Under “real world” conditions, desflurane increases drug cost without speeding discharge after short ambulatory anesthesia compared to isoflurane

PURPOSE

To compare the measured "real world" perioperative drug cost and recovery associated with desflurane- and isoflurane-based anesthesia in short (less than one hour) ambulatory surgery.

METHODS

We conducted a prospective, randomized, blinded trial with patients undergoing arthroscopic meniscectomy under general anesthesia. Following iv induction, patients received either isoflurane (group I; n = 25) or desflurane (group D; n = 20) for maintenance. The primary outcome variable was total perioperative drug cost per patient in Canadian dollars. Secondary outcome variables included volatile agent consumption and cost, adjuvant anesthetic and postanesthesia care unit (PACU) drug cost, readiness for PACU discharge, and incidence of adverse events.

RESULTS

Total perioperative drug cost per patient was 14.58 +/- 6.83 Canadian dollars (mean +/- standard deviation) for group I, and 21.47 +/- 5.18 Canadian dollars for group D (P < 0.001). Isoflurane consumption per patient was 6.0 +/- 3.0 mL compared to 18.6 +/- 7.7 mL for desflurane (P < 0.0001); corresponding costs were 0.83 +/- 0.42 Canadian dollars vs 7.61 +/- 3.15 Canadian dollars (P < 0.0001). There were no differences in adjuvant anesthetic or PACU drug cost. All but one patient from each group were deemed ready for PACU discharge at 15 min postoperatively (Aldrete score >or= 9). One patient in group D experienced postoperative nausea. No other adverse events were noted.

CONCLUSIONS

Measured total perioperative drug cost for a short ambulatory procedure (less than one hour) under general anesthesia was higher when desflurane rather than isoflurane was used for maintenance, essentially due to volatile agent cost. Desflurane use did not translate into faster PACU discharge under "real world" conditions.

[Impact of the decrease of nitrous oxide use on the consumption of halogenated agents]

OBJECTIVE

Nitrous oxide (N2O) toxicity and its impact on pollution lead to restrict its use. A decrease of N2O consumption should increase the hypnotic inhaled consumption. This monocentric study estimated consumptions and costs of halogenated agents (HA) and N2O over 5 years when the N2O consumption was reduced.

STUDY DESIGN

Retrospective from a computerized database.

PATIENTS

Between 2006 and 2010, 34,097 procedures were studied after two meetings exposing the risks of the N2O.

METHODS

At the end of anesthesia, consumptions of hypnotic agents (millilitres transmitted by the injectors and the blender) were archived in the database. The annual consumption of agents was obtained by adding the individual consumptions, then divided by the annual number of cases. The costs were given by the hospital pharmacy from invoices.

RESULTS

N2O consumption per anesthesia constantly decreased during the study, from 75.1L by act to 22.7L. The sum of the annual consumptions of N2O and air did not change suggesting that total fresh gas flow remained stable. Between 2006 and 2010, the sevoflurane consumption by act increased by 25%, from 16.5 to 20.6mL, and desflurane consumption by 37%, from 46.1 to 63.1mL by patient. The costs of the administration of hypnotic agents remained stable.

CONCLUSION

N2O consumption decrease had an impact on the consumption of HA. The cost reduction of the N2O was counterbalanced by the increase of halogenated vapor cost. The profit of the ecological impact of the reduction in N2O use could be quantified.

Desfluran und Isofluran bei Niedrigflussnarkosen

BACKGROUND

In the present investigation we compared the consumption of desflurane (DES) and isoflurane (ISO) using a standardized minimal-flow protocol with a forced reduction of the fresh gas flow (FGF).

METHODS

54 adult women were examined. After induction of anaesthesia a forced reduction of the FGF was started: 5 min 0.5 l/min O(2) + 1 l/min N(2)O, 10 min 0.5 l/min O(2) + 0.5 l/min N(2)O; finally 0.3 l/min O(2) + 0.2 l/min N(2)O up to the end of surgery. The consumption of DES/ISO was determined with a precision balance.

RESULTS

In the DES group the uptake was around 0.3 vol-%, i.e. less than 8% of the target 2/3 MAC value was taken up. For ISO the uptake was around 0.25 vol-%, i.e. the uptake was approximately 30% of the target 2/3-MAC value. The DES consumption was after 60 min 17.0+/-1.1 g, 120 min--27.3+/-1.8 g and 180 min--36.5+/-1.7 g. ISO consumption was significantly lower: 7.6+/-0.8 g, 12.4+/-1.7 g and 15.5+/-1.6 g. The use of DES yielded higher costs, i.e. 2.28 EUR for 60 min, 3.63 EUR for 120 min and 4.97 EUR for 180 min. The consumption of the inhaled anaesthetics can be calculated as: DES (g)=4.84+0.184 x duration (min) (R(2)=0.981), ISO (g)=2.049+0.0826 x duration (R(2)=0.979). The costs are: DES (EUR)=0.85+0.0323 x duration (min); ISO (EUR)=0.19+0.0077 x duration (min).

CONCLUSION

With a forced reduction of the FGF the DES consumption is still higher.

Efficacy and costs of 3 anesthetic regimens in the prevention of postoperative nausea and vomiting

STUDY OBJECTIVE

The aim of the study was to compare the antiemetic efficacy and costs associated with 3 different anesthesia regimens used in gynecologic laparoscopy.

DESIGN

This was a randomized, controlled study.

SETTING

The study was conducted at a university hospital.

PATIENTS

We studied 150 ASA physical status I or II patients, undergoing elective gynecologic laparoscopy with general anesthesia.

INTERVENTION

Patients were allocated into the following 3 groups: group P-preoperative placebo tablet, propofol induction, propofol-air/O2 maintenance; group I + O-preoperative 8-mg ondansetron tablet, thiopental induction, isoflurane-N2O maintenance; group I (control)-preoperative placebo tablet, thiopental induction, isoflurane-N2O maintenance.

MEASUREMENTS

The frequency of postoperative nausea and vomiting (PONV), number needed to treat to prevent PONV, and the costs of the anesthetic drugs to prevent PONV in one additional patient were evaluated.

MAIN RESULTS

The frequency of PONV within the 24-hour study period was lowest in group I + O (P, 38%; I + O, 33%; and I, 59%; P < 0.05 I + O vs I). The number needed to treat was 5 in group P and 4 in group I + O, compared with group I. The median costs of anesthetic drugs to prevent PONV in one additional patient were $65 in group P and dollar 68 in group I + O, compared with group I.

