Evaluation of remifentanil in endoscopic retrograde cholangio-pancreatography

Endoscopic retrogade cholangio-pancreatography (ERCP) is a painful procedure that requires transient analgesia and conscious sedation. Remifentanil an ultrashort, very potent narcotic, is eliminated by plasma esterases, and does not interfere with liver function. It does not accumulate and is free of residual depression. Our aim is to find out if remifentanil can provide safe and effective sedation in ERCP, without undue technical difficulty secondary to sphincter spasm.

Thirty five patients, ASA I-II and III, scheduled to undergo elective ERCP were divided randomly in two groups: Midazolam-remifentanil group (group I), received remifentanil a loading dose of 0.2 microg/Kg/min over 5 minutes and a maintenance dose of 0.1-0.15 microg/Kg/min to achieve an adequate level of sedation and analgesia. Midazolam-fentanyl group (group II), received intermittent doses of midazolam and fentanyl guided by level of sedation. All patients were premedicated with midazolam 0.05 mg/kg IV, in divided doses as per patient tolerance, before starting the procedure. Sedation was assessed depending on Ramsey scale of sedation. SpO2, blood pressure, heart rate, respiratory rate, dosages of the medications, peroperative amnesia and operative time were recorded. Operator and patient satisfaction were rated on a scale of 1 to 4.

There were statistically significant differences in the level of sedation (p = 0.003), patient satisfaction (p = 0.01) and the amount of midazolam used (p < 0.01) in favor of group I. Operator satisfaction was the same in the two groups. There was no statistically significant difference between the two groups regarding the peri-operative amnesia. The technical difficulty (catheterization of ampulla, duration of procedure, need of parasympatholytics...) was comparable in the two groups, as judged by the operator. There was one case of mild desaturation in group I that responded to stimulation. No other respiratory or cardiovascular events were noted.

We recommend remifentanil in ERCP. Vigilance, however, must be exercised in titration and supervision of patients.