What is the best sedative technique for patients undergoing endoscopic cholangiopancreatography (ERCP)?

Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable procedure that uses an endoscope and X rays to visualize problems with patients’ bile and pancreatic ducts. An endoscope is a medical device that can be used to examine the inside of a patient’s body and consists of a long, thin, flexible, fibreoptic tube with a light source and a video camera. A large number (in excess of several 100,000) of these procedures are performed annually on a worldwide basis. 

Patients have to be given medicines to make them adequately drowsy (sedated) or unconscious (anaesthetized) to tolerate the ERCP procedure. These medicines may be administered by anaesthetic or non-anaesthetic healthcare personnel, and there is currently some debate as to who should administer these drugs to patients for ERCP procedures.

Two common ways of  providing sedation for ERCP are to administer combined intravenous midazolam (sedative agent) and meperidine (morphine-like opioid) or the drug propofol (a sedative-anaesthetic agent) to patients. This review evaluated and compared the safety and effectiveness of the sedative techniques in patients undergoing ERCP procedures.

From a worldwide literature search we identified only four randomized controlled papers appropriate for review, involving a total of 510 patients. These papers compared the use of midazolam and meperidine with propofol sedation techniques for patients undergoing ERCP procedures. All the sedation was administered by non-anaesthetic healthcare personnel.

There was no significant difference between the sedation techniques as regards safety. There were no deaths in the trials and the number of major complications, such as lack of oxygen (hypoxaemia) and low blood pressure (hypotension), was comparable in both techniques. There was no difference in patient satisfaction in either group. However, the recovery of patients who received propofol was significantly better than for those who had received midazolam and meperidine for the procedure.

In conclusion, patients undergoing ERCP procedures under propofol sedation recover faster and better than those patients receiving midazolam and meperidine sedation. This would make propofol the preferred choice for these procedures as there was no difference in the safety of either technique. Further research should focus on the safety of the sedative techniques and involve anaesthesia personnel in the administration of the sedation.

Authors' conclusions: 

Results from individual studies suggested that patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine sedation. As there was no difference between the two sedation techniques as regards safety, propofol sedation is probably preferred for patients undergoing ERCP procedures. However, in all of the studies that were identified only non-anaesthesia personnel were involved in administering the sedation. It would be helpful if further research was conducted where anaesthesia personnel were involved in the administration of sedation for ERCP procedures. This would clarify the extent to which anaesthesia personnel should be involved in the administration of propofol sedation.

Read the full abstract...
Background: 

Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable therapeutic procedure that cannot be performed without adequate sedation or general anaesthesia. A considerable number of ERCPs are performed annually in the UK (at least 48,000) and many more worldwide.

Objectives: 

The primary objective of our review was to evaluate and compare the efficacy and safety of sedative or anaesthetic techniques used to facilitate the procedure of ERCP in adult (age > 18 years) patients.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 8); MEDLINE (1950 to September 2011); EMBASE (1950 to September 2011); CINAHL, Web of Science and LILACS (all to September 2011). We searched for additional studies drawn from reference lists of retrieved trial materials and review articles and conference proceedings.

Selection criteria: 

We considered all randomized or quasi-randomized controlled studies where the main procedures performed were ERCPs. The three interventions we searched for were (1) conscious sedation (using midazolam plus opioid) versus deep sedation (using propofol); (2) conscious sedation versus general anaesthesia; and (3) deep sedation versus general anaesthesia. We considered all studies regardless of which healthcare professional administered the sedation.

Data collection and analysis: 

We reviewed 124 papers and identified four randomized trials (with a total of 510 participants) that compared the use of conscious sedation using midazolam and meperidine with deep sedation using propofol in patients undergoing ERCP procedures. All sedation was administered by non-anaesthetic personnel. Due to the clinical heterogeneity of the studies we decided to review the papers from a narrative perspective as opposed to a full meta-analysis. Our primary outcome measures included mortality, major complications and inability to complete the procedure due to sedation-related problems. Secondary outcomes encompassed sedation efficacy and recovery.

Main results: 

No immediate mortality was reported. There was no significant difference in serious cardio-respiratory complications suffered by patients in either sedation group. Failure to complete the procedure due to sedation-related problems was reported in one study. Three studies found faster and better recovery in patients receiving propofol for their ERCP procedures. Study protocols regarding use of supplemental oxygen, intravenous fluid administration and capnography monitoring varied considerably. The studies showed either moderate or high risk of bias.

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