CONCLUSIONS

We conclude that in gynecologic laparoscopy, propofol-air/O2 anesthesia alone, and isoflurane-N2O anesthesia combined with an oral 8-mg dose of ondansetron had similar efficacy and costs to prevent PONV. Isoflurane-N2O anesthesia without ondansetron was less expensive, but was also less efficacious.

Early recovery, cognitive function and costs of a desflurane inhalational vs. a total intravenous anaesthesia regimen in long-term surgery

BACKGROUND

The purpose of the study was to compare time of recovery, return of cognitive function, post-anaesthetic care unit (PACU) stay and costs of a propofol/remifentanil (TIVA) with a desflurane/fentanyl-based anaesthesia (desflurane group) in surgical procedures lasting more than 150 min.

METHODS

Forty-nine patients undergoing elective abdominal prostatectomy were allocated randomly to receive bispectal index (BIS)-controlled desflurane/fentanyl (n=24) or propofol/remifentanil (n=25). Awakening, clinical recovery, direct drug acquisition and post-operative pain treatment were documented. Cognitive skills were tested using the Mini-Mental Status (MMST) test.

RESULTS

Extubation was significantly faster with desflurane (6.9+/-3.5 min) than with TIVA (11.2+/-4.0 min) as well as times for stating name and date of birth (desflurane: 6.1+/-3.9 and 6.6+/-4.0 min; TIVA: 12.4+/-11.5 min and 13.4+/-11.3 min). There were no significant differences in PACU discharge times or MMS scores between the groups. Significantly more patients suffered post-operative nausea and vomiting (PONV) in the desflurane (33% vs. 0%) than the TIVA group. Overall costs were significantly higher in the TIVA (58.8+/-11.6 euro) than in the desflurane group (35.0+/-5.7 euro).

CONCLUSION

Patients undergoing prolonged surgical procedures showed a faster early recovery after desflurane/fentanyl than using TIVA, whereas stay in the PACU and recovery of cognitive function were similar in both groups. Costs of a TIVA regimen were significantly higher than using a desflurane-based anaesthesia technique.

Cost minimisation and cost effectiveness in anaesthesia for total hip replacement surgery, in Belgium? A study comparing three general anaesthesia techniques

The aim of the prospective randomised study is to compare the cost effectiveness of three general anaesthesia techniques for total hip replacement surgery and the cost minimisation by use of anaesthetics. For induction propofol was used in the three techniques. For maintenance, we used desflurane, or sevoflurane, or propofol. There was no significant difference in consumption of drugs for pain treatment, treatment of nausea and vomiting or cost of hospital stay or total cost for pharmacy. In terms of cost-effectiveness we can consider that the three techniques are similar. The cost of an i.v. technique was always higher than inhaled anaesthetics. The major cost in anaesthesia is the fee for the anaesthesiologist. But all in, the cost of anaesthesia was only 15.1% of the total cost of the procedure. Cost of inhaled or i.v. anaesthetics was 0.55% to 1.0% of the total cost. There was a discrepancy between the measured consumption of inhaled anaesthetics and the consumption (and cost) on the invoice. Cost minimisation based on anaesthetic medication is ridiculously by small considering the total cost of the procedure.

Inhalation Anesthesiology and Volatile Liquid Anesthetics: Focus on Isoflurane, Desflurane, and Sevoflurane

Clinical pharmacists rarely are involved in the selection and dosing of anesthetic agents. However, when practicing evidence-based medicine in a cost-conscious health care system, optimizing drug therapy is imperative in all areas. Thus, we provide general information on anesthesiology, including the different types of breathing systems and the components of anesthesia machines. Modern inhalation anesthetics that are predominantly used in clinical practice include one gas--nitrous oxide--and new volatile liquid agents--isoflurane, desflurane, and sevoflurane. Desflurane and sevoflurane are the low-soluble inhalation anesthetics, and they offer some clinical advantages over isoflurane, such as fast induction and faster recovery with long procedures. However, efficient use of isoflurane can match the speed of induction and recovery of the other agents in certain cases. In addition, the patient characteristics, duration and type of procedure, type of breathing system, and efficiency in monitoring must be considered when selecting the most optimal therapy for each patient. Maximizing the clinical advantages of these agents while minimizing the waste of an institution's operating room and pharmacy budget requires an understanding of the characteristics, pharmacokinetics, and pharmacodynamics of these anesthetic agents and the collaborated effort from both the anesthesia and pharmacy departments. An anesthetic agent algorithm is provided as a sample decision-process tree for selecting among isoflurane, desflurane, and sevoflurane.

Laryngeal mask airway can be inserted with inhaled desflurane induction

PURPOSE

In this prospective, randomized, controlled trial, we investigated the reliability of laryngeal mask airway (LMA) insertion with inhaled desflurane.

METHODS

Eighty patients undergoing elective surgery were randomized into two groups to receive either 2.5 mg x kg(-1) propofol (n = 40) or tidal breath desflurane (n = 40) induction followed by LMA insertion. All patients received fentanyl 1 microg x kg(-1) 2 min before induction. Inhalation of desflurane was started at 3% and increased by 3% every 3-5 breaths up to settings of 12%.

RESULTS

Insertion of the LMA was faster in the propofol group (131.8 s versus 228.6 s, P < 0.01). The number of patients in whom the jaw opening was described as good (95% versus 72.5%, P = 0.27, for the desflurane and propofol groups, respectively) and the ease of LMA insertion described as good (87.5% versus 72.5%, P = 0.6) were comparable. The LMA was inserted in a single attempt in the majority of patients in both groups (80% versus 77.5%, P = 0.90). There were more complications at insertion in the propofol group than in the desflurane group (2.5% versus 19.5%, P < 0.01), especially for apnea (7.5% versus 70%, P < 0.01) and excitatory movements (2.5% versus 25%, P < 0.01). There were significant decreases in the mean arterial pressure in the propofol group compared to baseline data over the first 5 min of induction. Mean arterial pressure, heart rate, and S(p)(O2) remained stable during the same period in the desflurane group.

CONCLUSION

We demonstrated that inhaled desflurane when used with caution in a controlled manner provided acceptable conditions for LMA insertion.

Fast-track eligibility, costs and quality of recovery after intravenous anaesthesia with propofol-remifentanil versus balanced anaesthesia with isoflurane-alfentanil

BACKGROUND AND OBJECTIVE

The randomized, patient- and observer-blinded study was performed in 120 patients undergoing ear, nose and throat surgery to test the hypothesis that intravenous anaesthesia with propofol-remifentanil when compared with a balanced anaesthesia technique using isoflurane-alfentanil improves the speed of recovery, minimizes postoperative side-effects and, thus, leads to an improved quality of recovery without increasing total costs.

