MAC vs GA for ERCP New Guidelines

[coffeebythelake]

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

What do u mean u get extra pay to do thrm?

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[GassYous]

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

Remi?
Why use an expensive, unnecessary drug? I almost never give opioids to endo patients ever. Even when I tube I just use esmolol. No problems.

 

[pgg]

Mac for everyone. Goes fine once you figure it out.

Are you one of the authors?

More seriously - I sort of object to this sentiment. It implies that difference between safe "MAC" and GETA for an ERCP is merely experience and skill, and that's just not the case. We're 50 replies into this thread, with input from a lot of very experienced people, and the prevailing opinion by a pretty large margin favors GETA.

Also, we really should quit using the term "MAC" for these cases. It isn't "monitored anesthesia care" aka sedation. It's general anesthesia.

 

[PpfSuxTube]

A bit ironic that You object to the bja article but accept sdn sample selection...

you read some of that wallstreet guys posts?

 

[GassYous]

A bit ironic that You object to the bja article but accept sdn sample selection...

you read some of that wallstreet guys posts?

I mean blade alone has a n of 10,000 so...

 

[nimbus]

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

Do you continuously babysit the airway during these procedures or just chillax? Prone or supine?

 

[nimbus]

A bit ironic that You object to the bja article but accept sdn sample selection...

you read some of that wallstreet guys posts?

The BJA article is based on the opinion of 12 people.

 

[PpfSuxTube]

The BJA article is based on the opinion of 12 people.

50 posters on Sdn is probably only 12 people too 😀

 

[PpfSuxTube]

Do you continuously babysit the airway during these procedures or just chillax? Prone or supine?

All prone. Only really need to babysit the airway while they're "intubating ".

I mix a few 20 ml syringes of ppf with about a ml of remi, maybe 2, who knows.
So I spray em real good myself if I have the time, then shoot 4 to 7 mls of that remi/ppf mix
Then start one of those syringes running ppf at about 100 mcg/kg/min

That's it...

I don't work in US so we're payed different. We get paid well to do these lists and in between ercps do quick gastros. It's a very well paid day. Plenty ppl don't wanna do it still tho. I'm OK with it

 

[TheLoneWolf]

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.

Great point

Can were now start calling MAC cases GANAs (general anesthesia no airway), that what the surgeons really want and expect. If anything, more accurately describes what we are preforming.

 

[vector2]

All prone. Only really need to babysit the airway while they're "intubating ".

I mix a few 20 ml syringes of ppf with about a ml of remi, maybe 2, who knows.
So I spray em real good myself if I have the time, then shoot 4 to 7 mls of that remi/ppf mix
Then start one of those syringes running ppf at about 100 mcg/kg/min

That's it...

I don't work in US so we're payed different. We get paid well to do these lists and in between ercps do quick gastros. It's a very well paid day. Plenty ppl don't wanna do it still tho. I'm OK with it

~50% of the population of my state has a BMI over 30. You must have a different pt population if you're prone+ prop/remi but yet don't have to do much airway babysitting.

 

[nimbus]

All prone. Only really need to babysit the airway while they're "intubating ".

I mix a few 20 ml syringes of ppf with about a ml of remi, maybe 2, who knows.
So I spray em real good myself if I have the time, then shoot 4 to 7 mls of that remi/ppf mix
Then start one of those syringes running ppf at about 100 mcg/kg/min

That's it...

I don't work in US so we're payed different. We get paid well to do these lists and in between ercps do quick gastros. It's a very well paid day. Plenty ppl don't wanna do it still tho. I'm OK with it

Strange that people don’t want to do well paid cases. Do you think more people would want to do them if they were all GA/ETT?

 

[PpfSuxTube]

~50% of the population of my state has a BMI over 30. You must have a different pt population if you're prone+ prop/remi but yet don't have to do much airway babysitting.

Maybe, no idea. Don't care. It works fine. I just empty the syringes into people and go home. I'm no health economist. I don't really care what bmi 50% of anything has. I only deal with my own case in front of me and quickly forget about it. This way works grand so until it stops working I'll keep doing it

 

[vector2]

Maybe, no idea. Don't care. It works fine. I just empty the syringes into people and go home. I'm no health economist. I don't really care what bmi 50% of anything has. I only deal with my own case in front of me and quickly forget about it. This way works grand so until it stops working I'll keep doing it

Was there something in my post that necessitated you turning the flippant dbag knob to 11?

All I did was make an observation that I have a bunch of fat pts I have to deal with and IME these people are going to have some airway issues when Mac'ed prone with prop and opioid. If you don't have a lot of fat pts, great. If you do have a bunch of fat pts and yet you're able to pull off your technique with nary an issue, also great. All the latter says is that you are a top 1%er all star 'ologist stud like everyone else on SDN.

 

[pgg]

A bit ironic that You object to the bja article but accept sdn sample selection...

you read some of that wallstreet guys posts?

You've already admitted that, for some reason, you don't know why, despite these cases paying well, none of your colleagues want to do them.

