Where I work the local standard has been to do these cases sedation in the endo dept. In that area there are no anesthesia machines and there is the ability to attach the n/c etco2 which i use. The only other equip. available in this area is a BVM, intubation equipment and a pyxis. Essentially, intubating a patient in this setting would be highly risky and well outside the standard as there is no way to monitor ETCO2 or ventilation (BVM only). This means the case must then be scheduled in the OR if for some reason the pt really does require intubation (morbid obesity, Severe/uncontrolled GERD etc). As you can imagine, this case ends up at the end of the schedule and is a major issue for both the GI docs and the patients. There is certainly a push for sedation.

Having said that, my decisions are 100% respected and never questioned in this manner.

What does everyone else do? If you do sedation how do you decide who cant get it, what is your criteria. Keep in mind the average age of admission at my facility is 76.

Sedation with Propofol for Routine ERCP in High-Risk Octogenarians: A Randomized, Controlled Study

Andrea Riphaus MD1, Nikos Stergiou MD1 and Till Wehrmann MD, PhD1

1Department of Internal Medicine I (Gastroenterology and Interventional Endoscopy), Klinikum Hannover-Siloah, Teaching Hospital of the Hannover Medical School, Hannover, Germany

Correspondence: Andrea Riphaus, MD, Department of Internal Medicine I, Klinikum Hannover-Siloah, Roesebeckstrae 15, 30449 Hannover, Germany

Received 14 October 2004; Revised 0000; Accepted 4 May 2005.

OBJECTIVES: Adequate patient sedation is mandatory for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In this respect it is known that the short-acting anesthetic propofol offers certain potential advantages for sedation during ERCP, but there are no controlled studies concerning the feasibility and safety of propofol sedation in elderly, high-risk patients.

METHODS: One hundred and fifty consecutive patients aged 80 yr with high comorbidity (ASA score III: 91 %), randomly received midazolam plus meperidine (n = 75) or propofol alone (n = 75) for sedation during ERCP. Vital signs were continuously monitored and procedure-related parameters, recovery time, and quality as well as patients' cooperation and tolerance of the procedure were assessed.

RESULTS: Clinically relevant changes in vital signs were observed at comparable frequencies with a temporary oxygen desaturation (<90%) occurring in eight patients in the propofol-group and seven patients receiving midazolam/meperidine (n.s.). Hypotension was documented in two patients in the propofol group and one patient receiving midazolam/meperidine. Propofol provided a significantly better patient cooperation than midazolam/meperidine (p < 0.01), but the procedure tolerability was rated nearly the same by both groups. Mean recovery time was significantly shorter in the propofol group (22 7 min vs 31 8 min for midazolam/meperidine (p < 0.01)) while the recovery score was significantly higher under propofol (8.3 1.2 vs 6.1 1.1(p < 0.01)). During recovery a significant lower number of desaturation events (<90%) were observed in the propofol group (12%) than in the midazolam/meperidine group (26%, p < 0.01).

CONCLUSION: Under careful monitoring the use of propofol for sedation during ERCP is superior to midazolam/meperidine even in high-risk octogenarians.