Search

Background: Improving outcomes after surgery is a major public health research priority for patients, clinicians and the NHS. The greatest burden of perioperative complications, mortality and healthcare costs lies amongst the population of patients aged over 50 years who undergo major non-cardiac surgery. The Volatile vs Total Intravenous Anaesthesia for major non-cardiac surgery (VITAL) trial specifically examines the effect of anaesthetic technique on key patient outcomes: quality of recovery after surgery (quality of recovery after anaesthesia, patient satisfaction and major post-operative complications), survival and patient safety., Methods: A multi-centre pragmatic efficient randomised trial with health economic evaluation comparing total intravenous anaesthesia with volatile-based anaesthesia in adults (aged 50 and over) undergoing elective major non-cardiac surgery under general anaesthesia., Discussion: Given the very large number of patients exposed to general anaesthesia every year, even small differences in outcome between the two techniques could result in substantial excess harm. Results from the VITAL trial will ensure patients can benefit from the very safest anaesthesia care, promoting an early return home, reducing healthcare costs and maximising the health benefits of surgical treatments., Trial Registration: ISRCTN62903453. September 09, 2021., (© 2024. The Author(s).)

Background: Pharmacologic pre- and postconditioning with sevoflurane compared with total IV anesthesia in patients undergoing liver surgery reduced complication rates as shown in 2 recent randomized controlled trials. However, the potential health economic consequences of these different anesthesia regimens have not yet been assessed., Methods: An expostcost analysis of these 2 trials in 129 patients treated between 2006 and 2010 was performed. We analyzed direct medical costs for in-hospital stay and compared pharmacologic pre- and postconditioning with sevoflurane (intervention) with total IV anesthesia (control) from the perspective of a Swiss university hospital. Year 2015 costs, converted to US dollars, were derived from hospital cost accounting data and compared with a multivariable regression analysis adjusting for relevant covariables. Costs with negative prefix indicate savings and costs with positive prefix represent higher spending in our analysis., Results: Treatment-related costs per patient showed a nonsignificant change by -12,697 US dollars (95% confidence interval [CI], 10,956 to -36,352; P = .29) with preconditioning and by -6139 US dollars (95% CI, 6723 to -19,000; P = .35) with postconditioning compared with the control group. Results were robust in our sensitivity analysis. For both procedures (control and intervention) together, major complications led to a significant increase in costs by 86,018 US dollars (95% CI, 13,839-158,198; P = .02) per patient compared with patients with no major complications., Conclusions: In this cost analysis, reduced in-hospital costs by pharmacologic conditioning with sevoflurane in patients undergoing liver surgery are suggested. This possible difference in costs compared with total IV anesthesia is the result of reduced complication rates with pharmacologic conditioning, because major complications have significant cost implications., Competing Interests: See Disclosures at the end of the article.

In the current study, we assessed and evaluated the costs and benefits of three popular methods of general anesthesia practiced in our department for gynecological laparoscopic surgery in recent years. Sixty adult female patients who underwent elective gynecological laparoscopic surgery under general anesthesia were randomly divided into three groups: group V, group I and group C. In group V, anesthesia was induced intravenously with midazolam, remifentanil, propofol and vecuronium, and maintained with continuous infusion of propofol and remifentanil. In group I, anesthesia was intravenously induced with midazolam, fentanyl, propofol and vecuronium, and maintained with inhaled isoflurane and intravenous bonus of fentanyl. In group C, anesthesia was induced as in group I, but maintained with isoflurane inhalation combined with propofolremifentanil infusion. All patients received vecuronium for muscle relaxation. Perioperative incidences of complications and total anesthesia costs for patients in all groups were recorded. In addition, postoperative satisfaction of the patients was also noted, and similar outcomes of the satisfaction were reported in all 60 patients. Although there was no statistical significance among groups, the incidence of postoperative nausea and vomiting were higher in group C, and the rates of shivering and the needs for analgesics were higher in group V. Anesthesia costs in group I were the lowest. Therefore, it is concluded that the costs of anesthesia induced with midazolam, fentanyl, propofol, vecuronium, and maintained with isoflurane, fentanyl and vecuronium are cheapest, and there is no significant difference in patients' satisfaction and safety among the three above-mentioned methods of anesthesia in our department.

Purpose: The introduction of new medicine can change clinical practice patterns and may affect patient outcomes. In the present study, we investigated whether introduction of remifentanil in Japan affected the practice patterns of anesthesia., Methods: Using the Japanese Diagnosis Procedure Combination database, we extracted records of 423,491 patients who underwent surgery with general anesthesia in 243 hospitals before (2006) and after (2007) the introduction of remifentanil, and identified anesthetic agents used for each patient. A hierarchical mixed-effects logistic regression analysis was performed to analyze the factors that affected selection of remifentanil. Further, we compared postoperative length of stay (LOS), in-hospital mortality, and total costs between 2006 and 2007., Results: In 2007, remifentanil was used for up to 41.4% of all general anesthesia, accompanied by a reduction in nitrous oxide use and an increase in total intravenous anesthesia. Female gender, increasing age, and preoperative comorbidities including diabetes mellitus, hypertension, liver cirrhosis, and chronic renal failure were positively associated with the use of remifentanil, whereas accompanying cardiac disease and co-application of epidural anesthesia were negatively associated. In 2007, a similar in-hospital death rate, similar or decreased total costs, slightly reduced duration of anesthesia, and substantially reduced postoperative LOS were seen compared to those in 2006., Conclusions: Our data revealed rapid changes in practice patterns in anesthesia after the introduction of remifentanil in Japan. Remifentanil was used more often in patients with comorbidities and without epidural anesthesia, and its introduction did not affect increase in total medical costs.

