Costing anaesthetic practice. An economic comparison of regional and general anaesthesia for varicose vein and inguinal hernia surgery

Assessment of Operative Time for Lip and Oral Cancers: A Tool to Improve Operative Room Efficiency

Operation theatre (OT) time utilisation rates can be improved with an assessment of the procedure time that will result in effective scheduling of cases. Our study is the first of its kind to audit the amount of OT time required for a particular surgery in lip and oral cavity cancers, depending on the various components of this complex procedure. This prospective cross-sectional study, based on an operative room database of 323 OT sessions, was conducted in the Department of Surgical Oncology at a tertiary care centre on lip and oral cancer patients from January 1st, 2019 to December 31st, 2020. Various components of the surgery, like the primary site, operating surgeon, type of neck dissection, bone resection, and reconstructive procedure, were noted. The time of entry and exit of the patient from the OT was noted. Operative time and OT time utilisation rates were calculated. SPSS 21.0 statistical tool; Students 'T', ANOVA and Games-Howell tests were applied. In 323 OT sessions, while 303 surgeries were done for primary cases (93.8%), the remaining 20 cases were for recurrent cases (6.2%). Buccal mucosa and the floor of the mouth were the most and least common sites, respectively. The mean OT time was 212.42 ± 73.83 min, the maximum being the primary at alveolus. The mean OT late start time was 70.03 ± 23.41 min and the mean OT runover time was 37.62 ± 43.53 min. The mean time varied significantly with the type of neck dissection, bone resection, and reconstructive surgery done and the operating surgeon. The mean OT time was highest for free flap reconstructive surgery (328.71 ± 62.02 min), but it didn't vary with its type. Considering only the lip and oral cancer surgeries, the OT time utilisation rate was 57.1%. Assessment and quantification of the operative duration of lip and oral cancer surgeries will help in accurate prediction of surgical duration, better OT list planning, and thus improved OT time utilisation rate. Our research not only provides data on the historical mean of procedures, but it may also encourage other centres to adopt our quantitative approach to OT scheduling.

Cost-Effectiveness of Propofol (Diprivan) Versus Inhalational Anesthetics to Maintain General Anesthesia in Noncardiac Surgery in the United States

OBJECTIVES

It is not known whether using propofol total intravenous anaesthesia (TIVA) to reduce incidence of postoperative nausea and vomiting (PONV) is cost-effective. We assessed the economic impact of propofol TIVA versus inhalational anesthesia in adult patients for ambulatory and inpatient procedures relevant to the US healthcare system.

METHODS

Two models simulate individual patient pathways through inpatient and ambulatory surgery with propofol TIVA or inhalational anesthesia with economic inputs from studies on adult surgical US patients. Efficacy inputs were obtained from a meta-analysis of randomized controlled trials. Probabilistic and deterministic sensitivity analyses assessed the robustness of the model estimates.

RESULTS

Lower PONV rate, shorter stay in the post-anesthesia care unit, and reduced need for rescue antiemetics offset the higher costs for anesthetics, analgesics, and muscle relaxants with propofol TIVA and reduced cost by 11.41 ± 10.73 USD per patient in the inpatient model and 11.25 ± 9.81 USD in the ambulatory patient model. Sensitivity analyses demonstrated strong robustness of the results.

CONCLUSIONS

Maintenance of general anesthesia with propofol was cost-saving compared to inhalational anesthesia in both inpatient and ambulatory surgical settings in the United States. These economic results support current guideline recommendations, which endorse propofol TIVA to reduce PONV risk and enhance postoperative recovery.

Local anesthesia underutilized for inguinal hernia repair in northern Ghana

Introduction

Inguinal hernia repair is a common procedure and a priority for public health efforts in Ghana. It is essential that inguinal hernia repair be performed in a safe, efficient manner to justify its widespread use. Local anesthesia has many favorable properties and has been shown to be superior, compared to regional or general anesthesia, in terms of pain control, safety profile, cost-effectiveness, resources required, and time to discharge. Local anesthesia is recommended for open repair of reducible hernias, provided clinician experience, by multiple international guidelines. Regional anesthesia is associated with myocardial infarction and other complications, and its use is discouraged by multiple guidelines, especially in older patients. This study aims to assess the current state of anesthesia for inguinal hernia repair in the northern and transitional zone of Ghana. In addition we will assess the perceptions of different types of anesthesia along with understanding of evidence-based guidelines among clinicians participating in inguinal hernia repair.

