Division of Anesthesiology, The University of Illinois College C&Medicine a: Peoria, Peoria, IL.
anesthetics,
e&ion making, economics of; inhalational cost of; neuromuscular blocking agents, cost oft
ete” Stark has abe fdoaving
03
ctof to have to stand up, face
*Clinical
the East and say to the Gent, ‘I’m a greedy son of a bitch and I’m sending you to a facility re you’re going to be charged an outrageous stum for a procedure which is probably not necessary, may be harmful to your health, and I will pocket a large bunch of money for ris your come very close to doing things I protmised not to do hen 1 pocsatic oath.’ “I care costs account for more t esthesiologists or a~e~theti~t§ have any cones our choice of anesthetic drugs or techesthesia-care length of stay and potential niques have an impact on post ds of care because they may provide us ollar costs? Do we select me with additional income? We may have a say about cost, but to do so may requke a change in our practice pattern mind-set. That is not aiways easy; there are two constants in the world of healthcare-change and resistance to change.
Professor
Address reprint request5 to Dr. Wetchler at Department of Anesthesia, Methodist Medical Center of Illinois, 221 NE Glen Oak, Peoria, IL 61636, USA. Al! prices in this articie reflect 1992 costs to the Methodist Medical Center of Illinois. 0 1992 Butterworth-Heinemann j_ Clin. Anesth.
J. Clin.
4(Suppl
Anesth.,
P):2QS-24S,
1992.
vol. 4 (Suppl
At varying times the yers, consurners, and pr all used the term “c -effective quahty care.” fective quality care depends on the differing Gent wants the best available care; cost is never bealthcare players. The g as they are not aying the bill. Governnxnt, an issue with patients as corporate America, the insurance industry-the so-called &ix-d-party payI), SeptemberDctober
1992
Economic Impact of anesthesia dectiion making: Wetchler
ers-are interested in the lowest possible costs for to as safe care. For physicians and what is referre providers, cost must enter into quality-of-care decision making. anesthesiologists should not allow cost to be rriding factor in determining our choice of an tic drug or a particular technique (Table I). We must address how our choice affects the patient in both the operating room (OR) and the postanesthesis care unit (PACU) and how rapidly the patient can return to normal activities at home and in the workplace. Although it appears that the incentive for anesthesiologists to search out less expensive means of providing care is limited, fiscally responsible choices may nonetheless affect the very existence of the facility in which we practice. Saidman, in assessing the role of desflurane in the practice of anesthesia, asks, “Is desflurane sufficiently better than currently available inhaled anesthetics, esto warrant widespread incorpopecially isoflurane ractice?“2 The criteria applied to ration into clinical this assessment could and should be applied to any e must determine answers to the new anesthetic. following three questions: (1) Is the new agent sufficiently better than currently available anesthetics? (2) Are there added costs associated with the use of the new anesthetic? (3) Are there potential cost savings that could result from decreased patient morbidity and duration of PACIJ stay by using the new drug? Every new anesthetic drug that becomes available should be compared with currently available, similar drugs to assess associated morbidity, time to arousal, time to discharge, and anesthetic-related costs. New anesthetics must offer unique and important benefits to patients, to anesthesiologists, and to the healthcare system.
e must begin to think in terms of both direct and indirect costs (Table 2). Direct costs include not only the cost of the anesthetic but the additional cost of adjuvants, equipment, and drug waste. Indirect costs take into consideration the OR turnover time between cases-bow quickly and safely the patient can be moved from the OR to the PACIJ; length of stay in the PACK; Anesthesiologist Decision Making Intra-anesthetic effects Postanesthesia side effects Postanesthesia length of stay Return to normal activities Cost
%a:2,
Agent Acljuvants
Clin.
