Perspectives on anesthetic management for endoscopic retrograde cholangiopancreatography and interventional gastrointestinal endoscopy procedures: The case for the natural airway

The current trend for the relocation of complex patients undergoing complex procedures outside the traditional operating room (OR) suite is exemplified by the breadth and growth of advanced interventional endoscopy procedures available within the modern gastrointestinal (GI) endoscopy suite. A new anesthesia subspecialty, non-OR anesthesia has been born in response to the increasing demands for anesthesia and sedation services in GI suites, interventional radiology, and cardiology. Accordingly, a new multidisciplinary medical society has been founded—Society of Non-OR Interventionalists and Anesthesiologists. The mindset of anesthesiologists entering the GI suite may be at odds with the established practice of gastroenterologists and endoscopically oriented nurses who have successfully treated healthier patients with mild-to-moderate sedation for procedures that were more straightforward, diagnostic, and of short duration. This article presents a perspective in favor of propofol monotherapy, the administration of deep sedation with a natural airway for the vast majority of advanced endoscopic treatments, and the critical requirement that end-tidal carbon dioxide monitoring (or an equivalent independent measure of effective ventilation) be used at all times.