Clifford Gevirtz, MD
Clinical Director, Office-Based Ambulatory Anesthesia Services
October 2021

As a reviewer for several government agencies, some very sad cases cross my desk for review. But an increasing occurrence that I have noticed is severe morbidity and mortality associated with ERCP conducted in the prone position with sedation, but without intubation.

The scenario goes something like this: An older patient with biliary tract obstruction, either from stones or neoplasm, needs an ERCP. The gastroenterologist is a very respected member of the medical staff and board certified with many of these cases performed without complication. Similarly, the Anesthesiologist is often also board certified, but this may be a short assignment post call or an emergency add-on. It is being done in a separate location from the OR and the distance to the main OR may be significant, so help is not readily available.

The patient may have several co-morbidities, sometimes coagulopathic. The decision is made to start as a MAC procedure with intravenous sedation and the minimal monitoring standard in place, but not an arterial line or central venous access. At some point, the patient’s respirations become shallow, or cease, and the patient may not respond to a jaw thrust or the stopping of the Propofol infusion. At this point, it becomes a critical issue: can you mask ventilate the patient effectively? (i.e. the scope must be withdrawn and the mask applied and positive pressure ventilation begun.) It is challenging to ventilate someone in the prone position and flipping the patient may require additional help that is not immediately available. Think 250lb male and all the available personnel can’t manage it. Bringing a stretcher in can also be time consuming depending on the physical layout of the procedure room. While some may suggest the quick placement of an LMA, this can also be problematic. The most ominous scenario is the sudden loss of telemetry, i.e. cardiac arrest.
When a root cause analysis is done, it is usually the lack of a good airway that stands out as the most easily correctable item. Intubation and then turning prone should be strongly considered. Yes, it will increase case time and recovery time, but I promise you, avoiding presenting these cases at departmental QI is well worth it.