Turnever time PACU stay Staff time Unanticipated admission Equipment maintenance Pa&nt satisfaction
PAW
= postanesthesia
care unit.
intensity of PACU care needed; and equipment maintenance. For ambulatory surgery patients, anesthesiarelated unanticipated hospitalization should be considered an indirect expense. When we use controlled aperwork time must be substances, personnel and added into cost. Indirect costs must ah take patient satisfaction into account.3
~~tr~~eno~~ Anesthetics Thiopental is the least costly inrravenozs (IV) anesthetic. It is the standard against which al1 other IV drugs must be compared. It does, however, have disadvantages (e.g., prolonged sedation nausea, porphyria contraindication) that have fueled the search for- the ultimate IV anesthetics for induction and maintenance. The incidence of nausea and vomiting following a single IV induction dose of either ketamine or etomidate is significantly greater than if a barbiturate is used.4-6 When reviewing more than 5,000 cases from the world literature, the incidence of emetic symptoms following propofol was 2.2% compared with 10.1% for thiopental and 1 I .6% for methohexital.” Propofol also has significant advantages over thiopental, etomidate, and ketamine in the quality and speed of awakening. Bropofol costs more than thiopental-isor?urane. Why use it? One study observed that propofol-treated patients tolerated oral fluids significantly faster and experienced fewer emetic symptoms than did thiopental-isoflurane treated patients.’ For patients who experienced emetic symptoms in both groups, the propofol-treated patients were still discharged significantly faster. educed demands on PACU resources have been noted when propofol was used.R,g Propofol apparently decreased the time that patients spent in the PACU and the amount and intensity of nursing care they required (Tabldj. In another study, propofol-treated *Stuart
j.
Total Anesthetic Gosts
Xnesth.,
Pharmaceuticals.
Lroi. 4 (Suppl
Data on file.
I), SeptemberiOctober-
1992
21s
Table 3.
Postanesthesia
Care
Cnit Workload
Patient in Phase 1 (min) Patient in Phase 2 (min) RN care per patient (min) RN care per day (hr)* *Derived from economic RN = registered nurse.
37.5 81.4 64.6 29.1
averaged 15 minutes less time in the first phase lof recovery than did thiopental-~so~~ra~e treated patients. lo It was projected in a 4,000 caseper-year facility that propofol would save I,000 nursing hours. Propofol-treated patients had a significantly lower incidence of nausea and vomiting, took an average of 10 hours less time to resume normal activities, and returned to work a half day sooner than did thiopental-isoflurane-treated counterparts. These studies suggest that propofol could achieve more efficient use of nursing staff compared with thiopental-isoflurane. Although more costly initially, propofol may nonetheless exert a more global affect on the economics of the healthcare delivery system than less expensive agents. To achieve savings, however, PACU discharge must be geared to scoring systems for discharge criteria rather than designated time spent in the recovery area, and the facility’s nursing staff must be flexible and mobile.“~lz
Which inhalational anesthetic is best suited to adult ambulatory procedures? Although many anesthesiologists believe that isoRurane offers speedier and more trouble-free recovery than does enflurane, Bandit and colleaguesr3 noted no difference between the agents in comparing quality of recovery, speed of recovery, time to ambulation, and time to discharge. In another study, patients given isoflurane did not display any difference in recovery characteristics when procedures lasting less than 40 minutes and t lasting longer than 90 minutes were compared.* Enflurane-treated patients, however, bad an increased incidence of side effects and prolongation of recovery time for the longer procedures when compared with shorter procedures. Should we then seiectivePy use isoflurane for procedures that last longer than 90 minutes? *M Morttila, J Valanne: Recovery after outpatient isofiurane enflurane anesthesia [Abstract]. An&h Analg 1985;64:S239. J. Clin.
Anesth.,
vol. 4 (Suppl
21.0 74.5 45.8 20.6
- 16.5 -6.9 - 18.8 - 8.5
model applied to clinical data.
patients
22s
Reduction
and
I), September/October
Table
4.
Inhalational
Anesthetic
(ml Liquid)
Consumed
---
1 2 3 4 5
1.5 3 4.5 7.:
3 6 9 12 15
6 12 I.2 24 36
9 18 18 36 45
A simple formula can determine the cost of inhalationai anesthetics. The amount of inhalational an-
ufacturer of isoflurane and enflurane, more complex formula that takes into consi molecular weight and specific gravity tional drugs. The numbers for iso flurane are similar regardless of which The cost to my department for each of the three major inhalational anesthetics is pr For a l-hour ambulatory surgical 5-1 flow and a 1% concentration tb TEC vaporizer (Qhmeda, BOC ealth Care Inc., 3.20, enflurane alveolar concentratio flurane, 1.15; enflurane, 1.68), isofhrrane costs $15. I$, enflurane $15.12, not mcluding any other drugs or ad_juvants, Uniformly decreasing fresh gas flow rate from 5 !/mm to 2.5 limin while maintaining the same anesthetic concentration could save $225 million a year million in the U.S.)J4 In my deper hour savings would be realized US. 5 l/mm isoflurane 1%. Average annual savings per 8 (4-hour use, 5 dayslwk) wou%d approximate $8,300. *ME Antebi, AJ Patel: Cost containment in anesthesia. Presented at the American Society of AnesthesiologistsAnnual Meeting, 1990.
