Revie wer’s report  
 
Title: Dexmedetomidine is safe and reduces the additional  dose of midazolam for sedation 
during Endoscopic retrograde cholangiopancreatography in very elderly patients  
 
Version: 0 Date: 20 May 2018  
 
Reviewer: Daisuke Masuda  
 
Reviewer's report:  
 
Authors described the usefulness of dexmetomidine during ERCP for very elderly patients.  In 
this study, authors showed that the combined use of DEX was found to significantly reduce the 
amount of midazolam, resulting in a decrease in the frequency of respiratory suppression events 
in very elderly patients undergoing ERCP.  In addition, they showed although DEX tended to 
lower the minimum blood pressure and heart rate during examination, complications related to 
serious circulatory dynamics did not occur.   
 
 
In this study, authors demonstrated for the first time that the combined use of DEX with low 
respiratory depression was effective and safe for ERCP in very elderly patients.  
 
 
In this results, the minimum systolic blood pressure and heart rate during and after the 
examination decreased significantly with DEX when compared to that with conventional 
sedation.  Authors described that although catecholamine and atropine were used in some 
patients, the blood pressure and heart rate recovered promptly after discontinuing the 
administration of DEX, and there was no serious respiratory or circulatory failur e that would 
cause clinical problems during the recovery period in the all patients.   Why occurred decrease of 
systolic blood pressure and heart rate after examination in DEX group, even if discontinuing 
DEX.   
 
 
Systolic blood pressure in patients using m idazolam only is also more promptly recovered in 
DEX patients in this results although amount of midazolam were decreased in DEX group.  
Using DEX is thought to be more safe than propofol or midazolam during ERCP for elderly 
patients?  
 
 
 What of dexmetomidi ne was thought to result in reduce of respiratory depression?  Authors 
think simply reduce amount of using  midazolam in DEX group?  
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you re commend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indic ate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary fro m an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of  this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I  declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understan d that my na me will be included 
on my repo rt to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under a n Open Access Creati ve Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which will not be published.  
 
I agree to th e open peer review policy of the journal  
 
Revie wer’s report  
 
Title: Dexmedetomidine is safe and reduces the additional  dose of midazolam for sedation 
during Endoscopic retrograde cholangiopancreatography in very elderly patients  
 
Version: 0 Date: 20 May 2018  
 
Reviewer: Daisuke Masuda  
 
Reviewer's report:  
 
Authors described the usefulness of dexmetomidine during ERCP for very elderly patients.  In 
this study, authors showed that the combined use of DEX was found to significantly reduce the 
amount of midazolam, resulting in a decrease in the frequency of respiratory suppression events 
in very elderly patients undergoing ERCP.  In addition, they showed although DEX tended to 
lower the minimum blood pressure and heart rate during examination, complications related to 
serious circulatory dynamics did not occur.   
 
 
In this study, authors demonstrated for the first time that the combined use of DEX with low 
respiratory depression was effective and safe for ERCP in very elderly patients.  
 
 
In this results, the minimum systolic blood pressure and heart rate during and after the 
examination decreased significantly with DEX when compared to that with conventional 
sedation.  Authors described that although catecholamine and atropine were used in some 
patients, the blood pressure and heart rate recovered promptly after discontinuing the 
administration of DEX, and there was no serious respiratory or circulatory failur e that would 
cause clinical problems during the recovery period in the all patients.   Why occurred decrease of 
systolic blood pressure and heart rate after examination in DEX group, even if discontinuing 
DEX.   
 
 
Systolic blood pressure in patients using m idazolam only is also more promptly recovered in 
DEX patients in this results although amount of midazolam were decreased in DEX group.  
Using DEX is thought to be more safe than propofol or midazolam during ERCP for elderly 
patients?  
 
 
 What of dexmetomidi ne was thought to result in reduce of respiratory depression?  Authors 
think simply reduce amount of using  midazolam in DEX group?  
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you re commend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indic ate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary fro m an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of  this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I  declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understan d that my na me will be included 
on my repo rt to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under a n Open Access Creati ve Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which will not be published.  
 
I agree to th e open peer review policy of the journal  
 
Please review this paper.
user
Revie wer’s report  
 
Title: Dexmedetomidine is safe and reduces the additional  dose of midazolam for sedation 
during Endoscopic retrograde cholangiopancreatography in very elderly patients  
 
Version: 0 Date: 20 May 2018  
 
Reviewer: Daisuke Masuda  
 
Reviewer's report:  
 
Authors described the usefulness of dexmetomidine during ERCP for very elderly patients.  In 
this study, authors showed that the combined use of DEX was found to significantly reduce the 
amount of midazolam, resulting in a decrease in the frequency of respiratory suppression events 
in very elderly patients undergoing ERCP.  In addition, they showed although DEX tended to 
lower the minimum blood pressure and heart rate during examination, complications related to 
serious circulatory dynamics did not occur.   
 
 
In this study, authors demonstrated for the first time that the combined use of DEX with low 
respiratory depression was effective and safe for ERCP in very elderly patients.  
 
 
In this results, the minimum systolic blood pressure and heart rate during and after the 
examination decreased significantly with DEX when compared to that with conventional 
sedation.  Authors described that although catecholamine and atropine were used in some 
patients, the blood pressure and heart rate recovered promptly after discontinuing the 
administration of DEX, and there was no serious respiratory or circulatory failur e that would 
cause clinical problems during the recovery period in the all patients.   Why occurred decrease of 
systolic blood pressure and heart rate after examination in DEX group, even if discontinuing 
DEX.   
 
 
Systolic blood pressure in patients using m idazolam only is also more promptly recovered in 
DEX patients in this results although amount of midazolam were decreased in DEX group.  
Using DEX is thought to be more safe than propofol or midazolam during ERCP for elderly 
patients?  
 
 
 What of dexmetomidi ne was thought to result in reduce of respiratory depression?  Authors 
think simply reduce amount of using  midazolam in DEX group?  
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you re commend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indic ate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary fro m an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of  this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I  declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understan d that my na me will be included 
on my repo rt to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under a n Open Access Creati ve Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which will not be published.  
 
I agree to th e open peer review policy of the journal  
 
assistant