METHODS

The total costs for each anaesthesia technique were calculated considering drug acquisition costs, personnel costs for the additional time spent in the operating room and the postanaesthesia care unit until fast-tracking eligibility, and the costs to treat the side-effects during and after operation.

RESULTS

The times from the end of surgery to tracheal extubation and the time until leaving the operating room were not different between the two groups. However, more patients receiving intravenous anaesthesia (80 versus 49%) were eligible for fast tracking and thus could bypass the recovery room. This was associated with an average cost saving of 6.00 euros per patient. However, intravenous anaesthesia was associated with higher total costs (89 euros versus 78 euros) mainly because of higher acquisition costs of the anaesthetics (34.60 euros versus 16.50 euros). There was no difference in the quality of recovery as measured by a Quality of Recovery score and patient satisfaction between the two groups.

CONCLUSIONS

The higher acquisition costs of the intravenous anaesthetics propofol and remifentanil cannot be compensated for by improved speed of recovery. This anaesthesia technique is more cost intensive than balanced anaesthesia using isoflurane and alfentanil.

Clinical and economic choices in anaesthesia for day surgery: a prospective randomised controlled trial

We compared the cost-effectiveness of general anaesthetic agents in adult and paediatric day surgery populations. We randomly assigned 1063 adult and 322 paediatric elective patients to one of four (adult) or two (paediatric) anaesthesia groups. Total costs were calculated from individual patient resource use to 7 days post discharge. Incremental cost-effectiveness ratios were expressed as cost per episode of postoperative nausea and vomiting (PONV) avoided. In adults, variable secondary care costs were higher for propofol induction and propofol maintenance (propofol/propofol; p < 0.01) than other groups and lower in propofol induction and isoflurane maintenance (propofol/isoflurane; p < 0.01). In both studies, predischarge PONV was higher if sevoflurane/sevoflurane (p < 0.01) was used compared with use of propofol for induction. In both studies, there was no difference in postdischarge outcomes at Day 7. Sevoflurane/sevoflurane was more costly with higher PONV rates in both studies. In adults, the cost per extra episode of PONV avoided was pound 296 (propofol/propofol vs. propofol/ sevoflurane) and pound 333 (propofol/sevoflurane vs. propofol/isoflurane).

Multicenter randomized comparison of the efficacy and safety of xenon and isoflurane in patients undergoing elective surgery

BACKGROUND

All general anesthetics used are known to have a negative inotropic side effect. Since xenon does not have a negative inotropic effect, it could be an interesting future general anesthetic. The aim of this clinical multicenter trial was to test the hypothesis of whether recovery after xenon anesthesia is faster compared with an accepted, standardized anesthetic regimen and that it is as effective and safe.

METHOD

A total of 224 patients in six centers were included in the protocol. They were randomly assigned to receive either xenon (60 +/- 5%) in oxygen or isoflurane (end-tidal concentration, 0.5%) combined with nitrous oxide (60 +/- 5%). Sufentanil (10 mcirog) was intravenously injected if indicated by defined criteria. Hemodynamic, respiratory, and recovery parameters, the amount of sufentanil, and side effects were assessed.

RESULTS

The recovery parameters demonstrated a statistically significant faster recovery from xenon anesthesia when compared with isoflurane-nitrous oxide. The additional amount of sufentanil did not differ between both anesthesia regimens. Hemodynamics and respiratory parameters remained stable throughout administration of both anesthesia regimens, with advantages for the xenon group. Side effects occurred to the same extent with xenon in oxygen and isoflurane-nitrous oxide.

CONCLUSION

This first randomized controlled multicenter trial on the use of xenon as an inhalational anesthetic confirms, in a large group of patients, that xenon in oxygen provides effective and safe anesthesia, with the advantage of a more rapid recovery when compared with anesthesia using isoflurane-nitrous oxide.

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.

Cost-effectiveness of propofol anesthesia using target-controlled infusion compared with a standard regimen using desflurane

The cost-effectiveness of propofol anesthesia using target-controlled infusion (TCI) versus a standard regimen using desflurane for anesthesia maintenance was analyzed. This observational study consisted of 100 inpatients 18 to 75 years old with an American Society of Anesthesiologists physical status of I or II who were scheduled for otological surgery lasting less than four hours. Patients received one of two treatments. The desflurane-maintenance group received propofol 2-4 mg/kg and sufentanil 0.15-0.30 microg (as the citrate)/kg. A constant fresh gas flow of 1 L/min was used during maintenance of anesthesia. The propofol-maintenance group received TCI propofol and an additional infusion of sufentanil. Anesthesia was induced with 0.15-0.30 microg/kg. One blinded evaluator assessed the postoperative recovery from anesthesia for all patients. The cost of drugs and medical devices used during the intraoperative and postoperative periods was calculated. Effectiveness was defined as the absence of postoperative nausea and vomiting (PONV), while the cost-effectiveness of each procedure was the cost per PONV-free episode. The efficiency of each procedure represented the production of effectiveness per dollar invested. Chi-square and t tests, sensitivity analysis, and logistic regression were also performed. The only intergroup difference detected was the frequency of PONV occurring in the early recovery phase (11 in the desflurane group versus 2 in the propofol group). Of those patients requiring antiemetic rescue, 9 were in the desflurane group and only 2 were in the propofol group (p < 0.05). The TCI propofol regimen was more expensive than the desflurane regimen ($45 versus $28 per patient, respectively) (p < 0.001). The differential cost-effectiveness ratio was $94.7 per PONV-free episode. PONV 24 hours after surgery and patient satisfaction were similar between groups. A standard regimen of desflurane was more cost-effective than TCI propofol for anesthesia maintenance in achieving PONV-free episodes.

[Pharmacoeconomical model for cost calculation using a study on prophylaxis of nausea and vomiting in the postoperative phase as an example. Cost effectiveness analysis of a tropisetron supplemented desflurane anaesthesia in comparison to a propofol total intravenous anaesthesia (TIVA)]

AIM OF THE STUDY

Postoperative nausea and vomiting (PONV) are among the most frequent complications after general anaesthesia. Avoiding these symptoms is of utmost importance for most patients; PONV is not only a major source of discomfort for patients but also a cause of additional costs for the patients and the health care provider. The economical impact of PONV will become even more important in the near future because the number of surgical procedures performed on an ambulatory basis is increasing. The following article gives a short overview of the terminology and measures used in pharmacoeconomical studies concerning PONV. Furthermore the economical aspects of a low-flow anaesthesia supplemented with the 5-HT(3)-antagonist tropisetron compared with a total intravenous anaesthesia (TIVA) using propofol are described.