1992
Ecowvnic impact
gfanesthe,ria
decision m&zg:
@fet&e~-
hemodynamic stability is essential or when procedures run more than 3 hours. hen cijmpared with atracurium or vecuronium, nei er doxacurium nor pipecuronium is cost-effective for procedures that last less than 2-l/2 to 3 hours.
wkn
To reverse muscre relaxation,
10 ml costs $1.95; compare that with ! 5 ml o which costs $9.76. That is $.6O to $.M of neostigmine and $3.25 to $4.50 for 50 to 70 mg of edrophonium. Can we then justify routine use of
k;iglare 1, Cost per rpliof inhaIationa1 anesthetics.
A I.-mg/ml vial of atropine costs $22; a O.4-mgiml ampule of atropine costs $.22. By switching from ampules to vials, my department saves approximately $ .44 every time we use atropine as part of our reversal process. We should evaluate packaging, and we have to address issues of waste-how much Es left over in the ampule or vial? Pharmaceutical companies must be responsive to unit-dose packaging; waste must be included in cost to the facility.
Although succinylchoiine is the least expensive muscle relaxant, it can cause prolonged apnea and significant postanesthesia myalgia lasting from 24 to 72 hours. Succinylcholine also slows return to normal activities lay return to work. at home and ma ess the cost of several drugs that we must compare ap tent MAC for inhalational drugs ting doses for muscle relaxants. For 30 minutes of muscle relaxation in a TO-kg patient, ared succinyicholine in a flow pack ($9.20); oline in a vial ($2.94); vecuronium ($12.32); atracurium (.$14.‘iO); and mivacurium $10.80 (Table 5). Itiivacurium is competitive in cost with the older
often hear a surgeon say, ‘“Let me have Some Marcaine.” y checking with your phazmacy, you may find that bupivacaine under the trade name MarCaine@ (Winthrop) may be more costlythan bupivaCaine under the trade name Sensorcaine@ (Astra). In the ambulatory surgery patient, s~~p~e~e~ting IV or inhalation anesthetics with local or regional block decreases postoperative opioid requirements and PACU length of stay. The resultant savings to third-party payers more than offsets the charges for the local anesthetic. Postoperative pain following ingufnal hernia surgery can be controlled with local anesthetic splashed or sprayed into the wound, infiltration of the ilioWe
ow are costs and roles of the longer-acting muscle relaxants interrelated? At Methodist Medical Center, 1 mg of doxacurium costs $5.94; pipecuronium, $3.50; Pavulon@ (pancuronium, Organon), $1.2 1; generic pancuronium, $.I$. For procedures that last an hour or more in healthy patients, generic pancuronium would be my muscle relaxant of choice. As an example costly drug for a specific patient group, r using doxacurium or pipecuronium le 5.
Costs of‘lntubation and Maintenance: 30 Minutes in a ‘JO-kg Patient*
$9.20 *1992 costs to the Methodist tFlow-pack + Vial
Atraeurium (Tracriuma Burroughs
Succinylcholine (Quelicin@ il: Abbott)
Vecuronium (~or~~~~~~ O~~aA~A~
Welkome)
$2.94
$12.32
914.70
Medical Center of Illinois.
J. Gin.
Anesth.,
vol. 4 (Suppl I), Septemher/Octobes
1992
23s
Original Contributions
i~~u~ua~~iiiohy~oga§tric nerves by the surgeion, or administration of caudal block by the anesthesiologist. All three techniques provide comparable pain relief and early ambulation. r5-18 The splash technique is probably the least costly and has the fewest side effects. Ilioinguinal/iliohypogastric block during closure would be equally cost effective. Caudal block is costly and has the potential for more significant side effects.
Every one of us must give thought to becoming prudent providers. We must address issues direct and indirect costs. Costs impact on the profi ility of the facility in which we work; charges impact ion the healthcare delivery system. We must be aware of bow our choices affect both areas.
1 I.
2. 3. 4.
5.
6.
7.
