Entropy-Guided Sedation Is Associated with Improved Hemodynamic Stability and Recovery During ERCP: A Prospective Real-World Cohort Study

Background: Sedation-related adverse events remain a concern during endoscopic retrograde cholangiopancreatography (ERCP), even when sedation is administered by anesthesiologists. Standard monitoring may not accurately reflect sedation depth. Electroencephalogram-based monitoring using Entropy provides an objective assessment of sedation depth and may optimize sedation management. Methods: This prospective, single-center, observational cohort study included 100 adult patients undergoing ERCP under anesthesiologist-administered sedation. Patients were allocated to two study groups: standard monitoring or advanced monitoring. The primary outcome was the incidence of sedation-related adverse events. Secondary outcomes included sedation depth, hemodynamic parameters, and recovery profiles assessed by the Aldrete score. Results: The overall incidence of sedation-related adverse events did not differ significantly between groups. However, the Entropy-monitored group had a significantly lower incidence of hypertensive episodes (6% vs. 26%, p = 0.007) and showed a trend toward fewer cardiopulmonary events. Sedation depth correlated significantly with adverse events, with deeper sedation associated with increased hemodynamic instability. Despite achieving slightly deeper sedation, patients in the Entropy group demonstrated significantly faster recovery, with higher Aldrete scores at 5 min (p = 0.003) and 15 min (p < 0.001). Conclusions: Entropy monitoring during anesthesiologist-administered sedation for ERCP was not associated with a significant reduction in overall adverse event incidence, a finding that should be interpreted in the context of the study’s limited statistical power (29.3%). However, it was associated with a significantly lower incidence of intraprocedural hypertension and faster postprocedural recovery, suggesting a role in optimizing sedation depth and hemodynamic stability rather than broadly reducing composite adverse events. These findings are hypothesis-generating and require confirmation in larger, adequately powered randomized controlled trials before clinical implementation can be recommended.