Purpose of Review: The comparison of inhalational and intravenous anaesthesia has been the subject of many controlled trials and meta-analyses. These reported diverse endpoints typically including measures of the speed and quality of induction of anaesthesia, haemodynamic changes, operating conditions, various measures of awakening, postoperative nausea and vomiting and discharge from the recovery area and from hospital as well as recovery of psychomotor function. In a more patient-focused Health Service, measures with greater credibility are overall patient satisfaction, time to return to work and long-term morbidity and mortality. In practice, studies using easier to measure proxy endpoints dominate - even though the limitations of such research are well known., Recent Findings: Recent study endpoints are more ambitious and include impact on survival from cancer and the possibility of differential neurotoxic impact on the developing brain and implications for neuro-behavioural performance., Summary: Economic analysis of anaesthesia is complex and most published studies are naive, focusing on drug acquisition costs and facility timings, real health economics are much more difficult. Preferred outcome measures would be whole institution costs or the ability to reliably add an extra case to an operating list, close an operating room and reduce the number of operating sessions offered or permanently decrease staffing. Alongside this, however, potential long-term patient outcomes should be considered.

Background: During anaesthesia propofol is administered either by manual controlled infusion (MCI) or by target controlled infusion (TCI) techniques. In this study two different TCI systems for propofol administration were evaluated with regard to handling, patient safety, and costs and compared to administration of propofol by the MCI technique., Methods: In a prospective study, 90 patients scheduled for elective surgery of the nose or nasal sinuses were randomly enrolled in three groups. The two TCI systems were examined in two groups of 30 patients: one group received propofol following the pharmacokinetic TCI model of Schnider (TCI-Schnider) and the other group received propofol following the TCI model of Marsh (TCI-Marsh). A manual perfusion technique (MCI, n=30) was used in the control group. Depth of anesthesia was controlled using the bispectral index (BSI) which was adjusted to fall within the range of 40-55. Hemodynamics, extubation times and time of awaking, rate and quality of propofol dose adjustment, total drug requirements, costs, and quality of recovery were documented. The incidence of postoperative nausea and vomiting (PONV) as well as shivering and patient satisfaction were also documented., Results: Demographics, hemodynamics and perioperative data did not differ between the groups. Propofol consumption within the first 60 min also showed no significant differences. In the course of extended anaesthesia, propofol consumption was significantly less in both TCI groups compared to the control group (MCI) and the TCI-Schnider group also showed less episodes of bradycardia. The necessity of propofol dose adjustment did not differ significantly between the TCI groups. Administration and consumption of anaesthesia co-medication (fentanyl, remifentanil, cisatracurium) did not differ between the groups., Conclusion: The investigated propofol administration procedures using the MCI or TCI techniques were safe and easy to handle under BIS monitoring. No differences were found concerning extubation times and time of awaking. During extended anaesthesia procedures (>60 min), propofol consumption was lower with both TCI techniques and thus costs could be saved.

Background: Cost analyses of different anesthetic techniques have not been investigated in Taiwan. We compared propofol-based total intravenous anesthesia (TIVA), sevoflurane (SEVO) and desflurane (DES) anesthesias for cost and outcome under A-line auditory evoked potentials (AEP) monitoring., Methods: We studied 90 consecutive female patients (ASAI-II) scheduled to undergo elective gynecologic laparoscopic surgery. The study was prospective, randomized, and single-blind in design. All patients were randomly divided into 3 groups: i.e. groups TIVA, SEVO and DES. The A-line auditory evoked potential index (AAI) was maintained between 15-25. At the start of skin closure, the applied anesthetic was discontinued, and time of recovery from anesthesia was thenceforth reckoned until spontaneous opening of eyes and extubation. The costs of drugs were counted in New Taiwan (NT) dollars., Results: The total cost was significantly higher in the SEVO and DES groups than in the TIVA group (NT 1,243, 1028, and 889, respectively) (P < 0.001). In addition, the cost of the principal anesthetic drug was significantly higher in the SEVO than in the DES and TIVA groups (NT 756, 530, and 468, respectively) (P < 0.01). Faster recovery was seen in the TIVA group than in the DES group and SEVO group (8.2, 13.7, 16.2 min, respectively) (P < 0.001). Incidences of postoperative nausea, vomiting, and pain were not significantly different among 3 groups., Conclusions: The cost of TIVA with propofol was less than SEVO or DES anesthesia and moreover, propofol TIVA offered benefit of faster recovery in our study.

Background: The aim of this study was an improvement in patient comfort, reduction of anaesthesia costs and room contamination by the use of propofol for adenoidectomy., Methods: A total of 103 infants (aged 1-5 years) undergoing elective adenoidectomy were randomized for anaesthesia with sevoflurane-nitrous oxide/oxygen (group 1), sevoflurane-air/alfentanil (group 2), alfentanil-propofol under induction with sevoflurane (group 3) or alfentanil-propofol (group 4)., Results: Using propofol, postoperative agitation and emesis were significantly less and the anaesthesia costs as well as the need for analgesics was reduced compared to inhalative anaesthesia., Conclusions: The use of propofol for preschool children undergoing ear, nose and throat (ENT) surgery seems to be advantageous because of less postoperative agitation, emesis and costs.