24s
Medicare Compliance Alert: Bethesda, Maryland, October 16, 1989. Saidman LJ: The role of desflurane in the practice of anesthesia. Anesthesiology 1991;74:399-401. Cost considerations in anesthesiology: ambulatory anesthesia. Health Education Technologies, 1992. Thompson GE, Remington MJ, Millman BS, Bridenbaugh LD: Experiences with outpatient anesthesia. Anesth Analg 1973;52:881-7. Fragen RJ, Caldwell h’: Comparison of a new formulation of etomidate with thiopental: side effects and awakening times. AnesthesialoB 1979;50:242-4. Horrigan RW, Moyers JR, Johnson BH, Eger EI II, Margolis A, Goldsmith S: Etomidate vs. thiopental with and without fentanyl: a comparative study of awakening in man. Anesthesiology 1980;52:362-4. Korttila K, Ostman P, Faure E, et al: Randomized comparison of recovery after propofol-nitrous oxide versus thiopentone-isoflurane-nitrous oxide anaesthesia in pa-
J. Clin. Anesth., vol. 4 (Suppl I), September-/October
tients irndergoing ambulatory surgery. Artu AnaeslJEesaoJ Scolnd 1990;34:400-3. BV, et ai: Kedwed 8. Marais ML, Maher MW, Wekhler demands on recovery room resources with prop~fol (Diprivan) compared to thiogental-isonurarse. AnesQrRev H989;16:29-40. 9. Marais ML, Maher MW, Wetchler BV, et al: An adaptable computer model of the economic effects of aiternative anesthetic regimens in outpatiene surgery. Anesthesiology !990;93:A54. 10. Sung YE, Reiss N, Tillette T, et al: The differential cost of anesthesia and recovery with propofoi-nitrous oxide anesthesia versus thiopental sodium-isofiurane-nitrous oxide anesthesia./ Clin Anesth 1991;3:391-4. II. Wetchler BV: Problem solving in the postanesthesia care unit. In: Wetchler BV, ed. Anesthesia~oor Ambui~to~ Surge?. 2nd ed. Philadelphia: JB Lippincott, 3991:375436. 12. Chung F, Ong D, Seyone 6, et al: A new postanesthetic discharge scoring system for ambulatory surgery. AnesUz Analg 1991;71:§42. IS. Pandit SK, Levy L, Randel GI: Which volatile anesthetic for outpatient anesthesia? Quality and speed of recovery. Anesth Analg 1990;7O:S293. 14. Lampotang S, Nyland ME, Gravenstein N: The cost of wasted anesthetic gases [Abstract]. Anesth Anulg 199:; 71:§!51. 15. Shandling B, Steward DJ: Regional analgesia for postoperative pain in pediatric outpatient surgery.~/ P&atr SU?“~i980;15:477-80. 16. Sinclair R, Cassuto J, Hogstrom 3, et al: Topical anesthesia with lidocaine aerosol in the control of postoperative pain. AnesthesioloB 1988;68:895-901. 17. Casey WF, Rice LJ, Hannallah RS, Broadman L, NorM, Guzzetta P: A comparison between bupivaCaine instillation versus ilioinguinal-iliohypogastric nerve block for postoperative analgesia following inguinal herniorrhaphy in children. Anesthesiology 1990;72:6379. 18. Hannallah RS, Broadman LM, Belman AS, et al: Comparison of caudal and ihoinguinal-ihohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology P987;56:832-4.
1992
anesthetics,
e&ion making, economics of; inhalational cost of; neuromuscular blocking agents, cost oft
ete” Stark has abe fdoaving
03
ctof to have to stand up, face
*Clinical
the East and say to the Gent, ‘I’m a greedy son of a bitch and I’m sending you to a facility re you’re going to be charged an outrageous stum for a procedure which is probably not necessary, may be harmful to your health, and I will pocket a large bunch of money for ris your come very close to doing things I protmised not to do hen 1 pocsatic oath.’ “I care costs account for more t esthesiologists or a~e~theti~t§ have any cones our choice of anesthetic drugs or techesthesia-care length of stay and potential niques have an impact on post ds of care because they may provide us ollar costs? Do we select me with additional income? We may have a say about cost, but to do so may requke a change in our practice pattern mind-set. That is not aiways easy; there are two constants in the world of healthcare-change and resistance to change.