METHODS

For this comparison a decision analysis was performed using data of a randomised control trial on 150 female patients undergoing major gynaecological surgery. The patients were randomised to receive a total intravenous anaesthesia with propofol-alfentanil or a balanced anaesthesia with desfluran (fresh gas flow 1 l.min(-1)) supplemented by 2 mg tropisetron at the end of surgery.

RESULTS

Indirect costs associated with anaesthesia using desflurane-tropisetron (4.94 Euro) are not different from that of propofol-TIVA (4.81 Euro) because of a similar incidence of PONV in the PACU. Furthermore, the total cost for 100 min general anaesthesia is higher in the desflurane-tropisetron group (30.94 Euro) compared with the TIVA group (24.55 Euro) due to the decreasing acquisition costs of propofol in the last 2 years.

CONCLUSION

Total intravenous anaesthesia with propofol is more cost-efficient than balanced anaesthesia with desflurane and additional tropisetron as a prophylactic antiemetic.

Desflurane improves the throughput of patients in the PACU. A cost-effectiveness comparison with isoflurane

PURPOSE

In a pharmacoeconomic approach of anesthesia, postanesthesia care unit (PACU) occupancy can be chosen as a criteria of effectiveness to compare two anesthetic drugs with different rates of elimination and different costs of administration. Our objective was to develop a cost-effectiveness approach for the comparison of isoflurane (I) and desflurane (D).

METHOD

In this prospective observational study, 68 patients aged 18-70 received either D or I for maintenance of anesthesia for inpatient abdominal procedures. Length of stay (LOS) in PACU was collected by a blinded observer. After the relationship between duration of surgery and LOS in PACU had been established in the 68 observed patients, we estimated the PACU occupancy according to duration of surgery and time of admission in PACU using a computer model of 204 consecutive patients, based on the hypothesis of an exclusive use of either D or I. Outcome measures were direct costs of the anesthesia procedure and occupancy of the PACU.

RESULTS

The direct cost of the anesthetic was significantly higher with D than with I. This represents an increase of CAN$ 2 708 for the 204 patients. PACU occupancy was reduced by at least one patient (out of five beds) during 26.1% of the time with D (P <0.01).

DISCUSSION

Improving the throughput of patients in PACU by using new halogenated anesthetic agents with faster rates of elimination may outweigh the incremental cost of this strategy. This becomes particularly meaningful in operating theatres experiencing frequent overcrowded periods.

Inhalation anaesthesia is cost-effective for ambulatory surgery: a clinical comparison with propofol during elective knee arthroscopy

BACKGROUND AND OBJECTIVE

Cost consciousness has become increasingly important in anaesthesia as elsewhere in healthcare. Cost-minimization with uncompromised patient safety and quality requires systematic comparisons of alternative techniques. Inhalation anaesthesia with desflurane or sevoflurane is compared in this study with propofol delivered by the target controlled infusion technique. Directly measured drug consumption and costs and emergence times are compared.

METHODS

Consumed anaesthetics were measured during elective arthroscopy of the knee, and costs were calculated for ASA I-II patients (n = 102) randomized to 3 groups: one group received anaesthesia using propofol administered by target controlled infusion, the others inhalation anaesthesia with either desflurane or sevoflurane in combination with nitrous oxide. A partial rebreathing system was used with a laryngeal mask airway. Vaporizers were weighed before and after each anaesthetic.

RESULTS

Anaesthetic duration, postoperative pain and emesis as well as discharge time did not differ between groups. Inhaled anaesthetic techniques with desflurane or sevoflurane were associated with 2-3 min shorter emergence times (P < 0.001) and approximately 45% lower cost for consumed anaesthetics as compared with a propofol technique based on target controlled infusion. The inclusion of waste costs improved the cost reduction to 55%.

CONCLUSIONS

For this patient group, use of inhalation anaesthesia reduced drug costs by half and shortened emergence times compared to target controlled infusion with propofol with equal perioperative patient conditions.

Measuring the costs of inhaled anaesthetics

The cost of inhalation anaesthesia has received considerable study and is undoubtedly reduced by the use of low fresh gas flows. However, comparison between anaesthetics of the economies achievable has only been made by computer modelling. We have computed anaesthetic usage for MAC-equivalent anaesthesia with isoflurane, desflurane, and sevoflurane in closed and open breathing systems. We have compared these data with those derived during clinical anaesthesia administered using a computer-controlled closed system that measures anaesthetic usage and inspired concentrations. The inspired concentrations allow the usage that would have occurred in an open system to be calculated. Our computed predictions lie within the 95% confidence intervals of the measured data. Using prices current in our institution, sevoflurane and desflurane would cost approximately twice as much as isoflurane in open systems but only about 50% more than isoflurane in closed systems. Thus computer predictions have been validated by patient measurements and the cost saving achieved by reducing the fresh gas flow is greater with less soluble anaesthetics.

Inhalation versus total intravenous anesthesia for lumbar disc herniation: comparison of hemodynamic effects, recovery characteristics, and cost

The clinical effects, recovery characteristics, and costs of total intravenous anesthesia (TIVA), sevoflurane, and isoflurane anesthesia have been measured in various out-patient operations, but have not been evaluated in patients undergoing laminectomy or discectomy. In the current study, the authors assessed the hemodynamic characteristics, recovery, and cost analyzes after laminectomy and discectomy operations, comparing TIVA, sevoflurane, and isoflurane anesthesia. Sixty American Society of Anesthesiologists I and II patients were randomly divided into three groups, each consisting of 20 patients. Group I received propofol-alfentanil, Group 2 received sevoflurane-N2O, and Group 3 received isoflurane-N2O. At the end of surgery, the anesthetics were discontinued, and recovery from anesthesia was assessed by measuring the time until spontaneous eye opening and the time until response to verbal commands. The drug and delivery costs were calculated in United States dollars. No significant differences were found in the demographic data. Heart rate and mean arterial pressure decreased significantly after induction of anesthesia in the TIVA group, compared to the two other groups ( P < .05 for both comparisons). The fastest recovery was seen in the TIVA group. Incidences of postoperative nausea, vomiting, and pain were significantly reduced after TIVA ( P < .05 for both comparisons). Thus, TIVA patients required fewer additional drugs and showed the lowest additional costs in the post-anesthesia care unit. However, the total cost was significantly higher in the TIVA group than in the sevoflurane and isoflurane groups (52.73 dollars, 29.99 dollars, and 24.14 dollars, respectively) ( P < .05). Total intravenous anesthesia was associated with the highest intraoperative cost but provided the most rapid recovery from anesthesia, and the least frequent postoperative side effects.

