Acta Anaesthesiologica Taiwanica 53 (2015) 131e134

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Original Article

Age correlates with hypotension during propofol-based anesthesia for

endoscopic retrograde cholangiopancreatography
Chong-Sun Khoi 1, Jen-Jeng Wong 1, Hao-Chin Wang 1, Cheng-Wei Lu 1, 2 *, Tzu-Yu Lin 1, 2
1
2

Department of Anesthesiology, Far Eastern Memorial Hospital, Ban-Chiao, Taipei County, Taiwan
Department of Mechanical Engineering, Yuan Ze University, Chung-Li, Taiwan

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 13 June 2015
Received in revised form
7 October 2015
Accepted 19 October 2015

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used for diagnostic

and therapeutic purposes. Most of the patients may feel pain, anxiety, and discomfort during this procedure, so conscious sedation is usually used during ERCP. General anesthesia would be considered if
conscious sedation fails to achieve the requirement of the endoscopists. Several studies showed that
propofol-based sedation could provide a better recovery prole. However, propofol has a narrow therapeutic window and complications may occur beyond this window. The present study aimed to nd out
the complications and the associated risk factors during ERCP procedure under propofol-based deep
sedation.
Methods: We retrospectively reviewed data from anesthetic and procedure records of the patients who
underwent ERCP under propofol-based deep sedation from January 2006 to July 2010 at Far Eastern
Memorial Hospital, Taipei, Taiwan. All propofol-based deep sedations were conducted by anesthesiologists. The incidence of complications was determined and the independent risk factors identied by the
multivariable logistic regression model.
Result: Propofol-based deep sedation was provided for 552 patients who received ERCP procedure. The
majority of the patients were male, the mean age was 60 16 years and American Society of Anesthesiologists physical status IIeIII. Almost 30% of patients experienced hypotension during the procedure, although no mortality or morbidity was associated with this complication. Sex, age, anesthetic
time, American Society of Anesthesiologists status, hypertension, and arrhythmia were signicantly
different (p < 0.05) between patients with hypotension and without hypotension during the procedure.
Multivariable logistic regression identied sex and age to be the independent predictors of hypotension.
Conclusion: Hypotension was the most frequent anesthetic complication during procedure under
propofol-based deep sedation, but this method was safe and effective under appropriate monitoring. Age
is the strongest predictor of hypotension and therefore propofol-based deep sedation should be conducted with caution in the elderly.
Copyright 2015, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights
reserved.

Keywords:
age;
hypotension;
propofol;
ERCP;
deep sedation

1. Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is a
procedure used for diagnostic and therapeutic purposes such as
sphincterotomy.1 Because it is a relatively uncomfortable and prolonged procedure, adequate sedation is usually benecial for its

Conicts of interest: All authors have no conicts of interest to declare.

* Corresponding author. Department of Anesthesiology, Far Eastern Memorial
Hospital, 21, Section 2, Nan-Ya South Road, Ban-Chiao, Taipei County 220, Taiwan.
E-mail address: drluchengwei@gmail.com (C.-W. Lu).

successful completion. Sometimes, general anesthesia even may be

indicated when sedation fails.2
Various sedatives, hypnotics, and narcotics have been used for
ERCP.1 Several studies have shown that propofol-based sedation
could provide a better recovery prole including a shorter recovery
time and a higher recovery score during ERCP.3e5
Even for sedation in high-risk octogenarians, propofol has been
shown to be superior to midazolam or meperidine.6 However,
propofol has a narrow therapeutic window, and a small increase in
dosage may cause a patient to progress from deep sedation to
general anesthesia, during which hypoxemia and hypotension may

http://dx.doi.org/10.1016/j.aat.2015.10.002
1875-4597/Copyright 2015, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.

132

occur.7 Considering these possible complications, the aim of this

study was to investigate the possible predictors related to the
complications of propofol-based deep sedation for ERCP.
2. Methods
After obtaining the approval from the Institutional Review
Board of the Far Eastern Memorial Hospital, Taipei, Taiwan we
retrospectively reviewed the anesthetic records, history charts, and
procedure records of the patients who underwent ERCP under
propofol-based deep sedation from January 2006 to July 2010 at the
Far Eastern Memorial Hospital. The inclusion criteria included patients who received ERCP procedure under propofol-based deep
sedation. In those containing multiple ERCP procedure, data were
analyzed from the rst time of anesthetic record. The procedure
was performed with patients in the prone position. Appropriate
monitoring was used for all patients including electrocardiography,
pulse oximetry, noninvasive blood pressure measurements, and
continuous respiratory rate measurements. Supplemental oxygen
at 4 L/min was offered via nasal cannula throughout the procedure.
All patients received an initial dose of 1e2.5 mg midazolam and
20e50 mg propofol. Deep sedation was further maintained with
titration of continuous propofol infusion according to the guidelines of American Society of Anesthesiologists (ASA) and the depth
of anesthesia was monitored by clinical observation with the
modied observer's assessment of alertness/sedation score. A level
of deep sedation was targeted by the anesthesiologists to adjust the
rate of propofol infusion manually and boluses of propofol might be
given. After the procedure, patients were sent to postanesthesia
care units for observation at least 60 minutes.
Hypotension was dened by blood pressure dropping signicantly to < 20% of baseline blood pressure, which was measured
before sedation. Hypertension was dened by blood pressure
signicantly > 20% of baseline blood pressure before sedation.
Desaturation was dened by oxygen saturation dropped to < 90%. If
the patient developed desaturation under supplemental oxygen,
the airway was opened by head-tilt/chin-lift and jaw-thrust maneuvers. Nasal airway was inserted if the above maneuvers failed. If
desaturation persisted, the procedure was terminated and mask
ventilation with 100% oxygen was adopted.