Professor
Address reprint request5 to Dr. Wetchler at Department of Anesthesia, Methodist Medical Center of Illinois, 221 NE Glen Oak, Peoria, IL 61636, USA. Al! prices in this articie reflect 1992 costs to the Methodist Medical Center of Illinois. 0 1992 Butterworth-Heinemann j_ Clin. Anesth.
J. Clin.
4(Suppl
Anesth.,
P):2QS-24S,
1992.
vol. 4 (Suppl
At varying times the yers, consurners, and pr all used the term “c -effective quahty care.” fective quality care depends on the differing Gent wants the best available care; cost is never bealthcare players. The g as they are not aying the bill. Governnxnt, an issue with patients as corporate America, the insurance industry-the so-called &ix-d-party payI), SeptemberDctober
1992
Economic Impact of anesthesia dectiion making: Wetchler
ers-are interested in the lowest possible costs for to as safe care. For physicians and what is referre providers, cost must enter into quality-of-care decision making. anesthesiologists should not allow cost to be rriding factor in determining our choice of an tic drug or a particular technique (Table I). We must address how our choice affects the patient in both the operating room (OR) and the postanesthesis care unit (PACU) and how rapidly the patient can return to normal activities at home and in the workplace. Although it appears that the incentive for anesthesiologists to search out less expensive means of providing care is limited, fiscally responsible choices may nonetheless affect the very existence of the facility in which we practice. Saidman, in assessing the role of desflurane in the practice of anesthesia, asks, “Is desflurane sufficiently better than currently available inhaled anesthetics, esto warrant widespread incorpopecially isoflurane ractice?“2 The criteria applied to ration into clinical this assessment could and should be applied to any e must determine answers to the new anesthetic. following three questions: (1) Is the new agent sufficiently better than currently available anesthetics? (2) Are there added costs associated with the use of the new anesthetic? (3) Are there potential cost savings that could result from decreased patient morbidity and duration of PACIJ stay by using the new drug? Every new anesthetic drug that becomes available should be compared with currently available, similar drugs to assess associated morbidity, time to arousal, time to discharge, and anesthetic-related costs. New anesthetics must offer unique and important benefits to patients, to anesthesiologists, and to the healthcare system.
e must begin to think in terms of both direct and indirect costs (Table 2). Direct costs include not only the cost of the anesthetic but the additional cost of adjuvants, equipment, and drug waste. Indirect costs take into consideration the OR turnover time between cases-bow quickly and safely the patient can be moved from the OR to the PACIJ; length of stay in the PACK; Anesthesiologist Decision Making Intra-anesthetic effects Postanesthesia side effects Postanesthesia length of stay Return to normal activities Cost
%a:2,
Agent Acljuvants
Clin.
Turnever time PACU stay Staff time Unanticipated admission Equipment maintenance Pa&nt satisfaction
PAW
= postanesthesia
care unit.
intensity of PACU care needed; and equipment maintenance. For ambulatory surgery patients, anesthesiarelated unanticipated hospitalization should be considered an indirect expense. When we use controlled aperwork time must be substances, personnel and added into cost. Indirect costs must ah take patient satisfaction into account.3
~~tr~~eno~~ Anesthetics Thiopental is the least costly inrravenozs (IV) anesthetic. It is the standard against which al1 other IV drugs must be compared. It does, however, have disadvantages (e.g., prolonged sedation nausea, porphyria contraindication) that have fueled the search for- the ultimate IV anesthetics for induction and maintenance. The incidence of nausea and vomiting following a single IV induction dose of either ketamine or etomidate is significantly greater than if a barbiturate is used.4-6 When reviewing more than 5,000 cases from the world literature, the incidence of emetic symptoms following propofol was 2.2% compared with 10.1% for thiopental and 1 I .6% for methohexital.” Propofol also has significant advantages over thiopental, etomidate, and ketamine in the quality and speed of awakening. Bropofol costs more than thiopental-isor?urane. Why use it? One study observed that propofol-treated patients tolerated oral fluids significantly faster and experienced fewer emetic symptoms than did thiopental-isoflurane treated patients.’ For patients who experienced emetic symptoms in both groups, the propofol-treated patients were still discharged significantly faster. educed demands on PACU resources have been noted when propofol was used.R,g Propofol apparently decreased the time that patients spent in the PACU and the amount and intensity of nursing care they required (Tabldj. In another study, propofol-treated *Stuart
j.
