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* 1-10 scale 10 = best N= 1076 P<0.0001 * 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