Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.

BACKGROUND: Providing the appropriate anesthesia for endoscopic retrograde cholangiopancreatography (ERCP) cases is challenging. AIM: The aim of our study was to prospectively assess the safety of anesthesia directed deep sedation (ADDS) in non-intubated patients compared to general endotracheal anesthesia (GET) during an ERCP. METHODS: We conducted a prospective observational study in patients undergoing an ERCP. The choice of anesthetic-ADDS or GET-was made by the anesthesiologist. The pre-anesthesia assessment, intraoperative vital signs, and medications administered were collected. A standardized study instrument was used to record the number of procedure interruptions, intraprocedure and recovery room adverse events (AE). RESULTS: A total of 393 (89.7 %) patients received ADDS (no intubation) and 45 (10.2 %) received a GET. Age and comorbidities were similar in ADDS and GET groups. BMI was higher in the GET (32.6 ± 9.5) versus in the ADDS (27.3 ± 6.1) group; p < 0.001. The number of ASA 2 patients was higher in the ADDS versus the GET group (38.7 versus 22.2 %; p < 0.04); the number of ASA 4 patients was 15.6 % of GET versus 6.6 % of the ADDS cases (p = 0.05). During the procedure 16 (3.7 %) ADDS patients were intubated and converted to a GET anesthetic; 4 (25 %) of the converted ADDS cases were ASA 4 versus 6.4 % of ADDS patients (p = 0.006). Intraprocedure events occurred in 35.6 % of GET and 25.7 % of ADDS cases, without significant complications. CONCLUSION: Our data suggest that the administration of anesthesia without intubation for prone ERCP cases is feasible especially in non-obese, healthier patients.

Preoperative Assessment of Older Adults.

Older patients undergoing surgery have reduced physiologic reserve caused by the combined impact of physiologic age-related changes and the increased burden of comorbid conditions. The preoperative assessment of older patients is directed at evaluating the patient's functional reserve and identifying opportunities to minimize any potential for complications. In addition to a standard preoperative evaluation that includes cardiac risk and a systematic review of systems, the evaluation should be supplemented with a review of geriatric syndromes. Age-based laboratory testing protocols can lead to unnecessary testing, and all testing should be requested if indicated by underlying disease and surgical risk.

Preventing postoperative complications in the elderly.

Postoperative complications are directly related to poor surgical outcomes in the elderly. This review outlines evidence based quality initiatives focused on decreasing neurologic, cardiac, and pulmonary complications in the elderly surgical patient. Important anesthesia quality initiatives for prevention of delirium, the most common neurologic complication in elderly surgical patients, are outlined. There are few age-specific quality measures aimed at prevention of cardiac and pulmonary complications. However, some recommendations for adults can be applied to the geriatric surgical population. In the future, process measures may provide a more global assessment of quality in the elderly surgical population.

Polypharmacy and perioperative medications in the elderly.

Polypharmacy is a significant and complex problem affecting more than 40% of the geriatric population. Accurate medication histories may be difficult to obtain, but must include over-the-counter remedies as well as prescription. Physiologic changes occur with aging that predispose elderly patients to adverse drug events. At a minimum, medications with significant anticholinergic properties should be recognized and avoided in the perioperative period.