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Background and Aims Most ERCPs in the UK are performed under conscious sedation, yet increasing complexity and duration in HPB endoscopy can challenge patient tolerance. Deep sedation or general anaesthesia is recommended but not consistently available. This study assessed the safety and feasibility of higher-dose conscious sedation delivered through a sedationist–endoscopist model supported by capnography and high flow nasal oxygen.Methods We conducted a retrospective review of all ERCPs, combined EUS - ERCPs, EUS-BD, EUS-GE, ampullectomies and cholangioscopies performed between 1 July 2024 and 30 June 2025. All eligible procedures during that period were included. All patients received high flow nasal oxygen with continuous monitoring of oxygen saturation, heart rate and capnography. All patients received midazolam and fentanyl in increments of 1mg for Midazolam and 25μg for Fentanyl. This was administered by the sedationist (either trainee or trainer) while the other performed the endoscopy. Sedation doses were compared with JAG age-based thresholds. Outcomes included completion rates, need for reversal and sedation-related adverse events.Results Across 527 ERCPs, mean midazolam and fentanyl doses were 4 mg and 176.6 μg (median 4 mg and 150 μg). Thresholds were exceeded in 53.9% and 83.3% of patients. No ERCP was incomplete due to sedation. In 244 advanced HPB procedures, mean doses were 4.6 mg and 231.5 μg (median 4 mg and 200 μg). Thresholds were exceeded in 65.1% and 93.4% of cases. Three procedures (1.2%) were incomplete due to sedation. Maximum doses reached 12 mg midazolam and 850 μg fentanyl. No patient had hypoxaemia requiring intervention, no reversal agents were used and no sedation related adverse events were recorded.Conclusions This sedationist–endoscopist model with capnography and high flow nasal oxygen allowed higher dose conscious sedation to be used safely for ERCP and advanced HPB endoscopy. Completion rates were high and no sedation related complications were observed. This approach provides a practical option where deep sedation or general anaesthesia is limited.