Endoscopic Sedation

1
Endoscopic Sedation

• Todd H. Baron, MD, FASGE
• Chair, ASGE Standards of Practice Committee
• Professor of Medicine
• Div. Gastroenterology Hepatology
• Mayo Clinic, Rochester

2
The Landscape of Endoscopic Sedation

• Monitored anesthesia care (MAC) 33-40 of all
  endoscopic sedation
• Up to 67 (NY)
• Midazolam opiate 60 of sedation
• GI-directed propofol nearly 500,000 patients
  reported
• Excellent efficacy and safety
• Less than 1 of sedation nationally

3
The Landscape of Endoscopic Sedation

• Restricted label of propofol
• State nursing board rules limit propofol use by
  GI / nurse team
• Economics of MAC (anesthesia provider delivered)
• 150 to 440 per case
• Billions of dollars of health care costs
• Payers starting to deny reimbursement

4
Sedation Levels

• Various levels can be obtained by any drug or
  drug combination
• Anesthesia provider- delivered propofol is almost
  all deep sedation
• GI / Nurse delivered propofol (or fospropofol)
  targets moderate sedation

5
Endoscopist Satisfaction
Plt0.0001
1-10 scale 10 best N 1076
Cohen Am J Gastro 2006
6
Fospropofol

• Water soluble prodrug of propofol
• Without restricted label, may allow propofol
  superiority sedation experience given by GI /
  nurse team
• Potential decreased use of anesthesia providers
  may be cost saving

7
Concerns about Fospropofol

• No comparison to gold standard (midazolam
  opiate)
• No data for use in upper endoscopy
• Longer ½ life than propofol
• Perineal paresthesias
• Insufficient data in ASA III patients

8
Summary

• Future studies needed for upper endoscopy, ASA P3
• Training of procedural staff needed prior to
  implementation

9
ASGE Position

• Appropriately trained gastro-enterologists, and
  nurses under the direction of gastroenterologists,
  CAN safely administer propofol and fospropofol,
  for sedation during endoscopic procedures