Background: Propofol anesthesia based on target-controlled-infusion (TCI) has been shown to be superior to a manually-controlled-infusion (MCI) technique. A new optimal-target-controlled-infusion (OTCI) technique enables an individual plasma-targeted adjustment by including the concentration in the effect-compartment. This study compared practicability and costs of the new system with a conventional MCI-based propofol anesthesia regimen., Methods: In a prospective study, 50 patients scheduled for elective surgery of nose or nasal sinuses were randomly enrolled to receive BIS-controlled anaesthesia (level: 40-55) using either OTCI (n = 25) or MCI (n = 25). Hemodynamics, extubation times and time of awaking, rate and quality of propofol adjustment, total drug requirements, costs, postanaesthetic care unit (PACU) stay, Aldrete and pain scores, and adverse effects (postoperative nausea and vomiting (PONV), shivering) were recorded., Results: Demographics, hemodynamics, and perioperative data including extubation times were comparable for both study groups. Propofol consumption was similar within the first 60 min for both groups, thereafter, significantly less propofol in the OTCI group (5.03 mg/kg/h) than the MCI group (5.79 mg/kg/h) was used. Costs for propofol was significantly reduced with OTCI (0.2 vs. 0.23 Cent/anaesthesia minute/kg), the administration of other anaesthetics (fentanyl, remifentanil, cis-atracurium) did not differ between the groups. The number of infusion adjustments to BIS values were not significantly different., Conclusion: The new OTCI-system is a safe and easily controllable technique. The obvious advantage of this infusion system appears to be a reduction in propofol consumption and direct drug costs for anaesthesia lasting longer than 60 min.

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.

There is very little information about the practice of sedation in Japan. Despite the remarkable advances in dentistry, fear and anxiety continue to be significant deterrents for seeking dental services. Most dental procedures can fortunately be undertaken with the aid of sedation. A comprehensive survey of all the dental schools in Japan was carried out to determine what sedation practices were used in Japan. All 29 dental schools in Japan possessed a dedicated department of anesthesiology at the time of this survey. The survey attempted to determine the specific sedation methods (techniques, routes of administration, and agents used in sedation) as well as practices (monitoring, fasting, location, education, and fees involved in sedation). The results indicate that there was a broad range in sedation practices. The Japanese Dental Society of Anesthesiology may wish to examine the findings of this study and may wish to formulate guidelines appropriate for the practice of sedation in Japan. Others may also wish to compare their own practices with those of Japan.

Since venous cannulation in children has become easier and extensive experience has been gained with total intravenous anaesthesia (TIVA) in adults, the interest in TIVA for children has recently increased. An intensified sensitivity of the operating room atmosphere to contamination with volatile anaesthetic agents is another important reason to choose intravenous techniques for paediatric anaesthesia. One of the most interesting agents for TIVA in paediatric anaesthesia is propofol. The pharmacokinetic and pharmacodynamic data for modern intravenous drugs is poor. Because the interpatient variability is relatively large, pharmacokinetic data can only provide guidelines for the dosage of propofol. Propofol has a rapid and smooth onset of action and is as easy to titrate in children as in adults. Propofol can be excellently controlled. Severe haemodynamic side-effects are missing in healthy children and plasma is cleared rapidly of propofol by redistribution and metabolism. There is no evidence of significant accumulation, not even after prolonged infusion times. Because propofol has no analgetic properties it must be combined with analgetics or a regional block for all painful procedures. The combination with the ultra-short acting remifentanil is a major advantage, but requires effective analgetic concepts for painful procedures. In comparison the combination of propofol with long acting opioids abolishes some of the favourable properties of propofol. Further studies of the kinetics and dynamics of propofol and other intravenous agents are needed in paediatrics which should focus on age, maturity and severity of illness. The whole importance of the propofol-infusion syndrome has to be cleared up urgently. TIVA has an important significance in paediatric anaesthesia for diagnostic and therapeutic procedures, especially where these have to be repeated. In day-case anaesthesia TIVA has advantages for all short procedures and for ENT and ophthalmic surgery: even after prolonged infusion children have an short recovery time. There is no evidence of agitation or other behavioural disorders after TIVA with propofol in paediatric anaesthesia. Propofol has anti-emetic properties. TIVA with propofol can be combined with regional anaesthesia advantageously to provide long-lasting analgesia after surgery. TIVA with propofol has been used successfully for sedation of spontaneously breathing children for MRI and CT and other procedures with open airways like bronchoscopy or endoscopy. Propofol facilitates endotracheal intubation without the use of muscle relaxants. Of course, in malignant hyperthermia TIVA will continue to be the technique of choice. Nothing is known about awareness under TIVA in paediatric patients. TIVA must be considered by comparison with the volatile agents. The use of ultra-short acting agents may cause problems such as awareness, vagal response, involuntary movements and in some cases slow recovery after prolonged infusion of propofol. But it is not known exactly how often this happens during paediatric anaesthesia. With TIVA an effective postoperative analgesia must be provided. Newer administration techniques such as the target-controlled infusions or closed-loop control systems are under development and will help to minimise the potential risk of overdosage with TIVA in paediatrics. At the present TIVA is an interesting and practicable alternative to volatile anaesthesia for pre-school and school children. TIVA with propofol in infants younger than 1 year old requires extensive experience with TIVA in older children and with the handling of this special age group and should be undertaken with maximum precautionary measures.