C.-S. Khoi et al.

Table 1
Patient characteristics.
Characteristics
Sex (male/female)
Age (y)
Body mass index (kg/m2)
ASA classication (%)
1
2
3
4
Anesthetic time (min)
Comorbidities
Hypertension
Diabetes mellitus
Congestive heart failure
Arrhythmia
Old CVA
CAD
HBV/HCV carrier
Hepatic tumor
Chronic renal insufciency
COPD
Asthma
Biliary tract infection
Biliary pancreatitis
Acute pancreatitis
Anemia

283/269
60 16
24.5 3.9
8.7
68.8
22.3
0.2
53.8 23.1
200
136
9
15
21
37
41/14
4
21
10
4
210
78
29
7

Data are presented as n or mean standard deviation, unless otherwise

indicated.
ASA American Society of Anesthesiologists; CAD coronary artery
disease; CVA cerebrovascular accident; COPD chronic obstructive
pulmonary disease; HBV hepatitis B virus; HCV hepatitis C virus.

Body mass index and other comorbidities such as diabetes mellitus

and biliary tract infection showed no statistical difference between
the two groups (Table 3). Multivariate logistic regression identied
sex and age as signicantly associated with hypotension (p < 0.05;
Table 4). However, when age was excluded from analysis, hypertension and anesthetic time were identied as a signicant predictor (p 0.002 and p 0.03, respectively), while sex remained a
signicant independent predictor (p 0.038).
4. Discussion

2.1. Statistical analysis

Statistical analysis was performed using SPSS 17.0 (SPSS Inc.,
Chicago, IL, USA). Interval data were expressed as mean standard
deviation, and compared with Student t test. Categorical data were
coded and compared with Pearson Chi-square test or Fisher's exact
test where appropriate. A p value of < 0.05 was regarded as signicant. A multivariate logistic regression model was used to
identify the independent predictors with the hypotension during
propofol-based deep sedation.
3. Results
During the study period, a total of 552 patients were recruited.
Baseline characteristics are shown in Table 1. The majority of the
patients were male; the mean age was 60 16 years (range, 14e96
years) and ASA physical status IIeIII. More than 200 of patients had
hypertension or biliary tract infection. The number of patients with
hypotension, hypertension, and desaturation during anesthesia are
shown in Table 2. Almost 30% of patients experienced hypotension
during the procedure.
Sex, age, anesthetic time, ASA status, hypertension, and
arrhythmia were signicantly different (p < 0.05) between patients
with hypotension and without hypotension during the procedure.

Propofol-based deep sedation can cause some complications

during ERCP procedures. Results of this retrospective study showed
that hypotension was the most frequent anesthetic complication
during propofol-based deep sedation for ERCP, the incidence of
which was 29.9%. Our rate was higher than the series reported by
Amornyotin et al8 (8.8%), Kongkam et al3 (19.4%), and Vargo et al5
(15.8%), which might be due to the older age of patients and the
longer anesthetic time in our study. Indeed, in this study, the
incidence of hypotension in the elderly is relatively high (33.3%).9
Although hypotension was found during this procedure, there
was no sequela after the procedure.
Multivariable logistic regression identied sex and age were
independent predictor. In our study, we found that age is positively
correlated with hypertension and anesthetic time (Table 5). In
addition, clinical studies imply that increasing in blood pressure is

Table 2
Complications during anesthesia.
Complication

No. of patients (%)

Hypotension
Hypertension
Desaturation

165 (29.9)
13 (2.35)
1 (0.18)

Age related hypotension during IVG for ERCP

133

Table 3
Factors related to hypotension during anesthesia.
Parameter

Hypotension (n 165)

No hypotension (n 387)

74
91
67.7 12.7
24.3 3.8
57.4 23.4

209
178
57.1 16.8
24.6 3.9
52.3 22.9

8 (4.8)
110 (66.7)
47 (28.5)
0

40 (10.3)
270 (69.8)
76 (19.6)
1 (0.25)

77 (46.7)
1 (0.6)

123 (31.8)
14 (3.61)

p
0.049a

Sex
Male
Female
Age (y)
BMI (kg/m2)
Anesthetic time (min)
ASA
1
2
3
4
Comorbidity
Hypertension
Arrhythmia

<0.001b
0.516b
0.019b
0.034a

0.001c
0.048c

Data are presented as n (%) or mean standard deviation.

