundreds of experienced anesthesiologists. I don’t know anybody who prefers MAC for ERCP. WTAF. There has to be a hidden agenda behind this paper.

 

[GassYous]

If the patient is normal sized and the procedure is quick like a stent pull ok I'll push the prop
If not then they get the tube

 

[coffeebythelake]

Their international expert panel consisted of 12 people.


In that group,

25% agreed or strongly agreed that patients undergoing deep sedation/MAC need less preop testing than those undergoing GA. 59% of these so called experts agreed (42%) or strongly agreed (17%) that “experienced anesthesiologists usually prefer MAC compared with GA”. 0% disagreed or strongly disagreed with that statement. I know hundreds of experienced anesthesiologists. I don’t know anybody who prefers MAC for ERCP. WTAF. There has to be a hidden agenda behind this paper.

View attachment 374513View attachment 374514

I think some good data would involve actual polling anesthesiologists on their usual practice for ERCPs. There are many factors involved. I agree this BJA paper is crap. I don't care about the expert opinion of 12 nobodies. I am an expert. I can make my own decisions.

 

[nimbus]

I think some good data would involve actual polling anesthesiologists on their usual practice for ERCPs. There are many factors involved. I agree this BJA paper is crap. I don't care about the expert opinion of 12 nobodies. I am an expert. I can make my own decisions.

Like our opinions, their opinions are worthy of a post or thread on SDN. Their opinions are NOT worthy of being published as “Consensus Guidelines” in BJA. What is going on over there?

 

[Volatile]

Nope, ETT every time. many publications are complete BS and simply people trying to advance themselves in the world of academia. This is another to ignore.

 

[Maverikk]

My expert opinion and consensus guideline is that these should all be done supine.
There is literally no advantage to doing it prone other than that is how (almost) every GI doc trained, I've heard at virginia mason they train them to do it supine, worked with a slick GI doc from there 10-15 min ERCP.

 

[Ashers]

If the patient is normal sized and the procedure is quick like a stent pull ok I'll push the prop
If not then they get the tube

Same.

I do GETA for ERCPs aside from stent pulls. I worked with a GI doc several years ago who did ERCPs in left lateral and quickly, those still were GETA.

 

[Beeftenderloin]

If the patient is normal sized and the procedure is quick like a stent pull ok I'll push the prop
If not then they get the tube

This is my 1 exception as well. Reasonable size patient for ONLY a stent pull a few weeks after they cooled off, I’m okay with MAC. Everything else gets a tube.

 

[rick roller pump]

Our main guy that does these does them supine. He is also slick and very reasonable. A rare combination.
We still do GETA, but I don't think MAC would be totally unreasonable if the patient is supine.

 

[Urzuz]

Worked at previous with no machine or vent in the ercp suite so only option was mac.

Yikes. I would never ever agree to do a MAC case, especially one like an ERCP, without an anesthesia machine next to me (and I trained doing pretty much all of our ERCPs under MAC, and in practice I have done probably 80-90% under MAC). This sounds like an awful setup.

The only cases that we regularly do without an anesthesia machine next to use are TEE/cardioversions.

 

[secretasianman]

This is asinine. The one time I did a MAC the patient did fine, went home then was readmitted for aspiration pna.

 

[GassYous]

This is asinine. The one time I did a MAC the patient did fine, went home then was readmitted for aspiration pna.

Yeah but a bunch of nobodies said it was okay

 

[TheLoneWolf]

Yikes. I would never ever agree to do a MAC case, especially one like an ERCP, without an anesthesia machine next to me (and I trained doing pretty much all of our ERCPs under MAC, and in practice I have done probably 80-90% under MAC). This sounds like an awful setup.

The only cases that we regularly do without an anesthesia machine next to use are TEE/cardioversions.

Answer we always got was "there is no money in the budget for that". Things did not change even when I was called to bad codes there to help an anesthetist out.

 

[pgg]

Their international expert panel consisted of 12 people.


In that group,

25% agreed or strongly agreed that patients undergoing deep sedation/MAC need less preop testing than those undergoing GA. 59% of these so called experts agreed (42%) or strongly agreed (17%) that “experienced anesthesiologists usually prefer MAC compared with GA”. 0% disagreed or strongly disagreed with that statement. I know hundreds of experienced anesthesiologists. I don’t know anybody who prefers MAC for ERCP. WTAF. There has to be a hidden agenda behind this paper.