Background: The Narcotrend is a new electroencephalographic monitor designed to measure depth of anesthesia, based on a six-letter classification from A (awake) to F (increasing burst suppression) including 14 substages. This study was designed to investigate the impact of Narcotrend monitoring on recovery times and propofol consumption in comparison to Bispectral Index (BIS) monitoring or standard anesthetic practice., Methods: With institutional review board approval and written informed consent, 120 adult patients scheduled to undergo minor orthopedic surgery were randomized to receive a propofol-remifentanil anesthetic controlled by Narcotrend, by BIS(R), or solely by clinical parameters. Anesthesia was induced with 0.4 micro x kg-1 x min-1 remifentanil and a propofol target-controlled infusion at 3.5 microg/ml. After intubation, remifentanil was reduced to 0.2 micro x kg-1 x min-1, whereas the propofol infusion was adjusted according to clinical parameters or to the following target values: during maintenance to D(0) (Narcotrend) or 50 (BIS); 15 min before the end of surgery to C(1) (Narcotrend) or 60 (BIS). Recovery times were recorded by a blinded investigator, and average normalized propofol consumption was calculated from induction and maintenance doses., Results: The groups were comparable for demographic data, duration of anesthesia, and mean remifentanil dosages. Compared with standard practice, patients with Narcotrend or BIS monitoring needed significantly less propofol (standard practice, 6.8 +/- 1.2 mg x kg-1 x h-1 vs. Narcotrend, 4.5 +/- 1.1 mg x kg-1 x h-1 or BIS(R), 4.8 +/- 1.0 mg x kg-1 x h-1; P < 0.001), opened their eyes earlier (9.3 +/- 5.2 vs. 3.4 +/- 2.2 or 3.5 +/- 2.9 min), and were extubated sooner (9.7 +/- 5.3 vs. 3.7 +/- 2.2 or 4.1 +/- 2.9 min)., Conclusions: The results indicate that Narcotrend and BIS monitoring are equally effective to facilitate a significant reduction of recovery times and propofol consumption when used for guidance of propofol titration during a propofol-remifentanil anesthetic.

Total intravenous anaesthesia (TIVA) has many advocates and offers potential benefits, yet the direct costs of this technique are commonly greater than those of inhalation-based alternatives. Although many advantages are claimed for TIVA, in reality all modern anaesthetics are effective and have good safety and tolerability profiles, rendering these differences of less importance now than was perhaps once the case. The majority of direct comparisons between inhaled and intravenous anaesthetics have failed to demonstrate significant differences in recovery times, yet they have consistently shown greater direct costs associated with intravenous propofol anaesthesia. It is commonly believed that indirect costs may be offset by indirect savings achieved through more rapid recovery, reduction in adverse effects and decreased staff workloads. In some cases, these differences in outcome have not been observed, while in many where they have, indirect savings are only theoretical. Reductions in recovery time and nursing workload will only result in savings if fewer nurses are required or if the existing ones can be paid for fewer hours. Salary arrangements, peak demand for patient care, performance of multiple tasks in parallel and limitations in time accounting methodology all limit the ability to achieve such savings in reality. Drug wastage also contributes to the cost of anaesthesia and is common to both intravenous and inhaled techniques. With inhaled anaesthesia, wastage can be reduced by the use of lower fresh gas flows, which has no adverse consequences and may provide potential benefits. With intravenous anaesthesia, reducing drug wastage is difficult and potentially harmful through cross-contamination of drugs between patients. Recently, the cost of propofol has been reduced with the availability of generics, making TIVA a more attractive proposition. The costs of several inhaled anaesthetics have also decreased, however, reducing any relative benefit. Nevertheless, the net result of lowered costs is that all types of anaesthetic drugs, which typically comprise <5% of a hospital pharmacy budget, represent excellent value for money. With few new products in the immediate pipeline and most established drugs already generic or about to lose their patent protection, the expense of anaesthesia is likely to decline even further. Perhaps then we will be able to stop arguing over relatively small differences in cost and choose a technique that, in our own experienced hands, provides the best and safest patient outcomes.

Unlabelled: Remifentanil may be beneficial in patients undergoing coronary artery bypass graft surgery, by promoting hemodynamic stability, reducing drug requirements, and attenuating the neurohumoral "stress response." We enrolled 77 cardiac surgical patients in a double-blinded, randomized trial and randomly allocated them to one of three groups: remifentanil infusion at 0.83 micro g. kg(-1). min(-1) (Group R); fentanyl bolus, small dose, at 12 micro g/kg (Group FLD); and fentanyl bolus, moderate dose, at 24 micro g/kg (Group FMD). We found a significant difference in the median time to tracheal extubation: Group FLD, 6.5 h; Group R, 7.3 h; and Group FMD, 9.7 h (P = 0.025). Group R patients had similar times to those of Groups FLD (P = 0.14) and FMD (P = 0.30). Group FLD patients had a longer length of hospital stay (P = 0.030). Patients in Group R had a significantly infrequent rate of hypertension but a frequent rate of hypotension (P < 0.01). The urinary cortisol excretion was larger in Group FLD patients (P < 0.0005), and urine flow was smaller (P < 0.0005). Remifentanil was associated with a propofol dose reduction (P = 0.0005) and a concomitant higher bispectral index (P = 0.032). Three Group FLD patients, but none in groups FMD and R, had postoperative myocardial infarctions (P = 0.032). Remifentanil has larger drug acquisition costs but does not increase the total hospital costs associated with cardiac surgery., Implications: Remifentanil did not significantly reduce the duration of tracheal intubation after cardiac surgery. Remifentanil, when compared with fentanyl (total doses of approximately 15 and 28 micro g/kg), blunts the hypertensive responses associated with cardiac surgery but is associated with more hypotension; when compared with fentanyl 15 micro g/kg, remifentanil reduces cortisol excretion. Larger-dose opioids (remifentanil 0.85 micro g. kg(-1). min(-1) or fentanyl 28 micro g/kg) were associated with a decreased rate of myocardial infarction after cardiac surgery.

Healthcare costs are rising in all areas of medicine, especially in high technology specialities such as anaesthesia. Therefore, cost containment and reduction have become major goals in many hospitals and anaesthesia departments. One area that has received substantial attention is the cost of pharmaceutical products, in particular the cost of newer, shorter-acting inhaled and intravenous anaesthetics, analgesics and neuromuscular blocking agents. Numerous pharmacoeconomic studies have been published on the theoretical analysis of anaesthetic drug costs and the potential benefit of various anaesthesia techniques. However, the results are not conclusive and anaesthesia departments continue to seek ways to reduce costs. In this review, we intend to discuss cost terminology, common areas of cost containment in anaesthesia and the relationship of anaesthesia care costs to total perioperative costs.

