Division Chief, IR West Virginia University, United States
Purpose: Biliary drainage causes significant discomfort, with fentanyl/midazolam sedation often insufficient, prompting anesthesiology involvement. Ketamine/midazolam sedation administered by interventional radiologists (IRs) provides deeper sedation. The purpose was to assess how use of procedural sedation versus anesthesiology impacted room turnover time for primary biliary drainages, and whether ketamine use affected post-operative narcotic requirements.
Materials and Methods: All primary biliary drainages at one academic institution performed by an IR (11 years of experience) were identified by searching the Picture Archiving and Communication System (PACS). Procedure details and sedation/anesthetic/pain medications were abstracted from charts. All post-procedure day 1 narcotics were converted to oral morphine milligram equivalents (MME). Pre-procedure turnover was defined as the interval from the last image of the prior case to the first image of the drainage; case duration from the first to last image of the drainage; and post-procedure turnover from the last image of the drainage to the first image of the next case. Data are presented mean ± standard deviation or median with interquartile range. Turnover times, case durations, and post-procedure day 1 MME were compared with Mann-Whitney U tests.
Results: Seventy-two biliary drainages (40 internal-external, 8 external, 24 primary stents) were performed in 63 patients (23 women, 40 men; mean age 66±14 years; weight 83±26 kg). Thirty patients received procedural sedation, including 19 with ketamine (mean dose 65 mg, range 30–140 mg), and 33 received anesthesia (31 general, 2 monitored anesthesia care). Compared with procedural sedation, anesthesia was associated with longer pre- (65.0 IQR: 26.0 vs 116.0 IQR: 51.0 min, p< 0.01) and post-procedure (57.0 IQR: 15.5 vs 97.5 IQR: 44.3 min, p< 0.01) turnover times, adding roughly an hour on either end of the case. Case duration was similar (36.0 IQR: 27.5 vs 44.0 IQR: 36.5 min, p=0.18). Post-procedure day 1 MME was higher in patients who did not receive ketamine sedation (7.5 IQR: 13.0 vs 5.0 IQR: 30.0 mg; p=0.22), though the study was underpowered to detect a difference (76 per group required for 80% power at α=0.05).
Conclusion: Using anesthesiology services for primary biliary drainage was associated with substantially longer pre- and post-procedure room turnover times compared to IR-led sedation, adding two hours of non-procedural time to every case. Incorporating ketamine into IR sedation programs may increase efficiency by enabling deeper sedation independent of anesthesiology.