Total Anesthetic Gosts
Xnesth.,
Pharmaceuticals.
Lroi. 4 (Suppl
Data on file.
I), SeptemberiOctober-
1992
21s
Table 3.
Postanesthesia
Care
Cnit Workload
Patient in Phase 1 (min) Patient in Phase 2 (min) RN care per patient (min) RN care per day (hr)* *Derived from economic RN = registered nurse.
37.5 81.4 64.6 29.1
averaged 15 minutes less time in the first phase lof recovery than did thiopental-~so~~ra~e treated patients. lo It was projected in a 4,000 caseper-year facility that propofol would save I,000 nursing hours. Propofol-treated patients had a significantly lower incidence of nausea and vomiting, took an average of 10 hours less time to resume normal activities, and returned to work a half day sooner than did thiopental-isoflurane-treated counterparts. These studies suggest that propofol could achieve more efficient use of nursing staff compared with thiopental-isoflurane. Although more costly initially, propofol may nonetheless exert a more global affect on the economics of the healthcare delivery system than less expensive agents. To achieve savings, however, PACU discharge must be geared to scoring systems for discharge criteria rather than designated time spent in the recovery area, and the facility’s nursing staff must be flexible and mobile.“~lz
Which inhalational anesthetic is best suited to adult ambulatory procedures? Although many anesthesiologists believe that isoRurane offers speedier and more trouble-free recovery than does enflurane, Bandit and colleaguesr3 noted no difference between the agents in comparing quality of recovery, speed of recovery, time to ambulation, and time to discharge. In another study, patients given isoflurane did not display any difference in recovery characteristics when procedures lasting less than 40 minutes and t lasting longer than 90 minutes were compared.* Enflurane-treated patients, however, bad an increased incidence of side effects and prolongation of recovery time for the longer procedures when compared with shorter procedures. Should we then seiectivePy use isoflurane for procedures that last longer than 90 minutes? *M Morttila, J Valanne: Recovery after outpatient isofiurane enflurane anesthesia [Abstract]. An&h Analg 1985;64:S239. J. Clin.
Anesth.,
vol. 4 (Suppl
21.0 74.5 45.8 20.6
- 16.5 -6.9 - 18.8 - 8.5
model applied to clinical data.
patients
22s
Reduction
and
I), September/October
Table
4.
Inhalational
Anesthetic
(ml Liquid)
Consumed
---
1 2 3 4 5
1.5 3 4.5 7.:
3 6 9 12 15
6 12 I.2 24 36
9 18 18 36 45
A simple formula can determine the cost of inhalationai anesthetics. The amount of inhalational an-
ufacturer of isoflurane and enflurane, more complex formula that takes into consi molecular weight and specific gravity tional drugs. The numbers for iso flurane are similar regardless of which The cost to my department for each of the three major inhalational anesthetics is pr For a l-hour ambulatory surgical 5-1 flow and a 1% concentration tb TEC vaporizer (Qhmeda, BOC ealth Care Inc., 3.20, enflurane alveolar concentratio flurane, 1.15; enflurane, 1.68), isofhrrane costs $15. I$, enflurane $15.12, not mcluding any other drugs or ad_juvants, Uniformly decreasing fresh gas flow rate from 5 !/mm to 2.5 limin while maintaining the same anesthetic concentration could save $225 million a year million in the U.S.)J4 In my deper hour savings would be realized US. 5 l/mm isoflurane 1%. Average annual savings per 8 (4-hour use, 5 dayslwk) wou%d approximate $8,300. *ME Antebi, AJ Patel: Cost containment in anesthesia. Presented at the American Society of AnesthesiologistsAnnual Meeting, 1990.
1992
Ecowvnic impact
gfanesthe,ria
decision m&zg:
@fet&e~-
hemodynamic stability is essential or when procedures run more than 3 hours. hen cijmpared with atracurium or vecuronium, nei er doxacurium nor pipecuronium is cost-effective for procedures that last less than 2-l/2 to 3 hours.
wkn
To reverse muscre relaxation,
10 ml costs $1.95; compare that with ! 5 ml o which costs $9.76. That is $.6O to $.M of neostigmine and $3.25 to $4.50 for 50 to 70 mg of edrophonium. Can we then justify routine use of
k;iglare 1, Cost per rpliof inhaIationa1 anesthetics.
