Our hospital has recently required the use of anesthesiologists for sedation of ERCP patients. This means a lot of extra work for us that is very unpopular. The suite in which ERCPs are done is not set up for anesthesia - it is essentially a modified X-Ray room. The huge X-Ray table makes up much of the space, and access to both patient airway (at the head) and anesthesia machine/monitor (at the feet) is impossible simultaneously. Furthermore, the patient's position (semi-prone) is not ideal for airway management.

Despite the difficulties, I have developed what I consider a good technique for sedation and airway management of these patients.

Patients are sedated with a small dose of midazolam (1-3mg depending on frailty) and fentanyl (about 25mcg per 30 minutes) and then kept sedated with a propofol infusion in the range of 10-30mL/hr.

Once sedated, I place a nasopharyngeal airway in each nostril (that is, 2 N-P airways per patient). Into one, I insufflate O₂, and into the other I place my CO₂ sampling port. Much more effective than an oral airway or bite block for both O₂ delivery and CO₂ sampling. I find that I can now sedate my patients more deeply and still avoid obstruction.

Any other techniques out there?

I have a rather old-fashioned surgeon who insists of both arms tucked by the patient's side during laparoscopic cholecystectomies, to facilitate his access the the patient.

Naturally, this makes access the IV sites, blood pressure cuffs and pulse oximeters difficult. Surgeons leaning on the BP cuff produces artefactual readings, IV's kink and can't be re-positioned and pulse oximeters fall off and cannot be replaced easily.

I have adapted to this by placing BP cuffs on the legs, pulse oximeters on toes and a second IV in a foot. However, it seems unnecesarily difficult. While I tolerate this surgeon's foibles, I think I would be on safe ground to insist at least one arm be placed out and accessible to me - it is a patient safety issue, which, in my book, over-rides a surgical convenience issue.

Would like to hear from other members if they have similar scenarios. Who is the boss in the OR?