Endoscopist administered sedation during ERCP: Impact of chronic narcotic/benzodiazepine use and predictive risk of reversal agent utilization

OBJECTIVES: When administered by endoscopists conventional sedation regimens for endoscopic retrograde cholangipancreatography (ERCP) consist of intravenous (IV) benzodiazepines and opiates. As yet, standardized dosing regimens for individual patients do not exist. The aims of this study were to (a) determine sedative doses in patients with and without a history of narcotic or benzodiazepine use, (b) assess the frequency of reversal agent utilization, and (c) assess potential predictive factors for reversal agent utilization. METHODS: Clinical data from January 1, 2004, to December 31, 2005, were abstracted from a computerized endoscopy database to determine: demographics, median sedation dosages, risk of reversal agent use, and clinical outcome related to sedation. Univariate and logistic regression analysis were performed to assess independent predictive factors for reversal agent utilization. RESULTS: Of 3,179 patients undergoing ERCP, 3,058 received sedation directed by the endoscopists. Meperidine and midazolam IV were given at a median dose of 125 mg and 7 mg, respectively, during a mean procedure time of 42 min. One hundred eighty-six patients reported routine use of narcotics or benzodiazepines (6%). These patients were younger, predominantly female, required higher doses of meperidine and midazolam, and received IV promethazine during procedural sedation more frequently than patients not using narcotics or benzodiazepines. One hundred twenty-four patients required reversal agents (4%). They were relatively older, required significantly higher doses of meperidine and received promethazine more frequently than the nonreversed group. CONCLUSIONS: In a single, high volume ERCP center, endoscopist administered sedation was provided in 96% of cases. Patient age ≥80 yr, dose of meperidine, and the use of promethazine were independent risk factors for the need of reversal agents.