[Anesthesia with remifentanil combined with desflurane or sevoflurane in lumbar intervertebral disk operations]

Recovery characteristics, haemodynamic profile, analgesic requirement and costs were evaluated and compared in patients undergoing elective lumbar discectomy with remifentanil-based anaesthesia using either desflurane or sevoflurane as the volatile anaesthetic agent. Sixty-two patients (ASA I/II status) were randomly assigned to receive either desflurane and remifentanil or sevoflurane and remifentanil (in oxygen/air) for anaesthesia. After induction with 0.5 microgram/kg/min remifentanil, 4 to 5 mg/kg thiopentone and 0.5 mg/kg atracurium, the patients received 0.25 microgram/kg/min remifentanil and 0.5 +/- 0.05 MAC of one of the volatile anaesthetic agents for further maintenance of anaesthesia. At the end of surgery, early emergence from anaesthesia was recorded by assessing the time to sufficient spontaneous respiration, eye opening and tracheal extubation. The total demand of piritramide in the postoperative period was determined using patient-controlled analgesia (PCA device). Quality of pain therapy was assessed via a verbal ranking scale (VRS). Side-effects such as postoperative nausea, vomiting or shivering were recorded in the postanaesthetic care unit. In both groups, the haemodynamic profile was nearly identical. Mean arterial pressure (-18%) and heart rate (-23%) were significantly reduced throughout anaesthesia in both groups. All recovery parameters were significantly shorter in the desflurane group in comparison with the sevoflurane group (e.g. time to tracheal extubation: 8.5 +/- 3.0 min vs. 11.9 +/- 4.6 min). No significant differences between the groups were observed concerning the amount of piritramide required, side-effects such as nausea and vomiting or the total cost of anaesthesia. In conclusion, both anaesthetic techniques provide adequate haemodynamic stability and postoperative pain control in a surgical procedure with minimal trauma. Incidence and severity of side-effects such as nausea, vomiting or shivering did not differ between the groups and were acceptable under clinical conditions. Costs for desflurane were significantly higher than those for sevoflurane, but total costs were not different between the groups. Concerning recovery profile, desflurane/remifentanil seems to have small advantages over sevoflurane/remifentanil in patients undergoing lumbar vertebral disc resection.

Comparative analysis of costs of total intravenous anaesthesia with propofol and remifentanil vs. balanced anaesthesia with isoflurane and fentanyl

BACKGROUND AND AIM

We evaluated the costs and benefits of total intravenous anaesthesia compared with a balanced anaesthesia regimen.

METHODS

One-hundred and twenty-four patients undergoing cataract surgery were randomized to either a propofol/remifentanil or an isoflurane/fentanyl group. In the propofol/remifentanil group, both drugs were used for induction and maintenance of anaesthesia; in the isoflurane/fentanyl group, anaesthesia was induced with etomidate and fentanyl and maintained with isoflurane and fentanyl. All patients received mivacurium for muscle relaxation and the lungs were ventilated mechanically. The use of propofol and remifentanil resulted in a faster emergence and an overall savings per case of [symbol: see text] 12.25 due to a reduction in personnel costs which outweighs the higher drug acquisition costs.

RESULTS

In the propofol and remifentanil group, more patients were satisfied and would accept the same anaesthetic again.

CONCLUSION

We conclude that propofol and remifentanil is more cost-effective than isoflurane/fentanyl due to its better recovery profile, reduced total direct costs and higher patient satisfaction.

Part II: total episode costs in a randomized, controlled trial of the effectiveness of four anesthetics

Newer anesthetics promise improved clinical outcomes, but usually come at a higher price per dose. Previous studies have found few economic benefits in the immediate postoperative period, but have hypothesized that earlier recovery may lead to lower costs for the whole episode of hospitalization. This study uses cost data for patients enrolled in a randomized, controlled clinical trial comparing four anesthetics to test whether the higher costs of the newer anesthetics would be offset against decreased use of other hospital resources. Five hundred general surgery patients were randomly assigned to one of four anesthetic regimens. Estimates from the hospital's patient costing system were used, with validated cost records for a subset of 360 patients. Five patients admitted to the intensive care unit or requiring prolonged hospitalization skewed the distribution of costs, but none of these complications could be attributed to anesthesia. No significant differences were found on length of stay, mean episode cost, operating room costs, ward costs, or readmission rate within 3 mo. The study was not powered to sufficiently show differences in intensive care unit admission or other uncommon outcomes. Patient quality of recovery did not vary among groups, but neither patient willingness-to-pay nor satisfaction were directly measured.

IMPLICATIONS

Propofol and sevoflurane do not offer any significant economic advantages over thiopental and isoflurane in adults undergoing elective inpatient surgery.

Sevoflurane-N2O versus propofol/isoflurane-N2O during elective surgery using the laryngeal mask airway in adults

STUDY OBJECTIVES

To compare a sevoflurane-nitrous oxide (N2O) general anesthetic technique with a standard technique of propofol for induction, and isoflurane-N2O for maintenance.

DESIGN

Prospective, randomized study.

SETTING

University-affiliated tertiary-care hospital.

PATIENTS

62 adults undergoing elective surgery using the laryngeal mask airway (LMA).

INTERVENTIONS

Patients received either the standard technique of propofol for induction and isoflurane-N2O for maintenance (controls) or sevoflurane-N2O for both induction and maintenance of general anesthesia.

MEASUREMENTS

Induction and emergence times, heart rate, blood pressure, oxygen saturation, and end-tidal carbon dioxide were recorded.

MAIN RESULTS

Time to loss of consciousness was faster after propofol (mean +/- SEM: 51 +/- 3 sec) than after sevoflurane-N2O (85 +/- 10 sec; p < 0.05). Ready for surgery times, were however, similar between groups (10 +/- 1 vs. 11 +/- 1 min, respectively). All patients in the control group had apnea after LMA insertion compared with 4 patients in the sevoflurane-N2O group (p < 0.05). Heart rate was lower 5 and 10 minutes after LMA insertion in the sevoflurane-N2O group (69 +/- 3 and 66 +/- 3 bpm) versus the control group (81 +/- 3 bpm and 74 +/- 3 bpm, p < 0.05). After cessation of anesthetic gases, there were no differences in time to LMA removal, eye opening, or exiting the operating room (OR) between the control group (7, 8, and 10 min) and sevoflurane-N2O groups (7, 8, and 12 min, respectively). The majority of patients in both groups (92% to 97%) rated their anesthetic experience as excellent or good.