Methods

We performed a retrospective review of all inguinal hernia repairs for male patients, 18 and older, in over 90% of hospitals in northern Ghana. All 41 hospitals were visited and caselogs and patient charts were manually reviewed to extract data. Multivariate logistic regression was used to determine predictors of local anesthesia use. We designed a survey instrument to assess the perceptions of physicians and anesthetists regarding different types of anesthesia for inguinal hernia repair. The survey was designed by a Ghanaian surgeon, reviewed by all co-authors, and tested prior to implementation using a sample (n = 8) of clinicians having similar practices to those of the survey population. Of 70 clinicians, 66 responded, yielding a response rate of 94%.

Results

8080 patients underwent hernia repair of which 37% were performed under local anesthesia, while the majority, 60%, were performed under regional anesthesia. Negative predictors of local anesthesia were emergent repair (OR = 0.258, p < 0.001), surgery performed at a teaching hospital (OR = 0.105, p < 0.001), and bilateral hernia repair (OR = 0.374, p < 0.001). 1,839 (22.8%) of IH repairs were done on patients age 65 or older and RA was most frequently used among the elderly population (57.8%), while local anesthesia was used 39.5% of the time. Sixty-six clinicians participated in the survey with the majority reporting that local anesthesia requires fewer staff, less equipment, has a shorter recovery, is more cost-effective, and might be safer for patients. However 66% were unfamiliar with or incorrectly perceived international guidelines.

Conclusion

To our knowledge, this study is the largest assessment of anesthesia use for inguinal hernia repair in an LMIC. Although the selection of anesthetic technique should be guided by a patient’s general health, the anatomy of the hernia, and clinician judgment, local anesthesia appears to be underutilized in northern Ghana. Survey responses demonstrate high rates of unfamiliarity or incorrectly perceived evidence-based guidelines. Future research should assess how education on the benefits and technique of local anesthesia administration may further increase rates for inguinal hernia repair, especially for older patients.

[Spinal anesthesia versus general anesthesia in the surgical treatment of inguinal hernia. Cost-effectiveness analysis]

OBJECTIVE

To compare the costs related to the clinical effectiveness of general anesthesia versus spinal anesthesia in inguinal hernioplasty ambulatory surgery.

MATERIAL AND METHODS

An observational, retrospective cohort study measurement and analysis of cost-effectiveness, in the ambulatory surgery unit of a general hospital. All patients over 18 years of age diagnosed with primary inguinal hernia and scheduled for unilateral hernioplasty between January 2010 and December 2011 were included. Duration of anesthetic induction, length of stay in both the operating room, and in the post-anesthesia care unit, the anesthetic effectiveness (the incidence of adverse effects and the patient's comfort level), and variable economic costs associated with the use of drugs, as well as the use of human resources, were compared.

RESULTS

The final analysis included 218 patients, 87.2% male, with a mean age of 53 years (range: 18-85 years). Of these, 139 (63.76%) received subarachnoid anesthesia and 79,(36.2%) general anesthesia. The length of time a patient remained in the post-anesthesia care unit was 337.6±160.2min in the subarachnoid anesthesia group, and 210.0±97.5min for the general anesthesia group (P<.001). Costs of drugs for general anesthesia were higher than that for subarachnoid anesthesia (86.2±8.3 vs. 18.7±7.2). The total cost difference between the 2 techniques was €115.8 more for subarachnoid anesthesia (P<.001).

CONCLUSIONS

Both techniques showed similar effectiveness. The overall costs for subarachnoid anesthesia were greater than for the general. The cost-effectiveness of general anesthesia is better for outpatient inguinal hernia repair surgery.

[Significantly shorter anesthesia time for surgery of the lumbar spine : process analytical comparison of spinal anesthesia and intubation narcosis]

INTRODUCTION

Most surgery of the lumbar spine is performed with the patient under general anesthesia (GA); however, qualitative benefits of spinal anesthesia (SA) have been reported. The goal of this study was to compare time efficiency between these two anesthesia methods in lumbar spine surgery. To test the hypothesis that the use of SA leads to significant time saving compared to GA for lumbar spine surgery, key points in the preoperative, intraoperative and postoperative anesthesiology care times were analyzed. The focus was on anesthesia time excluding surgery time.

