Incidence of sedation-related adverse events during ERCP with anesthesia assistance: a multicenter observational study

Published:April 02, 2022DOI:

      Background and Aims

      Anesthesia assistance is commonly used for ERCP. General anesthesia (GA) may provide greater airway protection but may lead to hypotension. We aimed to compare GA versus sedation without planned intubation (SWPI) on the incidence of hypoxemia and hypotension. We also explored risk factors for conversion from SWPI to GA.


      This observational study used data from the Multicenter Perioperative Outcomes Group. Adults with American Society of Anesthesiologists physical status class I to IV undergoing ERCP between 2006 and 2019 were included. We compared GA and SWPI on incidence of hypoxemia (oxygen saturation <90% for ≥3 minutes) and hypotension (mean arterial pressure <65 mm Hg for ≥5 minutes) using joint hypothesis testing. The association between anesthetic approach and outcomes was assessed using logistic regression. The noninferiority delta for hypoxemia and hypotension was an odds ratio of 1.20. One approach was deemed better if it was noninferior on both outcomes and superior on at least 1 outcome. To explore risk factors associated with conversion from SWPI to GA, we constructed a logistic regression model.


      Among 61,735 cases from 42 institutions, 38,830 (63%) received GA and 22,905 (37%) received SWPI. The GA group had 1.27 times (97.5% confidence interval, 1.19-1.35) higher odds of hypotension but .71 times (97.5% confidence interval, .63-.80) lower odds of hypoxemia. Neither group was noninferior to the other on both outcomes. Conversion from SWPI to GA occurred in 6.5% of cases and was associated with baseline comorbidities and higher institutional procedure volume.


      GA for ERCP was associated with less hypoxemia, whereas SWPI was associated with less hypotension. Neither approach was better on the combined incidence of hypotension and hypoxemia.

      Graphical abstract


      ASA (American Society of Anesthesiologists), ASD (absolute standardized difference), AUC (area under the curve), CI (confidence interval), GA (general anesthesia), IPTW (inverse probability of treatment weighting), IQR (interquartile range), LASSO (least absolute shrinkage and selection operator), MAP (mean arterial pressure), MPOG (Multicenter Perioperative Outcomes Group), SpO2 (oxygen saturation), SRAE (sedation-related adverse event), SWPI (sedation without planned intubation)
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        • Enestvedt B.K.
        • Eisen G.M.
        • Holub J.
        • et al.
        Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?.
        Gastrointest Endosc. 2013; 77: 464-471
        • Chawla S.
        • Willingham F.F.
        Cardiopulmonary complications of endoscopic retrograde cholangiopancreatography.
        Tech Gastrointest Endosc. 2014; 16: 144-149
        • Chandrasekhara V.
        • Khashab M.A.
        • Muthusamy R.V.
        • et al.
        • Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy
        Adverse events associated with ERCP.
        Gastrointest Endosc. 2017; 85: 32-47
        • Smith Z.L.
        • Nickel K.B.
        • Olsen M.A.
        • et al.
        Type of sedation and the need for unplanned interventions during ERCP: analysis of the clinical outcomes research initiative national endoscopic database (CORI-NED).
        Frontline Gastroenterol. 2020; 11: 104
        • Buxbaum J.
        • Roth N.
        • Motamedi N.
        • et al.
        Anesthetist-directed sedation favors success of advanced endoscopic procedures.
        Am J Gastroenterol. 2016; 112: 290-296
        • Early D.S.
        • Lightdale J.R.
        • Acosta R.D.
        • et al.
        • Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy
        Guidelines for sedation and anesthesia in GI endoscopy.
        Gastrointest Endosc. 2018; 87: 327-337
        • Zhang C.C.
        • Ganion N.
        • Knebel P.
        • et al.
        Sedation-related complications during anesthesiologist-administered sedation for endoscopic retrograde cholangiopancreatography: a prospective study.
        BMC Anesthesiol. 2020; 20: 131
        • Smith I.
        • Durkin D.
        • Lau K.W.
        • et al.
        Establishing an anaesthetist-delivered propofol sedation service for advanced endoscopic procedures: implementing the RCA/BSG guidelines.
        Frontline Gastroenterol. 2018; 9: 185-191
        • Coté G.A.
        • Hovis R.M.
        • Ansstas M.A.
        • et al.
        Incidence of sedation-related complications with propofol use during advanced endoscopic procedures.
        Clin Gastroenterol Hepatol. 2010; 8: 137-142
        • Barnett S.R.
        • Berzin T.
        • Sanaka S.
        • et al.
        Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.
        Dig Dis Sci. 2013; 58: 3287-3292
        • Smith Z.L.
        • Mullady D.K.
        • Lang G.D.
        • et al.
        A randomized-controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients.
        Gastrointest Endosc. 2018; 89: 855-862
        • Sorser S.A.
        • Fan D.S.
        • Tommolino E.E.
        • et al.
        Complications of ERCP in patients undergoing general anesthesia versus MAC.
        Dig Dis Sci. 2014; 59: 696-697
        • Dhaliwal A.
        • Dhindsa B.S.
        • Saghir S.M.
        • et al.
        Choice of sedation in endoscopic retrograde cholangiopancreatography: Is monitored anesthesia care as safe as general anesthesia? A systematic review and meta-analysis.
        Ann Gastroenterol. 2021; 34: 879-887
      1. Multicenter Perioperative Outcomes Group. About the Multicenter Perioperative Outcomes Group (MPOG). Available at: Accessed February 17, 2021.