Unlabelled: Several anesthetic techniques have been used successfully to provide anesthesia for resection of intracranial supratentorial mass lesions. One technique used to enhance recovery involves changing anesthesia from vapor-based to propofol-based for cranial closure. However, there are no data to support a beneficial effect of this approach in the immediate postoperative period after craniotomy. We evaluated 3 anesthetic techniques in 60 patients undergoing elective surgery for supratentorial mass lesions. Patients were randomly assigned to three anesthesia study groups: propofol infusion, isoflurane inhalation, and these two techniques combined. In the combination group, once the dura was closed, isoflurane was discontinued and propofol infusion simultaneously started. We studied intra- and postoperative hemodynamics and several recovery variables for 2 h after the end of anesthesia. Baseline and average intraoperative blood pressure and heart rate values did not differ among the groups. Heart rate and blood pressure increased similarly in all groups in response to intubation and pin placement and postoperatively. None of the recovery event times (open eyes, extubation, follow commands, oriented, Aldrete score) or psychomotor test performance differed significantly. We conclude that the sequential administration of isoflurane and propofol did not provide earlier recovery and cognition than the intraoperative use of isoflurane alone., Implications: We evaluated three anesthetic techniques with and without propofol in patients undergoing elective surgery for supratentorial mass lesions by using a prospective, randomized clinical study design and found that the three anesthetics did not differ in intra- or postoperative hemodynamic stability or early postoperative recovery variables.

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.

Study Objective: To compare hemodynamics, recovery profiles, early postoperative pain control and costs of total intravenous anesthesia (TIVA) with propofol and remifentanil and propofol and alfentanil., Design: Randomized, double-blind study., Setting: University hospital., Patients: 40 ASA physical status I and II adult patients scheduled for lumbar discectomy., Interventions: Patients were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 1 microg kg(-1) or alfentanil 20 microg kg(-1) with propofol 2 mg kg(-1), and maintained with infusions of propofol 150 to 100 microg kg(-1)min(-1) and either remifentanil 0.1 microg kg(-1) min(-1) or alfentanil 0.5 microg kg(-1) min(-1)., Measurements: Hemodynamic parameters (heart rate and mean arterial pressure), times to awakening, and tracheal extubation were recorded. In the postanesthesia care unit, pain level, frequency of analgesic demand, frequency of postoperative nausea and vomiting (PONV), partial oxygen saturation (SpO2), and respiratory rates were noted. Drug dosages and costs of each technique were determined., Main Results: The mean arterial pressure significantly decreased compared to baseline values 1 minute after induction (p < 0.05) in both groups, and it significantly decreased at 5, 15, and 30 minutes perioperatively in the remifentanil group compared to the alfentanil group (p < 0.05). Time of extubation, spontaneous eye opening, and response to verbal command were similar in both groups. Visual analog scale pain scores at 30 minutes and 60 minutes were significantly lower in the alfentanil group than remifentanil group (p < 0.05). At 15, 30, and 60 minutes after terminating the operation oxygen saturation and respiratory rate were significantly higher (p < 0.05) and analgesics were required sooner in the remifentanil group than the alfentanil group (p < 0.05). The frequency of PONV was similar in both groups. The remifentanil-propofol anesthesia was found to be slightly more expensive as compared to the alfentanil based TIVA (33.41 +/- 4.53 vs. 29.97 +/- 4.1 USD) (p < 0.05)., Conclusions: Both remifentanil and alfentanil provided a reasonably rapid and reliable recovery. The remifentanil-based TIVA was associated with high intraoperative cost and early postoperative pain, but it allowed a more rapid respiratory recovery.

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.

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.

Objective: To compare hemodynamics, time to extubation, and costs of target-controlled infusion (TCI) with manually controlled infusion (MCI) of propofol in high-risk cardiac surgery patients., Design: Prospective, randomized., Setting: Major community university-affiliated hospital., Participants: Twenty patients undergoing first-time implantation of a cardioverter-defibrillator with severely reduced left ventricular function (left ventricular ejection fraction <30%)., Interventions: Anesthesia was performed using remifentanil, 0.2 to 0.3 microg/kg/min, and propofol. Propofol was used as TCI (plasma target concentration, 2 to 3 microg x mL; n = 10) or MCI (2.5 to 3.5 mg/kg/hr; n = 10)., Measurements and Main Results: Hemodynamics were measured at 6 data points: T1, before anesthesia; T2, after intubation; T3, after skin incision; T4, after first defibrillation; T5, after third defibrillation; and T6, after extubation. There were no significant hemodynamic differences between the 2 groups. Dobutamine was required to maintain cardiac index >2 L/min/m(2) in significantly more patients of the TCI group than of the MCI group. Mean dose of propofol was higher in the TCI patients (6.0 +/- 1.0 mg/kg/hr) than in the MCI patients (3.0 +/- 0.4 mg/kg/hr) (p < 0.05), whereas doses of remifentanil did not differ. Time to extubation was significantly shorter in the MCI (11.9 +/- 2.4 min) versus the TCI group (15.6 +/- 6.8 min). Costs were significantly lower in MCI patients (34.73 dollars) than in TCI patients (44.76 dollars)., Conclusions: In patients with severely reduced left ventricular function, TCI and MCI of propofol in combination with remifentanil showed similar hemodynamics. TCI patients needed inotropic support more often than MCI-treated patients. Although extubation time was longer in TCI patients and costs were higher, both anesthesia techniques can be recommended for early extubation after implantation of a cardioverter-defibrillator., (Copyright 2001 by W.B. Saunders Company.)