MATERIALS AND METHODS

Electronically based data of 473 anesthesia procedures (368 SA, 105 GA) for lumbar spine interventions performed in the prone position (i. e. decompression, discectomy and transpedicular instrumentation) were analyzed retrospectively. Patient population data including gender, age, American Society of Anesthesiologists (ASA) classification and body mass index (BMI) were analyzed. The focus was on the documented perioperative key time points which are defined as follows: (1) induction, (2) positioning (turning into prone position), (3) scrubbing and covering, (4) surgery time (knife to skin closure), (5) closing (end of surgery until leaving operating room) and (6) handing over to recovery. Differences in the amount of time for each perioperative period were calculated for SA and GA.

RESULTS

In 7 out of the 368 SA patients SA failed and had to be converted to GA. There were no significant differences in BMI, ASA prevalence and gender between SA and GA patients but SA patients were significantly older (median 61.7 ± 15.4 years) than GA patients (median 56.1 ± 14.6 years). However, SA required significantly less time for induction (SA: 17.7 ± 7.0 min, GA: 21.6 ± 7.2 min), preoperative preparation (SA: 9.7 ± 3.6 min, GA: 13.3 ± 5.4 min) and closing period (SA: 4.9 ± 1.1 min, GA: 15.3 ± 5.7 min) compared to GA. Total anesthesia time with exclusion of the surgery time revealed a significant time reduction using SA of 19 min (95 % confidence interval: range 13.6-24.4 min, median in SA: 56.7 min, median in GA: 75.7 min, p < 0.0001).

CONCLUSIONS

This study showed that in lumbar spine surgery 19 min of anesthesia time can be saved using SA compared to GA which could have an impact on economic aspects. Gender, BMI and ASA had no statistically detectable influence on the choice between the two anesthesia methods. The fact that time-intensive complex instrumentation is mainly performed in younger patients may explain why GA patients were younger than SA patients.

Implementation of a fast-track-pathway including analgo-sedation with local anaesthesia for outpatient varicose vein surgery: a cohort study

Objective

To evaluate the clinical and economical impact of a fast-track anaesthesia protocol in the management of primary varicose vein (VV) surgery.

Methods

Over a 10-month period (from 1 December 2009 to 30 September 2011), all patients eligible for open VV surgery ( N = 176) were enrolled in a fast-track clinical pathway including titrated analgo-sedation combined with local anaesthesia. This fast-track cohort was compared with a historical cohort undergoing similar procedures and receiving general anaesthesia (GA) or spinal anaesthesia (SA) (between 1 December 2009 to 30 September 2011, N = 200). The length of stay in the operating facilities and postoperative recovery areas were reported and hospital costs were estimated. In addition, the occurrence of adverse events and unplanned hospital admission were compared between the two consecutive periods.

Results

Patients characteristics and surgical procedure were not different in the two cohorts. After implementation of the fast-track pathway, the incidence of postoperative adverse events decreased from 41% to 2.3%, with no need for overnight hospital stay (0% versus 7%). The reduction in anaesthesia-controlled time (-47%) and in postoperative recovery time (-61%) were associated with an increased operating capacity (1 extra case per day) and with substantial cost-savings (mean reduction of €312 per case, P < 0.001).

Conclusions

Implementation of a fast-track pathway for outpatient VV surgery was successful, safe and efficient. Analgo-sedation combined with infiltrative anaesthesia (instead of GA or SA) contributed to increase the operating capacity and to reduce the workload of nursing personnel.

Transilluminated powered phlebectomy in an office setting: procedural considerations and clinical outcomes

PURPOSE

To report a series of non-sedated patients treated with transilluminated powered phlebectomy (TIPP) under tumescent anesthesia in an office setting.

METHODS

Thirty-six patients (31 women; mean age 54.8±11.8 years) with a mean body mass index of 25 kg/m(2) were selected for the in-office TIPP procedure between January 2009 and September 2010. Medical conditions included hypertension, asthma, hypothyroidism, and gastrointestinal problems. Twenty-eight had prior surgical procedures, 10 of which were for vascular abnormalities. Symptom duration was a mean of 19 years. Twenty-five had a family history of venous disease. The CEAP classification ranged from 2 to 4, but the majority were class 2. Seven patients had conditions that made the TIPP procedures more challenging. Medical data, preoperative venous status, postoperative findings, and patient-reported satisfaction were reviewed.

RESULTS

All procedures were completed as planned and without complications. The mean TIPP procedure time was 13.5±3.7 minutes. Thirty-three patients underwent concurrent endovenous ablation. Patient satisfaction measured on a scale from 0 to 10 ranged from a mean of 8.8 at 48 hours to 9.6 at 3 months. At the 3-month follow-up, there were no reports of hematoma, deep venous thrombosis, or extended paresthesia.