Apparently, your approach and opinion is a minority one there too.

 

[coffeebythelake]

I don't work in US

I do wonder if u have the same patient population that we deal with in the USA

 

[norski]

Remi?
Why use an expensive, unnecessary drug? I almost never give opioids to endo patients ever. Even when I tube I just use esmolol. No problems.

Not expensive when a 2mg glass gets mixed and split into four syringes, and when you're not in the US, as we are actually allowed to split narcotics between patients.

How does esmolol work for you when you're intubating without a relaxant? We don't have esmolol around here, closest thing would be metoprolol IV, but I think that is both longer acting and has a slower onset than esmolol? Could be wrong.

For regular EGDs, I mostly sedate with propofol only, larynx,pharynx and base of tongue numbed with viscuous lidocaine. Never opioids for these.

Edit: The anesthesiologist decides the anesthetic, unless the proceduralist wants to do everything in local, in which case none of you doctors nor I, nurse anesthetist, noctor, PITA, get called.

 

[GassYous]

Not expensive when a 2mg glass gets mixed and split into four syringes, and when you're not in the US, as we are actually allowed to split narcotics between patients.

How does esmolol work for you when you're intubating without a relaxant? We don't have esmolol around here, closest thing would be metoprolol IV, but I think that is both longer acting and has a slower onset than esmolol? Could be wrong.

For regular EGDs, I mostly sedate with propofol only, larynx,pharynx and base of tongue numbed with viscuous lidocaine. Never opioids for these.

Edit: The anesthesiologist decides the anesthetic, unless the proceduralist wants to do everything in local, in which case none of you doctors nor I, nurse anesthetist, noctor, PITA, get called.

prop lido roc esmolol

 

[anbuitachi]

Here it's routine 2 to 3 hour case. Hell no I'm not doing mac

 

[Simba1711]

Here it's routine 2 to 3 hour case. Hell no I'm not doing mac

Ditto

 

[DrN2O]

It's not black and white, you still have to decide what's appropriate based on the individual patient, procedure and proceduralist. Frequent flier with 15 ERCPs by the same GI w/ 30 year experience, sure, I won't reinvent the wheel. 3/4 prone is what I've seen most GIs prefer and it's surprisingly beneficial for the airway during deep sedation. They've been doing it at UCSF for 30 years. The bile runs out and out of the mouth. Unlike SDN, not everyone can be both cardiac trained and ERCP expert, so I would assume the experts on that paper are chosen for valid reasons. Working in ERCP is nobody's cup of tea, sedation or GETA. But that's why I supervise, often 3 rooms including ERCP on different floors. Most CRNAs do this with prop only, maybe K if feeling fancy. There is certainly production pressure behind preferring sedation--having a patient that self positions, spontaneously breathing (not really awake) at the end of the case and go back to GI holding room down the hall do speed things up. Much prefer this (30 min cases) x10 than GETA for someone that does 4x 2h cases.

 

[zizzer]

I prefer not intubating for most of these in a tertiary care setting but understand securing the airway. Having a guideline like this seems unnecessary.

 

[zizzer]

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

You take the time to prepare remifentanil for each one? Seems time and cost inefficient, but I'm sure it works well.

 

[repititionition]

These are generally 20-25 minutes from wheels in to wheels out including the time I take to perform GETA and for team to flip both ways. Like almost everything in our specialty, many of us seem willing to accrue risk even when we are not the rate limiting step in any case.

 

[AKMD_1984]

It's not black and white, you still have to decide what's appropriate based on the individual patient, procedure and proceduralist. Frequent flier with 15 ERCPs by the same GI w/ 30 year experience, sure, I won't reinvent the wheel. 3/4 prone is what I've seen most GIs prefer and it's surprisingly beneficial for the airway during deep sedation. They've been doing it at UCSF for 30 years. The bile runs out and out of the mouth. Unlike SDN, not everyone can be both cardiac trained and ERCP expert, so I would assume the experts on that paper are chosen for valid reasons. Working in ERCP is nobody's cup of tea, sedation or GETA. But that's why I supervise, often 3 rooms including ERCP on different floors. Most CRNAs do this with prop only, maybe K if feeling fancy. There is certainly production pressure behind preferring sedation--having a patient that self positions, spontaneously breathing (not really awake) at the end of the case and go back to GI holding room down the hall do speed things up. Much prefer this (30 min cases) x10 than GETA for someone that does 4x 2h cases.

If you’re having to do keto-fol for your ercps, might as well intubate

You can still keep the patient spontaneously breathing but with a secured airway and avoid then going bonkers in pacu

 

[Beeftenderloin]

If you’re having to do keto-fol for your ercps, might as well intubate

You can still keep the patient spontaneously breathing but with a secured airway and avoid then going bonkers in pacu

Dysphoric reactions from ketamine are way over blown, IMO. I use a fair amount of it in my practice, at least an handful of times per week, often without midazolam. I’ve had 1 dysphoric reaction in PACU in the past 14 months. Certainly not enough to ever deter me from using it if I felt it was the right drug for the job. Not defending its use for this indication specifically, just it’s use in general.