A retrospective study was performed to compare differences in hospital charges between monitored anesthesia care with retrobulbar block and general anesthesia among patients having vitrectomy. Of 128 consecutive patients undergoing vitrectomy between July 1996 and July 1997, group 1 received general anesthesia (n = 41), group 2 received monitored care anesthesia with retrobulbar block (n = 59), and 28 patients were eliminated from the study. There were significant differences in anesthesia charges, operating room charges, pharmacy charges, and total hospital charges between groups 1 and 2. Charges associated with monitored care anesthesia with retrobulbar block are 20% less than charges associated with general anesthesia. Fewer patients in group 2 required postoperative intravenous narcotics than in group 1.

In this study we compared operating room (OR) efficiency of total intravenous anaesthesia (TIVA) with remifentanil and propofol and balanced anaesthesia (BAL) with fentanyl and isoflurane in cataract surgery using computersimulation. We simulated patient flow for one OR and for three ORs. Time intervals of patient flow were randomly generated from the results of a prospective, randomized trial. Both for one and for three ORs, the postanaesthesia care unit (PACU) finished earlier and one additional case per OR and per day could be performed when TIVA was used for the procedures. Overtime in the PACU was less after TIVA. With a workload of 13 or 15 operations per day in three ORs, monitoring equipment for an additional patient in the PACU was required when BAL was used. TIVA with remifentanil and propofol was associated with more OR efficiency than balanced anaesthesia with fentanyl and isoflurane when given for cataract surgery.

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.

Background: Nasolacrimal duct obstruction occurs in 5% to 6% of neonates. Many studies advocate the probing of nasolacrimal duct obstruction under general inhalational anesthesia in patients at a late age (12 to 13 months) because a high percentage will resolve spontaneously. Others support early surgical intervention in patients aged younger than 6 to 9 months without anesthesia. We present late nasolacrimal duct probing under intravenous propofol sedation as an alternative approach to the treatment of nasolacrimal duct obstruction with a decrease in cost and time compared with probing under general inhalational anesthesia., Methods: We made a retrospective review of patient charts of children who underwent nasolacrimal duct probing with intravenous propofol sedation from April 1996 to September 1997. Procedure time and cost of procedure were compared for patients who had probings under propofol sedation to patients who had probings under general anesthesia., Results: A total of 22 patients (31 eyes) underwent nasolacrimal duct probing with propofol sedation; the patients' ages ranged from 11.5 to 39 months (average age, 17.8 months). Twenty-six (84%) of 31 eyes had resolution of the symptoms. The average total time for procedure under propofol sedation was 10.5 minutes, compared with 43.6 minutes under general inhalational anesthesia. The average total recovery time under propofol sedation was 13.6 minutes, compared with 121.1 minutes with general inhalational anesthesia. The cost of probing under propofol sedation was one third less than the cost of probing under general inhalational anesthesia., Discussion: Late probing for nasolacrimal duct obstruction under intravenous propofol sedation is comparable in efficacy to late probing under general inhalational anesthesia with a shorter time for the procedure and decreased expense.

Co-induction is the concurrent administration of two or more drugs that facilitate induction of anaesthesia. Some combinations have been shown to have pharmacological advantages. In addition to the safety and comfort of the patient, it is also important to find a cost effective combination in view of the rather stringent economy of the times. This project was undertaken to study the response of Nigerian patients to co-induction (midazolam and propofol) by comparison with the traditional thiopentone or propofol alone, and to study the cost implications. 45 patients who came in for various surgical procedures were randomly assigned to three different groups. The first group was induced with thiopentone alone. The second group had a combination of midazolam and propofol and the third group had propofol alone. In all other respects except for the surgery the patients had the same treatment. The induction was satisfactory in all groups. The cardiovascular and respiratory changes were within clinically acceptable limits but the emergence was best with propofol, followed by midazolam/propofol and thiopentone in that order. Although thiopentone was the cheapest in terms of absolute cost, the combination of midazolam and propofol was most cost-effective.

Day-case anaesthesia requires rapidly eliminated anaesthetics which are relatively expensive. This multinational, multicentre European study assessed the relative costs of propofol or sevoflurane anaesthesia in 211 patients. Anaesthesia was induced and maintained with propofol in group 1, with propofol and sevoflurane in group 2, and with sevoflurane in group 3. Drug and delivery costs were calculated in US$. Induction of anaesthesia was fastest in groups 1 and 2, although spontaneous ventilation resumed earliest in group 3. Emergence times and times at which patients were fit for discharge were similar in all groups. Group 2 had the lowest costs based on actual drug use (mean $14.2 (SEM 0.8) vs $18.7 (0.8) and $17.3 (0.8) in groups 1 and 3, respectively). Anaesthetic drug wastage and disposable costs were highest in group 1 and lowest in group 3. Consequently, total costs were highest in group 1 ($31.9 (0.9)) compared with groups 2 ($19.7 (0.9)) and 3 ($18.8 (0.9)). Although we observed increased nausea and vomiting in groups 2 and 3 and reduced patient satisfaction in group 3, these differences should be balanced against the greater cost of propofol anaesthesia.