View attachment 374513View attachment 374514

That's disturbing.

 

[The Duck Knows]

I’m surprised this krap got published. I thought Bja was a somewhat reputable journal. I skimmed through it but this expert panel is biased. Some key things are they argue that
“Patient age and ASA physical status were not considered to be factors for choosing between monitored anaesthesia care and general anaesthesia. “ this seems pretty important. Also they argue that osa may not be an independent risk factor for respiratory complications during mac but it might make intubation more difficult favoring mac. The fact that they dismiss apnic events and desaturations because we can manage them is stupid. They are in prone position what we can do is limited.

That’s a new one. Anyone taking oral boards in September who wants to try the argument “They are likely to obstruct so I would rather not have a secure airway”? I’m sure that would fly.

 

[DazedWanderer]

Their international expert panel consisted of 12 people.


In that group,

25% agreed or strongly agreed that patients undergoing deep sedation/MAC need less preop testing than those undergoing GA. 59% of these so called experts agreed (42%) or strongly agreed (17%) that “experienced anesthesiologists usually prefer MAC compared with GA”. 0% disagreed or strongly disagreed with that statement. I know hundreds of experienced anesthesiologists. I don’t know anybody who prefers MAC for ERCP. WTAF. There has to be a hidden agenda behind this paper.

View attachment 374513View attachment 374514

Seems regionally biased. Anesthesia culture/norms in Europe are different, I guess commonly doing ERCP under MAC is one of those cultural differences. I wouldnt feel comfortable doing it for most patients, dont care what they say in this study. They also routinely do LMAs in paralyzed and/or proned patients in Europe. Again, I don't see this done commonly at all in North America, most would laugh at you and put in a tube. They seem more cavalier about a lot of things, perhaps due to a less litigious culture.

 

[Xcellerator]

Study looks like garbage. Our ERCPs are prone, so GA 100% of time. My last one was a septic ~80BMI so argued for supine but GI do wanted to do prone so just made it work. Can't imagine doing ERCPs w/o an anesthesia machine !

 

[dannyboy1]

I have yet to regret an ETT for ANY case. Much less an ERCP…

 

[TheLoneWolf]

I have yet to regret an ETT for ANY case. Much less an ERCP…

This.

There have been times I placed an lma, where I wished I tubed and paralyzed. Would have saved so much heartache. Now I understand why in my residency program, changing from prop roc tube for the majority of cases was met with much chagrin.

 

[AKMD_1984]

GETA.

Its not a debate.

 

[MirrorTodd]

Lol Guess what I just did that I REALLY wished I hadn't done?

 

[nimbus]

It's definitely regionally biased. Anesthesia culture/norms in Europe are different, I guess commonly doing ERCP under MAC is one of those cultural differences. I wouldnt feel comfortable doing it for most patients, dont care what they say in this study. They also routinely do LMAs in paralyzed and/or proned patients in Europe. Again, I don't see this done commonly at all in North America, most would laugh at you and put in a tube. They seem more cavalier about a lot of things, perhaps due to a less litigious culture.

That would have been a good point but 10/12 panelists are from the USA. The remaining 2 are from Thailand and Australia. Maybe it’s an academic vs PP thing.

Can anybody who worked or trained at these US institutions (Beth Israel Deaconess, Einstein/Montefiore, Univ of Minnesota, USC, UCSF) weigh in? Are most ERCPs done with deep sedation at these places? If so, are they done prone or supine? Maybe it is an academic vs non-academic thing.

 

[coffeebythelake]

That would have been a good point but 10/12 panelists are from the USA. The remaining 2 are from Thailand and Australia. Maybe it’s an academic vs PP thing.

Can anybody who worked or trained at these US institutions (Beth Israel Deaconess, Einstein, Montefiore, Univ of Minnesota, USC, UCSF) weigh in? Are most ERCPs done with deep sedation at these places? If so, are they done prone or supine? Maybe it is an academic vs non-academic thing.



