ERCP (Off-Floor / Endoscopy)
Patient phenotype
Choledocholithiasis, pancreatitis, biliary obstruction, post-cholecystectomy stricture. Often elderly, malnourished, septic. Cholangitis cases very sick.
Procedure
Prone or semi-prone (supine for some). Side-viewing duodenoscope advanced through mouth → duodenum → ampulla. Cannulation of CBD, sphincterotomy, stone extraction, stent. 30-90 min.
Anesthetic plan
GETA OR deep sedation (propofol-based). GETA preferred for: prone position, full stomach, sick patient, long case. Deep sedation: stable patient, supine, short procedure.
Setup
- ·Off-floor anesthesia setup: portable gas, suction, monitors, drugs
- ·ETT or supraglottic airway depending on position + risk
- ·1 PIV adequate; 2 if sick
- ·A-line if shock from cholangitis
- ·Forced air warmer
- ·Reverse Trendelenburg often used to keep contrast in CBD
Biggest concerns by phase
Off-floor environment readiness
Backup help further away. Verify: O₂ supply adequate, suction working, monitors functional, emergency drugs (ephedrine, phenylephrine, atropine, glyco), airway equipment (LMA + ETT + video laryngoscope), defib accessible.
Septic cholangitis = unstable
Charcot's triad (fever + RUQ pain + jaundice) + Reynolds pentad (+ hypotension + AMS) = sepsis. Volume + pressors + early antibiotics before OR. ERCP IS the source control.
Aspiration risk + position
Many ERCP patients have gastric contents (obstruction, recent eating, obtundation). RSI if any concern. Prone + sedation high aspiration risk → favor GETA.
Position + airway access
Prone or semi-prone. Endoscope through mouth competes with anesthesia airway. Bite block + ETT secured laterally. Prone-positioned patients harder to access if airway issue.
Post-ERCP pancreatitis prophylaxis
Risk 5-10%. Rectal indomethacin 100 mg given by some endoscopists pre-procedure (anesthesia can administer or witness). Aggressive hydration also.
Post-procedure complications
Pancreatitis (most common), perforation (rare, surgical emergency), bleeding (after sphincterotomy), cholangitis worsening. Watch vitals + abdominal exam.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
78-yo F with choledocholithiasis + cholangitis, BP 95/55, HR 110, T 38.5, lactate 3.2, on cefepime + flagyl. ERCP requested. Off-floor in endoscopy. Plan?
What an examiner probes for
- ▹Recognizes septic shock physiology
- ▹Volume + pressor before procedure
- ▹GETA in prone for airway control
- ▹Off-floor preparedness
- ▹Postop disposition (ICU likely)
Sources
- Miller's Ch 80 (Off-Floor Anesthesia)
- ASGE ERCP Guidelines
Anatomy reference
Sourced reference images. 4 matches for "pancreas biliary duodenum".
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