PATIENT COMFORT DURING ERCP: THE UNCOMFORTABLE TRUTH

Aims:

ERCP is a complex endoscopic procedure that typically requires higher doses of sedation and analgesia compared to standard endoscopy. Our unit, like many countries in Europe, perform most ERCPs under conscious sedation. While monitoring patient comfort is routine during colonoscopy, no validated model exists for ERCP. The objective of our study is to evaluate comfort scores of patients undergoing ERCPs with conscious sedation, using a scoring system based on the modified Gloucester score.

Methods:

Consecutive ERCPs performed under conscious sedation in a single, tertiary referral centre in Ireland were prospectively evaluated over a six month period.

Results:

327 patients were evaluated. The median age was 72, and 54% were female. 123 patients (38%) were ≥75 years. 151 patients (46%) had a comfort score of ≤2, and 176 (54%) had a comfort score of ≥3. One patient required reversal of sedation due to respiratory compromise. Median doses of medication were: midazolam (4.32 mg), diazepam (7.8 mg), fentanyl (82mcg), and pethidine (40 mg). 39 patients received more than one benzodiazepine, 60 patients more than one opiate, and 31 patients all four medications. The average duration of the procedure was 37 minutes (10 – 100). 25 (8%) patients required a repeat procedure as a result of sedation related difficulties. There was no difference in comfort scores between patients ≥ or ≤ than 75 years.

Conclusions:

There are limited data to define what is acceptable sedation practice for ERCP. The RCPI (Royal college of Physicians of Ireland) have recently recommended that > 80% of colonoscopies should have a comfort score of 1 or 2. Though there are no validated comfort scores for ERCP, our data demonstrate that many patients undergoing ERCP with conscious sedation are subjected to an experience that would be considered unacceptable in general endoscopy. Our experience highlights the need for deep sedation with propofol in complex endoscopic procedure.