CONCLUSIONS

Sevoflurane-N2O and propofol provided comparable conditions for LMA insertion. Sevoflurane-N2O was not associated with a faster return of consciousness or faster time to exit the OR compared with isoflurane-N2O.

Cost analysis of xenon anesthesia: a comparison with nitrous oxide-isoflurane and nitrous oxide-sevoflurane anesthesia

STUDY OBJECTIVE

To determine the cost of xenon (Xe) anesthesia in relation to the anesthetic duration by conducting a cost analysis of this relatively expensive inhaled anesthetic.

DESIGN

Cost analysis based on the literature on Xe anesthesia.

SETTING

Anesthetic simulation based on data obtained in the operating rooms at a university hospital.

PATIENTS

A 40-year-old, ASA physical status I adult patient model weighing 70 kg, undergoing elective minor surgery with endotracheal intubation and mechanical ventilation.

INTERVENTIONS

Anesthesia was given in the following four techniques: 1) closed-circuit technique with Xe; 2) closed-circuit technique with nitrous oxide (N2O)-isoflurane; 3) semi-closed technique with N2O-isoflurane; and 4) semi-closed technique with N2O-sevoflurane.

MEASUREMENTS AND MAIN RESULTS

Cost of each anesthetic technique was compared in U.S. dollars. The cost of Xe anesthesia was consistently higher than that of N2O-isoflurane or N2O-sevoflurane (for 240-min anesthesia; $356 with Xe, $52 with closed-circuit N2O-isoflurane, $94 with semi-closed N2O-isoflurane, and $84 with semi-closed N2O-sevoflurane). The major cost of Xe anesthesia was a result of the cost of priming and flushing; the cost of Xe used for its anesthetic effects was comparable with the other semi-closed techniques after 240 minutes.

CONCLUSIONS

For Xe to be widely used in routine anesthesia, the methods of minimizing the amount of Xe necessary for priming and flushing must be developed.

Comparison of 3 different anesthetic techniques on 24-hour recovery after otologic surgical procedures

Intravenous propofol anesthesia is better than inhalational anesthesia for otologic surgery, but cost and intraoperative movement make this technique prohibitive. This study compares a propofol sandwich anesthetic with a total propofol or inhalational anesthetic for otologic surgery to determine which produces the best perioperative conditions and least expense. One hundred twenty patients undergoing ear surgery were randomly chosen to receive an anesthetic with either isoflurane (INHAL), total propofol (TPROP), or propofol used in conjunction with isoflurane (PSAND). Postoperative wakeup and the incidence and severity of nausea, vomiting, and pain were compared among groups. Antiemetic administration and discharge times from recovery and the hospital were also compared. The groups were similar, but anesthesia times were longer in the INHAL group. Emergence from anesthesia after PSAND or TPROP was more rapid than after INHAL. Recovery during the next 24 hours was associated with less nausea and vomiting with PSAND than with INHAL. The cost of the PSAND anesthetic was similar to that of INHAL, and both were less than TPROP. PSAND anesthesia may be similar to TPROP and better than INHAL for otologic procedures. PSAND was less expensive than TPROP and produced a similar recovery profile and antiemetic effect in the 24-hour period after surgery.

Cost analysis of target-controlled infusion-based anesthesia compared with standard anesthesia regimens

With the development of new computer-assisted target-controlled infusion (TCI) systems and the availability of short-acting anesthetics, total IV anesthesia (TIVA) has become increasingly popular. The aim of this study was to compare costs of TCI-based anesthesia with two standard anesthesia regimens. Sixty patients undergoing elective laparoscopic cholecystectomy were randomly divided into three groups. Group 1 (TIVA/TCI) received TIVA using a propofol-based TCI system and continuous administration of remifentanil; Group 2 (isoflurane) underwent inhaled anesthesia with isoflurane, fentanyl, and N2O; Group 3 (standard propofol) received fentanyl and N2O and a continuous infusion of propofol using a standard delivery system. Maintenance doses for anesthetics were adjusted according to the patient's need. Isoflurane consumption was measured by weighing the vaporizer by using a precision weighing machine. Duration of surgery and of anesthesia was similar in the three groups. Time from stopping administration of anesthetics until tracheal extubation (6+/-2 min) and stay in the postanesthesia care unit (PACU; 70+/-12 min) were shorter in Group 1 than in the Groups 2 (15+/-3 and 87+/-13 min, respectively) and 3 (10+/-4 and 81+/-14 min, respectively) (P < 0.05). Episodes of postoperative nausea and vomiting in the PACU and on the surgical ward were less common in Group 1 than in the other two groups. Intraoperative costs were higher in Group 1 ($62.19/patient; $0.55/min of anesthesia) than in Groups 2 ($16.97/patient; $0.13/min of anesthesia) and 3 ($34.68/patient; $0.32/min of anesthesia). Cost for discarded anesthetic drugs accounted for almost 18% of total intraoperative costs in Group 1. We conclude that TIVA/TCI anesthesia using propofol/remifentanil was associated with the highest intraoperative costs but the fewest postoperative side effects. An overall cost-effectiveness analysis of new anesthetic regimens must balance the direct cost of anesthetics and beneficial effects leading to improved patients' comfort.

IMPLICATIONS

In today's climate of cost-consciousness, careful economic evaluation of new anesthetic regimens is necessary. A target-controlled infusion (TCI)-based total IV anesthesia (TIVA) regimen using propofol and remifentanil was compared with a standard propofol anesthesia regimen and an inhaled anesthetic technique using isoflurane. Target-controlled infusion/total IV anesthesia was associated with the largest intraoperative costs but allowed the most rapid recovery from anesthesia, was associated with fewest postoperative side effects, and permitted earlier discharge from the postanesthesia care unit.

Reinforcing a "low flow" anaesthesia policy with feedback can produce a sustained reduction in isoflurane consumption

A three-month audit of isoflurane consumption at Palmerston North Hospital in 1994 showed an averaged vapour flow rate of approx 85 ml per minute of anaesthesia, equivalent to 1.4% isoflurane at six litres per minute. After purchasing volatile agent analysers, a program encouraging low flow anaesthesia and providing a report of the previous month's consumption rate was started in July 1996. The isoflurane averaged vapour flow rate was tracked over the following twenty-month period and fell by a sustained 65% to range around 30 +/- 5 ml/min, producing savings of approximately NZ$104,000 over this period.

