Fewer Sedation-Related Adverse Events With General Anesthesia During ERCP

Now try to sleep. Low angle of professional surgeons giving to patient a general anesthetic before an operation. They are holding the equipment and surgical instruments
Researchers compared outcomes between general anesthesia and monitored anesthesia care during endoscopic retrograde cholangiopancreatography in patients at risk for adverse events.

Using general anesthesia (GA) vs anesthesiologist-directed monitored anesthesia care (MAC) resulted in fewer sedation-related adverse events among patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), according to a study published in Gastrointestinal Endoscopy.

Researchers conducted a randomized trial, called “A Prospective Randomized Study of General Anesthesia Versus Anesthetist Administered Sedation for ERCP” (RAGE; ClinicalTrials.gov Identifier: NCT04099693) at a tertiary referral center in Saudi Arabia to compare outcomes of GA vs MAC in individuals at average risk for sedation-related adverse events during ERCP. Of 238 eligible patients, researchers enrolled 203 patients undergoing ERCP who had an American Society of Anesthesiology (ASA) risk score of 3 or lower. Patients (mean age, 50.3±19.3; women, 53%) were randomly assigned 1:1 to receive GA with cisatracurium (0.15 mg/kg), propofol (1.5-2 mg/kg), and sevoflurane or MAC with a propofol bolus (0.5-1 mg/kg) and continuous infusion.

The primary outcome was the proportion of patients who had composite sedation-related adverse events, defined as hypotension, arrhythmia, hypoxia, hypercapnia, apnea, and ERCP procedure interruption or termination. Secondary outcomes included sedation induction time, procedure time, and recovery time.

The proportion of patients who had sedation-related adverse events was significantly lower in the GA arm compared with the MAC arm at 9% and 35%, respectively (P <.001). Over 50% of sedation-related adverse events in patients receiving MAC led to procedure interruptions due to airway manipulation or significant apnea. Sedation induction time was significantly longer in the GA group compared with the MAC group (10.3 minutes vs 6.5 minutes; P <.001), though there was no significant difference in procedure time.

The main study limitation, researchers noted, was including procedure interruptions as sedation-related adverse events.

“GA for ERCP is safer primarily due to high rates of airway maneuvers in MAC with better endoscopist and patient satisfaction, but comes at an expense of prolonged induction time in patients with ASA scores ≤3,” the study authors wrote.


Alzanbagi AB, Jilani TL, Qureshi LA, et al. Randomized trial comparing general anesthesia with anesthesiologist administered deep sedation for ERCP in average-risk patients. Gastrointest Endosc. Published online June 8, 2022. doi:10.1016/j.gie.2022.06.003