CONCLUSION

Appropriately selected patients with a variety of clinical presentations can safely undergo the TIPP procedure in an office setting utilizing only local tumescent anesthesia.

The economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery: a comparative study of direct costs

BACKGROUND AND OBJECTIVES

Total knee and total hip arthoplasty (THA) are 2 of the most common surgical procedures performed in the United States and represent the greatest single Medicare procedural expenditure. This study was designed to evaluate the economic impact of implementing a multimodal analgesic regimen (Total Joint Regional Anesthesia [TJRA] Clinical Pathway) on the estimated direct medical costs of patients undergoing lower extremity joint replacement surgery.

METHODS

An economic cost comparison was performed on Mayo Clinic patients (n = 100) undergoing traditional total knee or total hip arthroplasty using the TJRA Clinical Pathway. Study patients were matched 1:1 with historical controls undergoing similar procedures using traditional anesthetic (non-TJRA) techniques. Matching criteria included age, sex, surgeon, type of procedure, and American Society of Anesthesiologists (ASA) physical status (PS) classification. Hospital-based direct costs were collected for each patient and analyzed in standardized inflation-adjusted constant dollars using cost-to-charge ratios, wage indexes, and physician services valued using Medicare reimbursement rates. The estimated mean direct hospital costs were compared between groups, and a subgroup analysis was performed based on ASA PS classification.

RESULTS

The estimated mean direct hospital costs were significantly reduced among TJRA patients when compared with controls (cost difference, 1999 dollars; 95% confidence interval, 584-3231 dollars; P = 0.0004). A significant reduction in hospital-based (Medicare Part A) costs accounted for the majority of the total cost savings.

CONCLUSIONS

Use of a comprehensive, multimodal analgesic regimen (TJRA Clinical Pathway) in patients undergoing lower extremity joint replacement surgery provides a significant reduction in the estimated total direct medical costs. The reduction in mean cost is primarily associated with lower hospital-based (Medicare Part A) costs, with the greatest overall cost difference appearing among patients with significant comorbidities (ASA PS III-IV patients).

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Reliability of the 'pop' sign as an indicator of dural puncture during obstetric spinal anaesthesia: a prospective observational clinical study

Anaesthetists rely upon a loss of resistance and flow of cerebrospinal fluid to indicate when a spinal needle has breached the dura. The loss of resistance is not always felt, with the danger that the needle may be advanced into neurological tissue. One hundred women undergoing elective caesarean section were recruited and spinal anaesthesia, using a 27-G Whitacre needle, was performed using an incremental advancement technique. After each advancement of the needle, and before removing the stylet, it was recorded whether the anaesthetist had perceived any sign that the dura had been breached, and then whether cerebrospinal fluid had been obtained. Six patients were not included in the study due to technical difficulties. In 27 of 94 patients (29%) there was no clear tactile sign that the dura had been breached when cerebrospinal fluid was obtained. This study demonstrates that loss of resistance is not always felt when a 27-G spinal needle breaches the dura in the pregnant woman.

[Realisation of material costs in anaesthesia. Alternatives to the reimbursement via diagnosis-related groups]

BACKGROUND AND GOAL

For reimbursement via diagnosis-related groups (DRG), lump compensation-based payment of medical cases in German hospitals requires a case-related measuring and billing of resources that has to be consistent with DRG guidelines. Only through this, can the real costs be compared with the standard costs as calculated by the hospital reimbursment system (InEK) on a case-related basis and the DRG-specific break-even level be identified.

METHODS

In the present paper the authors introduce and validate two newly created alternative methods for case-related allocation of material costs in the field of anaesthesia. Method 1 allows online documentation of material costs via pre-defined anaesthesia standards. This full cost method is suitable for hospitals that have implemented an electronic hospital information system in their daily clinical documentation routine. For other hospitals method 2 could be applicable as the case-related allocation of material costs is done retrospectively based on the data collected in an electronic anaesthesia protocol record system (andoc, medlinq).

RESULTS

Method 1 makes it possible to allocate 90.3% of anaesthesia-related material costs to a specific case corresponding to a Pearsson coefficient of 0.77. After iterative improvement through optimisation of modules the documentation quality could be raised to >98% and a Pearsson coefficient of 0.96. Although the expense for implementation and maintenance is considerable, the necessary documentation work for the clinician is low. Method 2 demands no further clinical effort in documentation and implementation and 49.1% of all material costs can be assigned on a case-related basis.