Economic considerations of the use of new anesthetics: a comparison of propofol, sevoflurane, desflurane, and isoflurane

Cost control in anesthesia is no longer an option; it is a necessity. New anesthetics have entered the market, but economic differences in comparison to standard anesthetic regimens are not exactly known. Eighty patients undergoing either subtotal thyroidectomy or laparoscopic cholecystectomy were randomly divided into four groups, with 20 patients in each group. Group 1 received propofol 1%/sufentanil, Group 2 received desflurane/sufentanil, Group 3 received sevoflurane/sufentanil, and Group 4 received isoflurane/sufentanil (standard anesthesia) for anesthesia. A fresh gas flow of 1.5-2 L/min and 60% N2O in oxygen was used for maintenance of anesthesia, and atracurium was given for muscle relaxation. Concentrations of volatile anesthetics, propofol, and sufentanil were varied according to the patient's perceived need. Isoflurane, desflurane, and sevoflurane consumption was measured by weighing the vaporizers with a precision weighing machine. Biometric data, time of surgery, and time of anesthesia were similar in the four groups. Times for extubation and stay in the postanesthesia care unit (PACU) were significantly longer in the isoflurane group. Use of sufentanil and atracurium did not differ among the groups. Propofol patients required fewer additional drugs in the PACU (e.g., antiemetics), and thus showed the lowest additional costs in the PACU. Total (intra- and postoperative) costs were significantly higher in the propofol group ($30.73 per patient; $0.24 per minute of anesthesia). The costs among the inhalational groups did not differ significantly (approximately $0.15 per minute of anesthesia). We conclude that in today's climate of cost savings, a comprehensive pharmacoeconomic approach is needed. Although propofol-based anesthesia was associated with the highest cost, it is doubtful whether the choice of anesthetic regimen will lower the costs of an anesthesia department.

IMPLICATIONS

Cost analysis of anesthetic techniques is necessary in today's economic climate. Consumption of the new inhaled drugs sevoflurane and desflurane was measured in comparison to a standard anesthetic regimen using isoflurane and an IV technique using propofol. Propofol-based anesthesia was associated with the highest costs, whereas the costs of the new inhaled anesthetics sevoflurane and desflurane did not differ from those of a standard, isoflurane-based anesthesia regimen.

Desflurane versus propofol maintenance for outpatient laparoscopic cholecystectomy

BACKGROUND

The aims of the study were to evaluate costs and clinical characteristics of desflurane-based anaesthetic maintenance versus propofol for outpatient cholecystectomy.

METHODS

All 60 patients received ketamine 0.2 mg kg(-1), fentanyl 2 microg kg(-1) and propofol 2 mg kg(-1) for induction. Ketorolac 0.4 mg kg(-1) and ondansetron 0.05 mg kg(-1) +droperidol 20 microg kg(-1) was given as prophylaxis for postoperative pain and emesis, respectively. The patients were randomly assigned into Group P with propofol maintenance and opioid supplements, or Group D with desflurane in a low-flow circuit system.

RESULTS

All the patients were successfully discharged within 8 h without any serious complications. Emergence from anaesthesia was more rapid after desflurane; they opened their eyes and stated date of birth at mean 6.4 and 8.4 min respectively, compared with 9.6 and 12 min in the propofol group (P<0.05). Nausea and pain were more frequent in Group D, 40% and 80% respectively; versus 17% and 50% in Group P (P<0.05). By telephone interview at 24 h and 7 d after the procedure, there was no major difference between the groups. With desflurane, drug costs per case were 10 $ lower than with propofol.

CONCLUSION

We conclude that desflurane is cheaper and has a more rapid emergence than propofol for outpatient cholecystectomy. However, propofol results in less pain and nausea in the recovery unit. Despite ondansetron and droperidol prophylaxis, there was still a substantial amount of nausea and vomiting after desflurane.

Pharmacoeconomic analysis of sevoflurane versus isoflurane anesthesia in elective ambulatory surgery

This study investigated the economic aspects of sevoflurane and isoflurane anesthesia in 47 healthy women undergoing elective ambulatory surgery, as part of a randomized, prospective clinical trial. Patient records were analyzed for anesthetic; duration of surgery, anesthesia, and recovery room stay; and associated charges. Sevoflurane is shorter acting than isoflurane, but it was not associated with a shorter duration of anesthesia or surgical unit stay, or earlier hospital discharge. Total charges associated with sevoflurane anesthesia were greater than those for isoflurane ($2641 and $2230, respectively) and primarily related to prolonged anesthesia and surgical unit stay. A minor decrease in recovery room charges ($15) associated with earlier discharge was observed with sevoflurane (p>0.05), but the agent was not associated with lower hospital charges. Larger trials and assessment of other patient populations may show sevoflurane to be more pharmacoeconomically advantageous than isoflurane.

Propofol vs isoflurane for neurosurgical anesthesia in Thai patients

Sixty Thai patients, ASA class I-II, Glasgow coma score of 15 undergoing elective intracranial surgery were randomly assigned to 2 groups. In group I, 30 patients were induced with thiopental 3-5 mg/kg, intubation with succinylcholine 1-2 mg/kg and then maintained with 60 per cent N2O in O2, isoflurane and vecuronium as a muscle relaxant. In group II, 30 patients received fentanyl 50 micrograms, propofol 1.0-2.5 mg/kg for induction and vecuronium 0.08 mg/kg for intubation then maintained with 60 per cent N2O in O2, continuous infusion of propofol 2-12 mg/kg/h and vecuronium as a muscle relaxant. Controlled ventilation in both groups was set to maintain PET CO2 in the range of 28-35 mmHg. 3 patients (1 in group I and 2 in group II) were excluded from the study due to surgical problems. There was no statistical difference in age, sex, ASA status, weight, duration of anesthesia. Group II had a more stable systolic BP, Diastolic BP and Pulse rate than Group I during induction and emergence from anesthesia. Glasgow coma scores in the recovery period, Group II had higher scores than Group I at 5 and 15 minutes but not at 30 minutes. Mean recovery times (eye opening) was 14.03 +/- 4.85 minutes in group I which is significantly different from 10 +/- 5.17 minutes in group II. The cost of anesthesia in group II was 1.3 times that of group I. In conclusion, although neurosurgical anesthesia for Thai patients with fentanyl-propofol technique produces more stable blood pressure during intubation and emergence, rapid recovery from anesthesia and a higher Glasgow coma score, the cost of anesthesia is more expensive. Furthermore, this technique is more difficult and needs more experience.