 

[Airway]

Dysphoric reactions from ketamine are way over blown, IMO. I use a fair amount of it in my practice, at least an handful of times per week, often without midazolam. I’ve had 1 dysphoric reaction in PACU in the past 14 months. Certainly not enough to ever deter me from using it if I felt it was the right drug for the job. Not defending its use for this indication specifically, just it’s use in general.

Agree about ketamine. If you don't use ketamine and people becomes dysphoric/agitated in pacu it's just normal emergence delerium. If you use ketamine and it happens it's the gd ketamine that did it. Stupid imo

 

[DesiredMemberName?]

Agree about ketamine. If you don't use ketamine and people becomes dysphoric/agitated in pacu it's just normal emergence delerium. If you use ketamine and it happens it's the gd ketamine that did it. Stupid imo

This is a great point. I’m not a hardcore ketamine enthusiast, but I use it not infrequently.

When the PACU nurses ask me if an agitated patient has received ketamine (with that look in their eye), the answer is no wayyyyy more often than yes.

 

[Simba1711]

I like ketamine. It’s a great drug that gets a lot of unwarranted hate especially from pacu nurses and older anesthesiologists. I would use it more if it wasn’t a pain to waste. It comes in 500mg vials at our place. For ercps they were > 2 hours and prone , much easier and safer to perform geta.

 

[coffeebythelake]

I'm a fan of ketamine as well but not large dkses for prone MAC cases.

 

[dmk5n]

Britain does not have the same medico-legal lottery system that the US has. We have public transit adverts with "Call Ken Nugent... one call does it all" No upside.

 

[nimbus]

Funny CRNA account 😂

 

[Anesthesia_Guy]

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

It's cool brother. Alcohol and desperation are strong motivators. The beer goggled female probably appreciated it.

 

[AKMD_1984]

Dysphoric reactions from ketamine are way over blown, IMO. I use a fair amount of it in my practice, at least an handful of times per week, often without midazolam. I’ve had 1 dysphoric reaction in PACU in the past 14 months. Certainly not enough to ever deter me from using it if I felt it was the right drug for the job. Not defending its use for this indication specifically, just it’s use in general.

I hear you but after I had a patient call me and tell me that ‘this is the worst I have felt’ after surgery, I just shyed away from giving it.

I probably use ketamine maybe once every two years for some compelling reason…just not a part of my routine practice. I’m fine with it.

 

[nimbus]

I hear you but after I had a patient call me and tell me that ‘this is the worst I have felt’ after surgery, I just shyed away from giving it.

I probably use ketamine maybe once every two years for some compelling reason…just not a part of my routine practice. I’m fine with it.

How much ketamine did that patient get?

 

[AKMD_1984]

How much ketamine did that patient get?

It was for an eras gyn case - so an infusion…maybe 100 mg total for a 4-5 hour case? I don’t remember exact amount but it wasn’t that much tbh

 

[AKMD_1984]

All prone. Only really need to babysit the airway while they're "intubating ".

I mix a few 20 ml syringes of ppf with about a ml of remi, maybe 2, who knows.
So I spray em real good myself if I have the time, then shoot 4 to 7 mls of that remi/ppf mix
Then start one of those syringes running ppf at about 100 mcg/kg/min

That's it...

I don't work in US so we're payed different. We get paid well to do these lists and in between ercps do quick gastros. It's a very well paid day. Plenty ppl don't wanna do it still tho. I'm OK with it

I’m curious, where do you practice then?

 

[MirrorTodd]

Are y'all not seeing ketamine shortages?

 

[Ashers]

Are y'all not seeing ketamine shortages?

It's been disappearing from the Pyxises (Pyxi?), so I was starting to wonder. I've gotten no official word. I've heard about clinda shortages.

I use ketamine frequently as a part of multimodal analgesia, and I wish they would get the 50mg syringes, so I wouldn't have to waste so much of the 500mg vials.

 

[MirrorTodd]

It's been disappearing from the Pyxises (Pyxi?), so I was starting to wonder. I've gotten no official word. I've heard about clinda shortages.

I use ketamine frequently as a part of multimodal analgesia, and I wish they would get the 50mg syringes, so I wouldn't have to waste so much of the 500mg vials.

We had the 50mg syringes as well and they have reduced that to block bay only (large military hospital). Now I think we have to go to pharmacy for a vial.

 

[fakin' the funk]

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.

Given that our ERCPs are done nearly prone on septic patients and take 90-120 minutes: nah.

Last gig, almost all done with a slight tilt and 20-30 minutes, sure MAC will prob be fine.

 

[circleK]

We do >95% of our ERCPs under sedation with just propofol. Everyone in our 21 person group does it this way. Our GI guys take 30-90mins typically. We do about two per day.

Which technique is done seems to vary based on the culture at the specific hospital more than any other procedure.

This paper is unnecessary.