Total intravenous anesthesia (TIVA) has been recommended in view of avoiding air pollution. However, intermittent administration of anesthetic agents has a large disadvantage of delayed emergence. We reported that continuous TIVA with propofol, ketamine, vecuronium and buprenorphine (PKBp) could bring rapid emergence. In this study, we calculated and compared the cost of anesthesia in the subjects who had undergone general anesthesia either with continuous PKBp or nitrous oxide-oxygen-sevoflurane. In group PKBp subjects, after induction with propofol, ketamine, vecuronium and buprenorphine, anesthesia was maintained with continuous intravenous administration of propofol corresponding to the patient's age using twice step down method; ketamine (240 micrograms.kg-1.h-1), vecuronium (80 micrograms.kg-1.h-1) and buprenorphine (0.4 microgram.kg-1.h-1). Group GOS subjects, after the same induction method, received nitrous oxide, sevoflurane and vecuronium. Moreover, the group GOS subjects were divided to two groups; the high flow GOS (N2O:O2:sevoflurane = 4 l:2 l:30 ml) and the low flow GOS (N2O:O2:sevoflurane = 2 l:1 l:15 ml). Continuous PKBp group showed lower cost than the high flow GOS group. The PKBp group showed lower cost than the low flow GOS group except in patients weighing more than 100 kg. Furthermore, we calculated the cost of continuous PKBp anesthesia in Japan, U.S.A. and U.K. The U.S.A. cost of PKBp was higher than the Japanese and the U.K., because the cost of ketamine in U.S.A. is higher than in the other countries. Continuous PKBp is more economical than the high flow GOS, and continuous PKBp in Japan is more economical than in U.S.A.

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.

The objective of this study was to determine the methods of anaesthesia used for the reduction of distal radius fractures in adults in Scotland and to compare this with the UK situation. The method used was a telephone questionnaire of accident and emergency doctors in 25 Scottish hospitals dealing with trauma. Thirty-two per cent still use general anaesthesia routinely for these procedures despite its cost, complexity and need for admission in the majority of cases. Forty-four per cent now use the Bier's block technique of regional anaesthesia, with the attendant advantages of ease of use, rapid recovery and no need for admission in the majority of patients. Twelve per cent use intravenous sedation and 12% use haematoma blocks for manipulations. It is concluded that Bier's block may be the anaesthetic method of choice for the management of distal radius fractures both in efficiency and economic terms in Scotland. However, training for Bier's blocks needs to be standardized and improved.

Purpose: To compare the cost and effectiveness of intravenous regional anaesthesia (IVRA) with general anaesthesia (GA) for outpatient hand surgery., Method: A retrospective record analysis of 121 patients who received IVRA were compared with 64 patients who received GA in our Daycare centre. The costs of anaesthesia and recovery were calculated from an institutional perspective using 1995 Canadian Dollar values. Effectiveness was measured in terms of time for anaesthesia, recovery and discharge, % with unsatisfactory anaesthesia and complications., Results: Both groups were well matched in terms of weight, sex and ASA class. Patients in the IVRA group were older (45 +/- 16 vs 38 +/- 13 yr) and had a lower frequency of two types of operation. The median total cost for the IVRA group of $24.60 (15.76-55.29) was less than that for the GA group of +f448.66 (35.59-73.11), (P < 0.00001). Anaesthesia was unsatisfactory in 11% of the IVRA group, but in none having GA,(P < 0.01). Recovery was faster in the IVRA group with a median time to discharge of 70 (35-180) min compared with 118 (45-320) min in the GA group, (P < 0.00001). Vomiting requiring treatment occurred in 5% of the GA group, but in none having IVRA, (P < 0.05). Dizziness which delayed discharged also occurred in 5% of the GA group, but in none having IVRA, (P < 0.05)., Conclusion: The cost of anaesthesia and recovery using IVRA for outpatient hand surgery was half that of GA. intravenous regional anaesthesia was less effective than GA in achieving satisfactory anaesthesia, equally effective in time to administer anaesthesia, and more effective in speeding recovery and minimising postoperative complications.

Unlabelled: Several procedures performed in the electrophysiology laboratory (EP lab) require surgical manipulation and are lengthy. Patients undergoing such procedures usually receive general anesthesia or deep sedation administered by an anesthesiologist. In 536 consecutive procedures performed in the EP lab, we assessed the safety and efficacy of deep sedation administered under the direction of an electrophysiologist and in the absence of an anesthetist. Patients were monitored with pulse oximetry, noninvasive blood pressure recordings, and continuous ECGs. The level of consciousness and vital signs were evaluated at 5-minute intervals. Deep sedation was induced in 260 patients using midazolam, phenergan, and meperidine, then maintained with intermittent dosing of meperidine at the following mean doses: midazolam 0.031 +/- 0.024 mg/kg; phenergan 0.314 +/- 0.179 mg/kg; and meperidine 0.391 +/- 0.167 mg/kg per hour. In the remaining 276 patients, deep sedation was induced with midazolam and fentanyl and maintained with a continuous infusion of fentanyl at a mean dose of 2.054 +/- 1.43 micrograms/kg per hour. Fourteen patients experienced a transient reduction in oxygen saturation that was readily reversed following administration of naloxone. An additional 11 patients desaturated secondary to partial airway obstruction, which resolved after repositioning the head and neck. Fourteen patients experienced hypotension with fentanyl. All but one returned to baseline blood pressures following an infusion of normal saline. No patient required intubation and no death occurred. Only three patients had recollection of periprocedure events. No patient remembered experiencing pain with the procedure. Hospital stays were not prolonged as a result of the sedation used., In Conclusion: (1) deep sedation during EP procedures can be administered safely under the guidance of the electrophysiologist without an anesthetist present; (2) the drugs used should be readily reversible in case of respiratory depression; and (3) this approach may reduce the overall cost of the procedures in the EP lab, maintaining adequate patient comfort.

Well-trained nonanesthesiologists can safely and effectively administer IV anesthetics for cardioversion. This practice results in considerable cost savings without compromising patient care.