CONCLUSIONS

The online documentation of material costs via predefined anaesthesia standards accounts for nearly all material costs in anaesthesia and only a negligible documentation effort is necessary for the clinician. Nevertheless, a complex and time-consuming configuration of standards and a continuous iterative alignment of the modules with the actual processes are required. Due to its process-orientated character, method 1 can also be used for workflow optimisation in terms of standard operating procedures (SOPs). Allocation of material costs with data from the electronic anaesthesia record system is a method that can be easily implemented but only a partial case relation is rendered possible.

Local anesthesia for inguinal hernia repair in adolescents

BACKGROUND

Many centers use local anesthesia for adult inguinal hernia surgery in the setting of day-case surgery. There are no reports on, or guidelines for, use of anesthesia for inguinal hernia surgery in adolescents. We describe our initial experience with the use of local anesthesia and intravenous sedation for inguinal hernia surgery in adolescents in the setting of a day-surgery facility.

METHODS

The charts of 14 consecutive adolescent patients (aged 12-17) who had inguinal hernia surgery from July 2004 to March 2005 were reviewed retrospectively. Intravenous sedation was administered 1-3 min before injection of local anesthetic. Sedation consisted of midazolam 0.085 mg kg(-1) and either fentanyl 0.85 mug kg(-1) or ketamine 0.085 mg kg(-1), according to the preference of the anesthesiologist. Additional sedation with half the initial dose was administered if required. Local anesthesia using a combination of lignocaine and bupivacaine was administered by the surgeon with infiltration in the skin and deep tissues.

RESULTS

Fourteen adolescents aged 12-17 years (mean 14.8 +/- 1.37), weighing 34-100 kg (mean 61.2 +/- 16.5), had 15 inguinal hernia repairs with sedation and local anesthesia. All the patients were male. All completed the surgery with sedation and local anesthesia. None required conversion to general anesthesia. There were no immediate or subsequent complications. Mean time from the end of surgery to discharge home was under 2 h (mean 106 +/- 36 min). Examination of patient charts did not reveal any complaints regarding the surgery or the postoperative course at the postoperative follow up visit.

CONCLUSIONS

The use of local anesthesia with intravenous sedation for inguinal hernia repair in the adolescent age group seems feasible and requires further prospective study.

Cost-effectiveness analysis of local, regional and general anaesthesia for inguinal hernia repair using data from a randomized clinical trial

BACKGROUND

Inguinal hernia repair is a common operation in general surgery and can be performed under local, regional or general anaesthesia. This multicentre randomized trial was undertaken to compare the costs of the three anaesthetic methods in general surgical practice.

METHODS

Between January 1999 and December 2001, 616 patients at ten hospitals who underwent primary inguinal hernia repair were randomized to local, regional or general anaesthesia. The primary endpoints were direct costs. Secondary endpoints were indirect costs and recurrence rates.

RESULTS

Total intraoperative, as well as total early postoperative, data showed local anaesthesia to have significant cost advantages over regional and general anaesthesia (P < 0.001). The advantage was also significant for total hospital and total healthcare costs (P < 0.001), whereas there was no significant difference between regional and general anaesthesia.

CONCLUSION

The use of local anaesthesia for inguinal hernia repair was significantly less expensive than regional or general anaesthesia.

Estimating the duration of common elective operations: implications for operating list management

Over-running operating lists are known to be a common cause of cancellation of operations on the day of surgery. We investigated whether lists were overbooked because surgeons were optimistic in their estimates of the time that operations would take to complete. We used a questionnaire to assess the estimates of total operation time of 22 surgeons, 35 anaesthetists and 16 senior nursing staff for 31 common, general surgical and urological procedures. The response rate was 66%. We found no difference between the estimates of these three groups of staff, or between these estimates and times obtained from theatre computer records (p = 0.722). We then applied the average of the surgeons' estimates prospectively to 50 consecutive published surgical lists. Surgical estimates were very accurate in predicting the actual duration of the list (r2= 0.61; p < 0.001), but were poor at booking the list to within its scheduled duration: 50% of lists were predictably overbooked, 50% over-ran their scheduled time, and 34% of lists suffered a cancellation. We suggest that using the estimates of operating times to plan lists would reduce the incidence of predictable over-runs and cancellations.

