Cost effectiveness of general anaesthesia: inhalation vs i.v

Propofol and halothane versus sevoflurane in paediatric day-case surgery: induction and recovery characteristics

BACKGROUND

The aim of this study was to compare the induction and recovery characteristics associated with propofol induction and halothane maintenance with sevoflurane anaesthesia in paediatric day surgery.

METHODS

In total, 322 children were assigned randomly to i.v. propofol induction and halothane/nitrous oxide maintenance or sevoflurane/nitrous oxide alone. The patients' age, sex, and type of surgery were recorded, as were the times required for anaesthetic induction, maintenance, recovery and time to discharge home. Postoperative nausea and vomiting, and the incidence of adverse events during induction and recovery were also noted.

RESULTS

No significant differences were detected in age, sex, type of surgery performed or intraoperative opioid administration. Excitatory movement was more common during induction with sevoflurane. The mean time required for induction with propofol was 3.1 min compared with 5 min in the sevoflurane group (P<0.001). The recovery time was shorter in the sevoflurane group compared with propofol/halothane (23.2 vs 26.4 min, P<0.002). The incidence of delirium in recovery was greater in the sevoflurane group (P<0.001). There was no difference between groups in the time spent on the postoperative ward before discharge home. On the postoperative ward the incidence of both nausea and vomiting was significantly higher in the sevoflurane group (P=0.034). Five children were admitted to hospital overnight, none for anaesthetic reasons.

CONCLUSIONS

The increased incidence of adverse events during induction, postoperative nausea and vomiting and postoperative delirium in the sevoflurane group suggests that sevoflurane is not ideal as a sole agent for paediatric day case anaesthesia.

Prospective, randomized cost analysis of anesthesia with remifentanil combined with propofol, desflurane or sevoflurane for otorhinolaryngeal surgery

BACKGROUND

In the era of cost containment, cost analysis should demonstrate the cost-effectiveness of new anesthetic drugs.

METHODS

This single-blind, prospective, randomized study compared the costs of three remifentanil (REM)-based anesthetic techniques with a conventional one in 120 patients undergoing otorhinolaryngeal surgery. The patients were randomized (n=30 each group) to either receive a combination of REM with propofol, desflurane or sevoflurane, or a conventional anesthetic with thiopentone, alfentanil, isoflurane and N2O.

RESULTS

The costs for anesthetic and nonanesthetic drugs and for disposables were twice as high in the three REM-based groups as in the conventional group (REM/PRO 0.51 Euro;/min, REM/DES 0.42 Euro;/min, and REM/SEVO 0.41 Euro;/min vs. 0.18 Euro;/min in the ALF/ISO/N2O group; P<0.05). Wastage of intravenous drugs accounted for up to 40% of total costs. In all REM groups, early recovery was predictably faster and more complete (P<0.05). Patient satisfaction was equally high (90-97%) in all groups, with less nausea in the REM/PRO group.

CONCLUSION

This study demonstrates that REM-based anesthetic techniques are more expensive than a conventional technique using alfentanil, isoflurane and N2O. This is the result of higher costs of anesthetic and nonanesthetic drugs and of disposables. The wastage of intravenous drugs contributes considerably to these costs.

Sevoflurane vs. isoflurane: a clinical comparison in day surgery

Discharge times after ambulatory surgery are determined by postoperative complications and in particular by the presence and severity of nausea and vomiting. Sevoflurane has become a popular agent for day-case surgery despite little evidence of clear advantages over current alternatives. We compared this agent with isoflurane in day-case patients undergoing knee arthroscopy in order to quantify the incidence of complications associated with each agent. One hundred and eighty patients received a standardised anaesthetic induction with propofol and fentanyl followed by maintenance with either isoflurane or sevoflurane. Standardised postoperative analgesic and anti-emetic drugs were prescribed. Any intra-operative cardiovascular or respiratory instability was recorded. After surgery, nausea, vomiting and pain were assessed. Almost all patients made an uneventful recovery and were discharged as scheduled. There was a significantly higher incidence of complications in the sevoflurane group. These included the presence of nausea and vomiting, and cardiovascular and respiratory complications. We found nothing to commend the routine use of sevoflurane rather than isoflurane in the context of day case anaesthesia.

Cost-effectiveness of anaesthesia

Cost-effectiveness analyses of anaesthesia regimens will become more and more important in the future because of increasing pressure to reduce the cost of health care. Inhalational and intravenous techniques are vying for the position of being the most cost-effective form of general anaesthesia. However, erroneous or misleading results are a considerable risk if the boundary conditions of the analyses are not chosen carefully. Recent comparative studies on this topic are analyzed with regard to their results and to the premises under which they were conducted.

Anaesthetic drug costs in a district general hospital day surgery unit

Propofol infusions for the induction and maintenance of anaesthesia are associated with many advantages. In some units their cost is thought to be prohibitive and limits their use. We have analysed the drug costs within a Day Surgery Unit over a 4-year period in order to quantify the cost of the increased use of these infusions. In our unit this has not resulted in increased anaesthetic drug costs. We therefore advocate the continued use and development of these techniques which have been shown to have many advantages both to patients and to the smooth and efficient running of theatre units.

Cost considerations in the use of anaesthetic drugs

Anaesthetic drugs typically comprise approximately 5% or less of a hospital pharmacy budget, yet they are a common target for cost reduction measures. In particular, there is considerable pressure to use less costly products where alternatives exist and to limit the introduction of expensive new items. In considering strategies to reduce a departmental drug budget, or in defending against restrictions imposed from outside, it is important to consider all of the costs associated with anaesthetic drug delivery. These costs comprise not only the expense of the anaesthetic drugs themselves, but also fixed and variable costs associated with their delivery and related to their effects. Elimination of drug waste will always be beneficial, since it has no direct effect on the patient yet clearly reduces cost. Waste is by no means confined to anaesthetic drugs, however. Using less expensive drugs may appear an attractive option and can reduce costs, provided that patient outcome is in no way affected. Rarely is this the case. Once patient care is modified, through changes in recovery times or complication rates, determining the true cost of the intervention becomes essential; there may be increases in indirect costs which dwarf the apparent savings. Sometimes indirect costs will rise by a lesser amount than savings in direct costs, such that there is still an overall benefit but less than that originally anticipated. Exactly how indirect effects result in indirect costs is highly variable. The requirement for additional drugs or supplies to treat an adverse event, such as emesis, will always have an associated cost. Delayed recovery or prolonged hospital stay will waste operating room time or increase the amount of time that a patient requires nursing care, but whether this carries an associated cost depends on what the staff would otherwise have been doing. Depending on the employment method, staff may have been sent home early (with less pay) or employed at identical cost but with less to do. Many studies which purport to consider all costs either ignore such issues, or make invalid assumptions. These issues are complex, but anyone involved with decisions concerning anaesthetic costs should be familiar with the underlying principles and be able to make a rational assessment of the likely indirect costs in their own institution.