A I.-mg/ml vial of atropine costs $22; a O.4-mgiml ampule of atropine costs $.22. By switching from ampules to vials, my department saves approximately $ .44 every time we use atropine as part of our reversal process. We should evaluate packaging, and we have to address issues of waste-how much Es left over in the ampule or vial? Pharmaceutical companies must be responsive to unit-dose packaging; waste must be included in cost to the facility.
Although succinylchoiine is the least expensive muscle relaxant, it can cause prolonged apnea and significant postanesthesia myalgia lasting from 24 to 72 hours. Succinylcholine also slows return to normal activities lay return to work. at home and ma ess the cost of several drugs that we must compare ap tent MAC for inhalational drugs ting doses for muscle relaxants. For 30 minutes of muscle relaxation in a TO-kg patient, ared succinyicholine in a flow pack ($9.20); oline in a vial ($2.94); vecuronium ($12.32); atracurium (.$14.‘iO); and mivacurium $10.80 (Table 5). Itiivacurium is competitive in cost with the older
often hear a surgeon say, ‘“Let me have Some Marcaine.” y checking with your phazmacy, you may find that bupivacaine under the trade name MarCaine@ (Winthrop) may be more costlythan bupivaCaine under the trade name Sensorcaine@ (Astra). In the ambulatory surgery patient, s~~p~e~e~ting IV or inhalation anesthetics with local or regional block decreases postoperative opioid requirements and PACU length of stay. The resultant savings to third-party payers more than offsets the charges for the local anesthetic. Postoperative pain following ingufnal hernia surgery can be controlled with local anesthetic splashed or sprayed into the wound, infiltration of the ilioWe
ow are costs and roles of the longer-acting muscle relaxants interrelated? At Methodist Medical Center, 1 mg of doxacurium costs $5.94; pipecuronium, $3.50; Pavulon@ (pancuronium, Organon), $1.2 1; generic pancuronium, $.I$. For procedures that last an hour or more in healthy patients, generic pancuronium would be my muscle relaxant of choice. As an example costly drug for a specific patient group, r using doxacurium or pipecuronium le 5.
Costs of‘lntubation and Maintenance: 30 Minutes in a ‘JO-kg Patient*
$9.20 *1992 costs to the Methodist tFlow-pack + Vial
Atraeurium (Tracriuma Burroughs
Succinylcholine (Quelicin@ il: Abbott)
Vecuronium (~or~~~~~~ O~~aA~A~
Welkome)
$2.94
$12.32
914.70
Medical Center of Illinois.
J. Gin.
Anesth.,
vol. 4 (Suppl I), Septemher/Octobes
1992
23s
Original Contributions
i~~u~ua~~iiiohy~oga§tric nerves by the surgeion, or administration of caudal block by the anesthesiologist. All three techniques provide comparable pain relief and early ambulation. r5-18 The splash technique is probably the least costly and has the fewest side effects. Ilioinguinal/iliohypogastric block during closure would be equally cost effective. Caudal block is costly and has the potential for more significant side effects.
Every one of us must give thought to becoming prudent providers. We must address issues direct and indirect costs. Costs impact on the profi ility of the facility in which we work; charges impact ion the healthcare delivery system. We must be aware of bow our choices affect both areas.
1 I.
2. 3. 4.
5.
6.
7.
24s
Medicare Compliance Alert: Bethesda, Maryland, October 16, 1989. Saidman LJ: The role of desflurane in the practice of anesthesia. Anesthesiology 1991;74:399-401. Cost considerations in anesthesiology: ambulatory anesthesia. Health Education Technologies, 1992. Thompson GE, Remington MJ, Millman BS, Bridenbaugh LD: Experiences with outpatient anesthesia. Anesth Analg 1973;52:881-7. Fragen RJ, Caldwell h’: Comparison of a new formulation of etomidate with thiopental: side effects and awakening times. AnesthesialoB 1979;50:242-4. Horrigan RW, Moyers JR, Johnson BH, Eger EI II, Margolis A, Goldsmith S: Etomidate vs. thiopental with and without fentanyl: a comparative study of awakening in man. Anesthesiology 1980;52:362-4. Korttila K, Ostman P, Faure E, et al: Randomized comparison of recovery after propofol-nitrous oxide versus thiopentone-isoflurane-nitrous oxide anaesthesia in pa-
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