Sedation Safety in Advanced Endoscopy: A Comparative Analysis of ERCP and EUS Procedures

Aim: This study aimed to compare sedation-related adverse events between endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) and to identify predictors of intra-procedural hypoxemia.Material and Methods: This retrospective single-center study included 236 adults who underwent ERCP or EUS under sedation between January 2015 and December 2025. The primary outcome was intra-procedural hypoxemia, defined as SpO₂ <90%. Secondary outcomes included severe hypoxemia, airway intervention, procedure interruption, hypotension, bradycardia, escalation of airway management, and unplanned post-procedural observation. Logistic regression analysis was used to determine predictors of hypoxemia.Results: ERCP was performed in 128 patients and EUS in 108 patients. Baseline characteristics were comparable between groups. ERCP procedures were longer and more frequently performed in the prone or semi-prone position. Sedation-related adverse events were more common in ERCP than EUS (28.9% vs. 13.9%, p=0.006). Hypoxemia (18.8% vs. 7.4%, p=0.011) and airway intervention requirement (14.8% vs. 5.6%, p=0.021) were also higher in the ERCP group. In multivariable analysis, ERCP procedure, ASA III–IV status, chronic pulmonary disease, procedure duration >60 minutes, additional sedative requirement, and lower baseline SpO₂ were independently associated with hypoxemia.Conclusion: ERCP was associated with more sedation-related respiratory events than EUS. Hypoxemia risk appeared to be influenced by both patient- and procedure-related factors. Careful pre-procedural risk assessment and close respiratory monitoring may improve sedation safety, particularly during ERCP.