ASA American Society of Anesthesiologists; BMI body mass index.
a
Pearson Chi-square.
b
Student t test.
c
Fisher's exact test.

Table 4
Logistic regression for factors associated hypotension during anesthesia.
Univariable

Hypertension
Sex
Age
Anesthetic time

Multivariable

Multivariable

OR

95% CI

OR

95% CI

OR

95% CI

1.878
0.693
1.046
1.009

(1.293e2.728)
(0.48e0.999)
(1.032e1.060)
(1.001e1.017)

0.001
0.049
< 0.001
0.021

1.134
0.598
1.045
1.006

(0.752e1.712)
(0.405e0.883)
(1.030e1.059)
(0.998e1.014)

0.548
0.01
< 0.001
0.149

1.808
0.674
NA
1.009

(1.240e2.637)
(0.464e0.979)
NA
(1.001e1.017)

0.002
0.038
NA
0.03

CI condence interval; OR odds ratio.

age related.10e12 Therefore, hypertension and anesthetic time were

identied as a signicant predictor when age was excluded from
analysis. We found that age, hypertension, sex, and anesthetic time
are predictors of hypotension during ERCP procedure under
propofol-based sedation in this study.
The incidence of desaturation in this study was 0.18%, which was
lower than the other studies.3e6,13 Only one patient with arterial
oxygen saturation of 90% was observed in our study, and the patient
recovered immediately after chin-lift and jaw-thrust. In our study,
100% O2 at 4 L/min via nasal cannula was offered throughout the
whole procedure for preoxygenation and supplemental oxygen, so
fewer decrease in SpO2 during the procedure was expected. Wang
et al14 found supplementary oxygen with nasal cannula at 4 L/min in
sedated patients reduced desaturation and hypoxia. Moreover, supplemental oxygen plays a signicant role for a safer sedation; however, it may decrease the chance to detect early desaturation.5 Due to
many factors that can cause desaturation of oxygen during apnea,1,15
preoxygenation is important that deep breathing of 100% O2 can
against hypoxia after induction of anesthesia.16,17 Thus, preoxygenation and supplemental oxygen should be advocated during ERCP.
Pulse oximetry provides an indirect measurement of the respiratory function during gastrointestinal endoscopy, but detection of
Table 5
Correlation between age and other factors.
Parameter

Age

p*

Hypertension
Sex
ASA
Anesthetic time

0.372
0.076
NA
0.157

0.01
0.75
NA
0.01

ASA American Society of Anesthesiologists; NA not applicable.

*
Pearson's correlation.

abnormal ventilator activity can be delayed, especially if supplemental oxygen is provided.18 Capnography is a simple and inexpensive device, but it was not used in our study. Capnography
provides a continuous graphic record of respiratory movement and
is more reliable than pulse oximetry in the early detection of respiratory depression during colonoscopy with sedation.18 FriedrichRust et al19 found that capnography monitoring can reduce the
incidence of hypoxemia during propofol-based sedation for colonoscopy. Therefore, capnography can be considered another
advance monitor during ERCP.
Target-controlled infusion (TCI) of propofol is an alternative
sedation during ERCP. Several studies have reported that TCI provides safe and effective sedation during ERCP.20,21 Chiang et al22
found that TCI of propofol combined with opioids was associated
with better hemodynamic and respiratory stability than manually
controlled infusion of propofol. In the setting of propofol administered by TCI combined with bispectral index, it is possible to
maintain stable sedation during endoscopic procedure, but some
complications were still found during sedation.23
In our study, propofol-based deep sedation was provided during
the procedure. Hypotension and respiratory depression are the
most common adverse effects observed during propofol continuous infusion.3,4 The major complication observed with the use of
intravenous propofol is transient oxygen desaturation during induction, and the mid-procedural period.13 Furthermore, concomitant use of propofol with narcotics amplies the respiratory
depressant effects.24 However, Lee et al9 found that there was no
static signicant in the cardiopulmonary complication rates in the
group given propofol combined with midazolam and fentanyl
compared with propofol monosedation, and patients who received
fentanyl had less minor pain.25 Alfentanil and propofol were prescribed during this study, which was safe with careful monitoring.

134

4.1. Limitations
Some inaccurate and incomplete records were encountered.
In conclusion, hypotension was the most frequent anesthetic
complication during the procedure under propofol-based deep
sedation, but this method was safe and effective with appropriate
monitoring. Age is the strongest predictor of hypotension and
therefore propofol-based deep sedation should be conducted with
caution in the elderly.
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