View attachment 374531

Their small "expert panel" includes 3 anesthesiologists from the same institution.
The guy from UCSF runs the acute pain service... I wonder how often he is in the GI suite doing cases? Almost certainly less than I do.
The writing is nonsense... "There are distinct pathophysiological differences between monitored anaesthesia care and general anaesthesia that need to be considered"... so they are calling different states of anesthesia pathophysiologic?
Should I care what the gastroenterologist thinks about what constitutes safe anesthetic care? I doubt they care about much other than the turnover time... what they call "maximising healthcare resource utilisation".
These guys are fukking clowns

 

[pgg]

That would have been a good point but 10/12 panelists are from the USA. The remaining 2 are from Thailand and Australia. Maybe it’s an academic vs PP thing.

Can anybody who worked or trained at these US institutions (Beth Israel Deaconess, Einstein, Montefiore, Univ of Minnesota, USC, UCSF) weigh in? Are most ERCPs done with deep sedation at these places? If so, are they done prone or supine? Maybe it is an academic vs non-academic thing.

Someone should look up their email addresses and send a group email inviting them to visit this thread and defend this garbage, so we can heckle them more directly.

I mean, they were foolish enough to put their names on this, maybe they'll actually pop in.

 

[coffeebythelake]

Someone should look up their email addresses and send a group email inviting them to visit this thread and defend this garbage, so we can heckle them more directly.

I mean, they were foolish enough to put their names on this, maybe they'll actually pop in.

Their "CYA" statement is how the anesthesiologist should use their own clinical judgement in determining whether thr pt gets GA vs MAC. So if something happens it's not their fault for saying ERCP patients should get MAC. It's your fault for not having better judgement!

 

[GravelRider]

I like intubating for ERCPs. Patients going for ERCP are often “sick” and there are just too many good reasons to intubate and not enough good reasons not too. Occasionally I sedate if the circumstance calls for it. Speedy turnovers and “skipping Phase I recovery” are not usually good reasons to affect my intubate or not intubate decisions.

 

[vector2]

In 5 years of supervisory practice, I've been called to the ERCP room exactly 0 times mid case for airway issues. In the endo suites, I lost count years ago of the number of times I've been called for that issue. Guess which kind of anesthesia we do for ERCP?

I don't need an "expert" consensus paper to tell me what I already know.

 

[Simba1711]

Imagine having to save a colleague because they lose an airway during a prone ercp sedation. You ask them why they didn’t just intubate the patient and they quote this article and tell you “ they had osa and they were likely to obstruct but I can manage apnea and respiratory complications. Also their osa might have made them difficult to intubate so I opted for sedation. Oh and I also wanted to minimize pacu time for the patient. You would tell them they suck as an anesthesiologist.

 

[Maz777]

Do Mac for 99% of cases with no issues. Another hospital I go to does under GA.

I don't particularly care. If the GI is skilled and fast, not much issue

You are doing GA for all of them. The difference is whether or not they have a controlled airway or not.

 

[GravelRider]

The other (dumb) thing about these dumb studies is they measure turnover time and recovery time as endpoints to be considered. Nowhere is there any discussion of procedural time. This is a problem even in our own hospital OR when discussing OR efficiency. I’m measuring my pee break time and how long it takes me to shove a peanut butter sandwich in, but no one is telling the surgeons they have to speed up. More importantly to this specific circumstance, it would not surprise me if procedural times were faster with patients under general anesthesia.

 

[AKMD_1984]

I genuinely don't understand why this is even a debate.

If people are concerned about "turnover time", they are forgetting that it is perfectly possible to keep the patient spontaneously breathing with an ETT. Deepen as needed with propofol boluses/inhaled agents/ or opioids. Far far far SAFER.

There is nothing worse than an off site/ GI suite sick patient undergoing complicated ERCP who is now requiring deepening of anesthesia in prone position with an unprotected airway. And as someone mentioned already - these are patients with co-morbid conditions.

Extubation is straight forward while the patient is already spontaneously breathing on an ETT.

Turnover time is a non issue. What exactly are they accomplishing by saving a few minutes on turnover?

GI wants to save time? Sure. start your cases early. We can save time that way.

When I do a risk:benefit analysis on anesthesia for ERCP; to me, personally its not even close. I do not see a good reason to ever do this with unprotected airway.