        • Kool N.P.
        • van Waes J.A.R.
        • Bijker J.B.
        • et al.
        Artifacts in research data obtained from an anesthesia information and management system.
        Can J Anesth. 2012; 59: 833-841
        • Salmasi V.
        • Maheshwari K.
        • Yang D.
        • et al.
        Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: a retrospective cohort analysis.
        Anesthesiology. 2017; 126: 47-65
        • Schulte P.J.
        • Mascha E.J.
        Propensity score methods: theory and practice for anesthesia research.
        Anesth Analg. 2018; 127: 1074-1084
        • Austin P.C.
        Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.
        Stat Med. 2009; 28: 3083-3107
        • Mascha E.J.
        • Turan A.
        Joint hypothesis testing and gatekeeping procedures for studies with multiple endpoints.
        Anesth Analg. 2012; 114: 1304-1317
        • Mascha E.J.
        • Sessler D.I.
        Design and analysis of studies with binary-event composite endpoints: guidelines for anesthesia research.
        Anesth Analg. 2011; 112: 1461-1471
        • Mascha E.J.
        • Imrey P.B.
        Factors affecting power of tests for multiple binary outcomes.
        Stat Med. 2010; 29: 2890-2904
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Kapral C.
        • Mühlberger A.
        • Wewalka F.
        • et al.
        Quality assessment of endoscopic retrograde cholangiopancreatography: results of a running nationwide Austrian benchmarking project after 5 years of implementation.
        Eur J Gastroenterol Hepatol. 2012; 24: 1447-1454
        • Garewal D.
        • Powell S.
        • Milan S.J.
        • et al.
        Sedative techniques for endoscopic retrograde cholangiopancreatography.
        Cochrane Database Syst Rev. 2012; CD007274
        • Berzin T.M.
        • Sanaka S.
        • Barnett S.R.
        • et al.
        A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation.
        Gastrointest Endosc. 2011; 73: 710-717
        • Ruetzler K.
        • Smilowitz N.R.
        • Berger J.S.
        • et al.
        Diagnosis and management of patients with myocardial injury after noncardiac surgery: a scientific statement from the American Heart Association.
        Circulation. 2021; 144: e287-e305
        • Barakat M.T.
        • Angelotti T.P.
        • Banerjee S.
        Use of an ultra-slim gastroscope to accomplish endoscopist-facilitated rescue intubation during ERCP: a novel approach to enhance patient and staff safety.
        Dig Dis Sci. 2021; 66: 1285-1290
      2. American Society of Anesthesiologists. ASA physical status classification system. Available at: Accessed November 25, 2018.

        • Zakeri N.
        • Coda S.
        • Webster S.
        • et al.
        Risk factors for endoscopic sedation reversal events: a five-year retrospective study.
        Frontline Gastroenterol. 2015; 6: 270-277
      3. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures—an updated report by the American Society of Anesthesiologists Task Force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration.
        Anesthesiology. 2017; 126: 376-393
      4. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea.
        Anesthesiology. 2014; 120: 268-286
        • Perbtani Y.B.
        • Summerlee R.J.
        • Yang D.
        • et al.
        Impact of endotracheal intubation on interventional endoscopy unit efficiency metrics at a tertiary academic medical center.
        Am J Gastroenterol. 2016; 111: 800-807