[Cost aspects in anesthesia. Propofol versus isoflurane anesthesia]

Cost control is no longer an option, but a necessity. Propofol anaesthesia is expensive, however, the true differences in comparison to volatile anaesthetics (isoflurane) are not known.

METHODS

Sixty patients undergoing either thyroidectomy (n = 30) or laparoscopic cholecystectomy (n = 30) were randomly divided into 3 groups of 20 patients. In group I propofol and fentanyl were used for anaesthesia, in group II isoflurane ('standard' isoflurane anaesthesia), and in group III isoflurane using a low-flow system (fresh gas flow 2 l/min) was given. All patients were ventilated using 70% N2O in oxygen. Vecuronium was used in all cases for muscle relaxation. Isoflurane consumption was measured by weighing the isoflurane vaporizer.

RESULTS

Biometric data and time of administration of the anaesthetic were similar in the three groups. Propofol patients stayed significantly shorter than isoflurane patients in the postanaesthesia care unit (PACU). Costs of additional drugs (antiemetics, analgesics) in the PACU were least in the propofol patients. Costs were without differences between the propofol (78.30 DM/patient) and 'standard' isoflurane groups (81.69 DM/patient). Patients in group III showed the lowest overall costs (57.46 DM/patient) (P < 0.05).

CONCLUSION

A climate of cost-consciousness and cost-containment prevails at the present time. The costs of propofol and 'standard' isoflurane anaesthesia were without differences; however, isoflurane used in a low-flow system had the lowest cost in this study. Doubts are justified, however, as to whether the choice of anaesthetic agents may considerably lower the costs of an anaesthesia department.

Desflurane is not associated with faster operating room exit times in outpatients

STUDY OBJECTIVE

To determine the influence of anesthetic technique and primary drug on operating room (OR) exit time (time between end of surgery until time patient exists the OR) after addition of desflurane to the hospital formulary.

DESIGN

Prospective study.

SETTING

Ambulatory surgery unit of a university hospital.

PATIENTS

1,568 outpatients requiring anesthesia.

INTERVENTIONS

Addition of desflurane to the hospital formulary, and substitution of desflurane vaporizers for enflurane vaporizers in the ambulatory surgery unit.

MEASUREMENTS AND MAIN RESULTS

The following information was recorded for all anesthetic encounters over a six-month time interval: demographics, duration of surgery, primary anesthetic technique, primary anesthetic drug, and exit times. General anesthesia was used in 907 patients [desflurane: 209 patients, isoflurane: 429 patients, halothane: 192 patients, propofol: 72 patients, other intravenous (i.v.): 5 patients], major conduction anesthesia (spinal and epidural) in 43 patients, peripheral nerve blocks in 90 patients, and i.v. sedation in 528 patients. The exit time was significantly greater ( < 0.05) in patients who received general anesthesia (mean +/- SEM 14 +/- 0.2 min) compared with spinal/epidural (8 +/- 0.7 min), nerve blocks (8 +/- 0.4 min) and i.v. sedation (7 +/- 0.2 min). Exit times were longer in older patients receiving general anesthesia (exit time = 12.3 + 0.04 x age, SE = 6.7 min, p < 0.0009), whereas exit times were shorter in older individuals receiving i.v. sedation (exit time = 8.97 - 0.038 x age, SE = 3.6 min, p < 0.0001). For patients receiving i.v. sedation, exit times were shorter as duration of surgery increased (exit time = 7.86 - 0.015 x duration of surgery, SE = 3.6 min, p < 0.0002). Primary anesthetic drug did not affect exit times.

CONCLUSION

Regional anesthesia and i.v. sedation were associated with faster OR exit times compared with general anesthesia. Despite desflurane's shorter elimination kinetics and recovery characteristics, use of this drug did not result in shorter exit times.

Cost-effective anesthesia: desflurane versus propofol in outpatient surgery

This study compared the costs of desflurane and propofol as maintenance anesthetic agents in outpatient surgery. Recovery time and related drug expenses were included in the cost comparison. Fifty-three ASA physical status I and II patients were randomly assigned to receive a maintenance anesthetic of either desflurane with 50% nitrous oxide or propofol with 50% nitrous oxide. All patients received a propofol induction and were administered narcotics, sedatives, muscle relaxants, reversal agents, and antiemetics as determined necessary by the anesthesia provider. The mean propofol cost was $31.88 +/- 14.44, whereas, the mean desflurane cost was $12.99 +/- 7.61 (P < .05). The mean cost of all medications, anesthetics, and ancillary agents included was $57.97 +/- 20.22 for the propofol group and $34.86 +/- 14.13 for the desflurane group (P < .05). Of the desflurane patients, 41% experienced nausea compared to 12% of the propofol patients (P < .05). There was no significant difference between the recovery times of the two groups. Desflurane was more cost-effective than propofol. Although desflurane patients experienced more nausea, this did not affect their discharge time.

Economic analysis and pharmaceutical policy: a consideration of the economics of the use of desflurane

Several factors have to be considered in determining the cost of applying a new inhalational anaesthetic such as desflurane into clinical practice. Factors beyond the immediate control of the anaesthetic practitioner include the price set by the manufacturer (although this may be influenced by economic and political pressures), and the physical-pharmacological properties of the anaesthetic (e.g. vaporization, potency, solubility). The anaesthetic practitioner can minimise cost by applying lower inflow rates. Lower solubility (and hence lower uptake) provides a greater economy at lower inflow rates than does higher solubility. Furthermore, lower solubility permits the use of lower inflow rates with greater precision to the control of anaesthesia, and greater ease of application. At present unit prices, the cost of desflurane approximately equals that of isoflurane when a 1 l.min-1 inflow rate is used. The use of lower inflow rates presupposes that such rates do not allow the production of toxic compounds in recirculating gases. Modern equipment makes low-flow anaesthesia reliable and easy to control, and as desflurane is not degraded by the standard carbon dioxide absorbents, its use in low-flow systems is effective and economical. These cost considerations do not take into account the savings that may result from a more rapid recovery from anaesthesia, nor do they take into account the increased expense of capital equipment needed to apply a new anaesthetic.

Providing comfort to critically ill pediatric patients: isoflurane

Isoflurane is a fluorinated ether used primarily as an inhalation anesthetic. Rapid titratable effects, limited metabolism, and a reliable mode of administration make isoflurane an appealing alternative to the use of intravenous sedatives and narcotics in critically ill patients requiring prolonged mechanical ventilation. This article, in reviewing this novel approach to management of patient discomfort, focuses on nursing practice issues and provides a critical analysis of isoflurane use in the intensive care unit.