Purpose: A randomized, blinded clinical trial was undertaken to compare recovery characteristics and cost-benefits associated with three general anaesthetic techniques for arthroscopic knee surgery in an ambulatory care setting., Methods: Ninety three, ASA Physical Status I-II patients were randomly allocated to receive one of three types of general anaesthesia: isoflurane/fentanyl/N2O (Group INH); alfentanil/N2O (Group BAL); or propofol/alfentanil/O2 (Group TIVA). Postoperative recovery profiles were evaluated at 30, 60, 90 and 120 min after emergence from anaesthesia, and direct and indirect costs of each anaesthetic were compared., Results: The most rapid emergence was observed in Group BAL (2.2 +/- 1.5 min, P < 0.0001 compared with groups INH and TIVA), although the incidence of post-operative nausea and vomiting was also highest in this group (P = 0.02 compared with groups INH and TIVA). However, overall patient satisfaction, and mean times to discharge from the Post Anesthesia Recovery Unit and hospital, were rapid and similar in all three groups. During anaesthesia which lasted 40-45 min, nearly a four-fold difference was observed in the direct costs of anaesthetic drugs: $16.4 +/- 4.4 (Group INH), $45.3 +/- 11.4 (Group BAL) and $63.4 +/- 17.9 (Group TIVA, P < 0.001 between groups); while indirect costs were similar., Conclusions: For arthroscopic knee surgery, INH anaesthesia with isoflurane/fentanyl/N2O is associated with similar hospital discharge times, and comparable levels of patient satisfaction as either BAL or TIVA. While indirect costs were similar, lower direct costs suggest that there may be a pharmacoeconomic benefit associated with the use of a "standard" isoflurane/fentanyl/N2O anaesthetic in certain day care surgery procedures.

The economic impact of the new German health care laws requires an awareness of cost-effectiveness when using newer drugs. The main goal in patient care, i.e., effective treatment, must be achieved by the rational use of restricted resources at a maximum degree of effectiveness. Economic aspects of the new inhalational anaesthetics such as sevoflurane are discussed in this article. The cost of inhalational anaesthetic agents accounts for up to 5% of all the running expenses of an anaesthesia department. The consumption and cost of an inhalational agent depend on fresh gas flow, vapour setting, and duration of anaesthesia. Comparing the cost for 1 MAC-h of anaesthesia, desflurane is more expensive at current market prices than sevoflurane and isoflurane. However, at low or minimal fresh gas flows, the price for one MAC-h is almost the same for these volatile anaesthetics. Total intravenous anaesthesia using propofol is even more expensive, partly due to wastage, i.e., opened ampoules with a remainder of propofol that has to be discarded after each case. When choosing an anaesthetic agent, the price of 1 ml liquid anaesthetic is an important factor. However, the overall cost-effectiveness analysis must balance the cost of the agent with its pharmacodynamic advantages such as more rapid recovery from anaesthesia. Furthermore, the indirect costs of side effects have to be taken into account. For example, nausea and vomiting lead to a prolonged stay in the recovery room after anaesthesia for outpatient surgery, which in turn incurs additional costs for antiemetic drugs and the extra time for nursing care. Therefore, a lower incidence of nausea and vomiting and a more rapid recovery from anaesthesia leading to earlier discharge from the recovery room may compensate for the higher price. Volatile agents account for up to 1% of the total intraoperative costs. In analysing the costs of 1 h of anaesthesia, other products such as plasma substitutes and blood products account for a much higher proportion than anaesthetic agents, and reductions or increases in costs pertaining to these products have a bigger impact on overall costs than do volatile anaesthetics. We conclude that volatile anaesthetics account for only a minor portion of the anaesthesia department budget and the cost of anaesthesia delivery. The higher market price of the new agents may be compensated for by the economic impact of fewer side effects and a shorter post-anaesthesia stay in the hospital. In analysing data for sevoflurane, this agent may be cost-effective, for example, for outpatient anaesthesia.

One hundred and one women (ASA grades I and II) were anaesthetized for routine gynaecological surgery using an intravenous (i.v.) anaesthetic technique combining propofol and alfentanil. The patients were allocated randomly into groups. Group one received 33% oxygen in nitrous oxide and group two received 33% oxygen in air (total i.v. anaesthesia). The group receiving nitrous oxide required significantly less (P < 0.05) of the propofol and alfentanil mixture to maintain anaesthesia and this was found to reduce the mean cost of anaesthesia by 1.70 pounds, (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups. We suggest that nitrous oxide may be used to reduce the cost of total i.v. anesthesia with propofol and alfentanil without causing any increase in post-operative morbidity in patients undergoing routine gynaecological surgery.

Early tracheal extubation in the operating room after atrial septal defect (ASD) surgery was recommended as part of a clinical practice guideline (CPG) established in the Cardiovascular Program at the Children's Hospital, Boston, MA. This retrospective review was undertaken to determine whether this practice was efficient without compromising patient care. The charts and hospital charges for 102 patients undergoing secundum ASD or sinus venosus defect surgery between March 1992 and July 1994 were reviewed; 36 patients (Group I) had surgery prior to introduction of the CPG, and 66 patients were managed according to the CPG. Of the latter, 25 patients (Group II) were tracheally extubated in the operating room (OR) and 41 patients (Group III) were extubated in the cardiac intensive care unit (CICU). Patients in all three groups were similar with respect to height, weight, and surgical conditions including cardiopulmonary bypass time, lowest esophageal temperature, hematocrit, total OR time, and the time from completion of bypass to leaving the OR. Patients in Group II received significantly less fentanyl during anesthesia, were more likely to have a respiratory acidosis on admission to the CICU, and had an increased frequency of vomiting in the CICU. There was no difference in duration of CICU stay among groups. The length of hospital stay was reduced in Groups II and III after introduction of the CPGs, but was not influenced by tracheal extubation in the OR. There was no difference among groups in the hospital charges for OR, anesthesia and CICU time. However, when the combined hospital charges for services provided both in the OR and CICU were included, patients in Group II were charged significantly less, and this primarily reflects the absence of postoperative mechanical ventilation charges. Tracheal extubation in the OR after ASD surgery in children can result in lower patient charges without significantly compromising patient care.