 

[secants]

Just the time it takes to position and the position itself is so annoying and uncomfortable - GA. Some of the older guys who used to do MAC until a few near codes happened.

 

[coffeebythelake]

Just the time it takes to position and the position itself is so annoying and uncomfortable - GA. Some of the older guys who used to do MAC until a few near codes happened.

Supine GA

 

[pgg]

I genuinely don't understand why this is even a debate.

If people are concerned about "turnover time", they are forgetting that it is perfectly possible to keep the patient spontaneously breathing with an ETT. Deepen as needed with propofol boluses/inhaled agents/ or opioids. Far far far SAFER.

There is nothing worse than an off site/ GI suite sick patient undergoing complicated ERCP who is now requiring deepening of anesthesia in prone position with an unprotected airway. And as someone mentioned already - these are patients with co-morbid conditions.

Extubation is straight forward while the patient is already spontaneously breathing on an ETT.

Turnover time is a non issue. What exactly are they accomplishing by saving a few minutes on turnover?

GI wants to save time? Sure. start your cases early. We can save time that way.

When I do a risk:benefit analysis on anesthesia for ERCP; to me, personally its not even close. I do not see a good reason to ever do this with unprotected airway.

Agreed

I don't really like our endo setup for ERCPs, but it's OK. There usually isn't an anesthesia machine set up in that room, but if you really want it for a respiratory cripple or stupendously obese patient, you can roll it in and set it up. There are one or two of the nurses who'll huff and roll their eyes, but their opinions don't really matter.

Mostly it's just prop, succ, tube, Mapleson circuit, propofol infusion. If you don't give any opioids they'll be spontaneously breathing in a couple minutes. Extubate when done. It really isn't much slower than "MAC" (aka general anesthesia with an unsecured airway).

In my younger and unwiser days I'd do these prone unsecured general with propofol and ketamine, and it worked well with the better GI docs. It took a few long, painful cases struggling with the airway as Dr. GI shoved the scope back and forth for me to just start putting tubes in all of them. Life's hard enough already, it's just dumb to make it harder for the sake of maybe saving those guys a couple minutes.

 

[AKMD_1984]

Yeah

Also, these days if a surgeon is in disagreement or totally unreasonable, I simply decline to do the case citing Professional differences and conflict of interest (both of these are true). It’s really not upto them to dictate anesthesia choice. Their job is to focus on the operation. Need to stay in their lane.

I tell them in a very polite manner to please find another “provider”. This is the only time I use this word actually. Lol

It’s a trust thing.

This is because they will turn around and blame you in case something happens.

No way will they say ‘we’ll it’s my fault because I put the pressure on the anesthesiologist and almost compelled them to do MAC/ sedation because I wanted a fast turnover’

Not in a million years.

 

[AKMD_1984]

Agreed

I don't really like our endo setup for ERCPs, but it's OK. There usually isn't an anesthesia machine set up in that room, but if you really want it for a respiratory cripple or stupendously obese patient, you can roll it in and set it up. There are one or two of the nurses who'll huff and roll their eyes, but their opinions don't really matter.

Mostly it's just prop, succ, tube, Mapleson circuit, propofol infusion. If you don't give any opioids they'll be spontaneously breathing in a couple minutes. Extubate when done. It really isn't much slower than "MAC" (aka general anesthesia with an unsecured airway).

In my younger and unwiser days I'd do these prone unsecured general with propofol and ketamine, and it worked well with the better GI docs. It took a few long, painful cases struggling with the airway as Dr. GI shoved the scope back and forth for me to just start putting tubes in all of them. Life's hard enough already, it's just dumb to make it harder for the sake of maybe saving those guys a couple minutes.

This is exactly how I do my ERCPs plus minus sux

 

[epidural man]

Weird stuff happens with ERCPs. Better to have a tube.

 

[norski]

I like prop+remi+tube for these. Tci, though. Easy to titrate the remi to spontaneous breathing, then use PSV.

 

[PpfSuxTube]

Unfortunately I probably do more of these than anyone here.. 18 in the last 3 days... avg 15 per month

Mac for everyone. Goes fine once you figure it out.
Spray lido, prop remi bolus, then infusion prop. No bother

We get extra pay to do them, so that's why. Everyone hates them tho including myself