Sa1501 An Audit of ERCP in the Intensive Care Unit (ICU) Setting At a Tertiary Referral Centre

Abstract

Sa1501 An Audit of ERCP in the Intensive Care Unit (ICU) Setting At a Tertiary Referral Centre Edward Britton, Mahesh Bhalme, Derrick F. Martin, Jayapal Ramesh Gastroenterology, University Hospital South Manchester, Manchester, United Kingdom; Radiology, University Hospital South Manchester, Manchester, United Kingdom Introduction: While the emergency use of ERCP in acute gallstone pancreatitis without concurrent cholangitis or jaundice remains under some debate, the use of early ERCP is universally accepted as best practice for the management of acute cholangitis. A proportion of these patients need ICU support for haemodynamic compromise and /or mechanical ventilation. There is however, little in the published literature documenting outcomes and standards in this patient population. Aim: To audit the indications, procedure and outcome of ERCP carried out in a North West hospital providing a tertiary service. Methods: From February 2000 to January 2010 the records of all consecutive ERCP procedures performed on patients in ICU were analysed using a standardised proforma. Results: Total of 22 /4565 (0.48%) procedures were identified during this period. Of these, 17 (77%) case notes were obtained and data extracted. Fifty-nine percent were male with a mean age were 73.2 years (34-92). Mean ASA grading of 2.4 (1-3). The most common indication for admission to ICU was septic shock in 88%, pancreatitis in 6% and needing respiratory support in 6%. Sixty-five percentage underwent mechanical ventilation; 53% required inotropic support and the mean eGFR was 51.00 (15-90). The mean time from ICU admission to procedure was 12.8 hours (2-36). ERCP was carried out under full GA in 41%; fentanyl/midazolam combination in 35% and fentanyl propofol in 24% .Indications were jaundice in 35%; obstructive LFT’s in 29%; cholangitis in 24% and pancreatitis in 12%. All procedures were carried out in the interventional radiology suite with 65% in prone position and the rest supine. The biliary cannulation success rate was 87.5% and the findings were dilated duct with evidence of recently passed stones in 5/14 (36%), ductal stones in 6/14 (43%), obstructed existing stent in 2/14 (14%) and biliary leak in 1/14 (7%). During the procedure, 86% underwent sphincterotomy and 71% underwent stent insertion. Two of the three failed patients underwent biliary drainage with PTC (5.9%) or surgical exploration (5.9%), whilst the other one was managed conservatively. No post ERCP pancreatitis or bleeding was recorded but there was one duodenal perforation (5.9%). The overall 30 day mortality following the procedure was 47% with a mean of 4.71 days (range 2-9 days) with no procedure related deaths. The average length of stay on ITU for those that survived was 13.22 days (1-39). Conclusions: Patients requiring ERCP in the ICU setting have a very high mortality despite early intervention, high success rate of biliary drainage and low procedure related complications. Further work with larger patient populations may allow better prediction of outcomes.