Dexmedetomidine versus midazolam for conscious sedation in endoscopic retrograde cholangiopancreatography: An open-label randomised controlled trial.

Sir,

In the open-label randomised controlled trial on dexmedetomidine versus midazolam for conscious sedation published in Indian Journal of Anaesthesia, Sethi et al. have concluded that dexmedetomidine can be a superior alternative to midazolam for conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP) based on early recovery, better patient and endoscopist satisfaction score, less complication and better Facial Pain Scale (FPS) score at 5 and 10 min of procedure.[1]

We differ on the use of FPS for assessment of pain during ERCP procedure. It is not only difficult but rather impossible to evaluate pain score in patient with a distorted face due to bite-block and endoscope passing through mouth, by his/her facial expression. We think author should have considered other scoring systems[23] for evaluation of pain such as Behavioural Pain Scale, Colorado Behavioural Numerical Pain Scale and 4-point pain score (1 - no pain, 2 - mild, 3 -moderate and 4 - severe pain), expressed by patient through gestures like showing fingers, as in this study, authors’ have aimed at achieving Ramsay sedation score (RSS) of 3-4 with patient able to respond on command. We also disagree with the statement “venous access was secured on non-dominant hand of every individual by 18G/20G cannula”. During ERCP, mostly patients are positioned in left lateral position with left hand behind. Hence, practically, during ERCP, the preferred site for venous access is ‘non-dependent hand’ (i.e., usually right hand), rather than ‘non-dominant hand’ (i.e., usually left hand).