Effect of spinal flexion on the conus medullaris: a case series using magnetic resonance imaging

Anatomy textbooks state that the conus medullaris moves cephalad when the vertebral column is flexed. This could confer protection against spinal cord damage during dural puncture, but has not been demonstrated in vivo. We therefore imaged the spine of 10 volunteers using magnetic resonance imaging to determine if such movement occurs with the spine in the neutral and flexed positions. The position of the conus medullaris in relation to the superior endplate of the L1 vertebra was determined. On spinal flexion, the conus medullaris moved cephalad in three subjects and caudad in three subjects, with no change in the remaining four. The median overall movement (95% CI [range]) was 0 mm (4 mm caudad to 1 mm cephalad [3 mm caudad to 1 mm cephalad]; p = 1.0). Whilst spinal flexion may facilitate needle insertion during dural puncture, it is unlikely to confer extra protection against spinal cord damage.

Groin Hernia Repair: Anesthesia

The choice of anesthesia for groin hernia repair is between general, regional (epidural or spinal), and local anesthesia. Existing data from large consecutive patient series and randomized studies have shown local anesthesia to be the method of choice because it can be performed by the surgeon, does not necessarily require an attending anesthesiologist, translates into the shortest recovery (bypassing the postanesthesia care unit), has the lowest cost, and has the lowest postoperative morbidity regarding risk of urinary retention. Spinal anesthesia has no documented benefits for this small operation and should be avoided owing to the risk of rare neurologic side effects and the high risk of urinary retention. General anesthesia with short-acting agents may be a valid alternative when combined with local infiltration anesthesia, although an anesthesiologist is required. Despite sufficient scientific data to support the choice of anesthesia, large epidemiologic and nationwide information from databases show an undesirable high (about 10-20%) use of spinal anesthesia and low (about 10%) use of local infiltration anesthesia. Surgeons and anesthesiologists should therefore adjust their anesthesia practices to fit the available scientific evidence.

A Retrospective Comparison of Costs for Regional and General Anesthesia Techniques

In this retrospective study, we compared the costs for three different regional anesthesia techniques with the costs of general anesthesia (GA). A total of 1587 anesthesia cases which were performed for orthopedic and trauma patients over a 1-yr period in a tertiary level, university hospital setting were analyzed. The anesthesia technique-related costs were determined calculating case-specific costs for personnel, supplies, and drugs. The techniques were compared on the basis of anesthesia costs and surgical procedure duration. As a result, we found that the costs per surgical minute largely depend on the surgical procedure duration. Based on the regression function, the cost advantage of spinal anesthesia over GA can be estimated to be 13% for a 50-min case, 9% for a 100-min case, and 5% for a 200-min case. The cost disadvantage of brachial plexus anesthesia over GA can be estimated to be 19% for a 50-min case, 8% in a 100-min case, and 1% for a 200-min case. We found no difference in costs between epidural and GA. We concluded that cost comparisons of anesthesia techniques largely depend on the surgical duration of the cases studied. Even in a teaching hospital setting, spinal anesthesia has economic advantages over GA. Especially for short cases, brachial plexus block is more expensive in this setting.

Anaesthetic practice for groin hernia repair--a nation-wide study in Denmark 1998-2003

BACKGROUND

Recent scientific data suggest that local infiltration anaesthesia for inguinal hernia surgery may be preferable compared to general anaesthesia and regional anaesthesia, since it is cheaper and with less urinary morbidity. Regional anaesthesia may have specific side-effects and is without documented advantages on morbidity in this small operation.

METHODS

To describe the use of the three anaesthetic techniques for elective open groin hernia surgery in Denmark from January 1st 1998 to December 31st 2003, based on the Danish Hernia Database collaboration.

RESULTS

In a total of 57,505 elective open operations 63.6% were performed in general anaesthesia, 18.3% in regional anaesthesia and 18.1% in local anaesthesia. Regional anaesthesia was utilized with an increased rate in elderly and hospitalized patients. Outpatient surgery was most common with local infiltration anaesthesia.

CONCLUSION

Use/choice of anaesthesia for groin hernia repair is not in accordance with recent scientific data. Use of spinal anaesthesia should be reduced and increased use of local anaesthesia is recommended to enhance recovery and reduce costs.

Total intravenous anaesthesia: is it worth the cost?

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.

Investigation of the radiological relationship between iliac crests, conus medullaris and vertebral level in children

BACKGROUND

The inability of anaesthetists to accurately identify vertebral spaces has been documented. The aim of our magnetic resonance imaging (MRI) study was to find the relationship of vertebral body level with Tuffier's line and the conus medullaris in children.

METHODS

Forty-nine children aged 10 years or less who had MRI scanning in the region of the lumbar spine were identified. If either the conus medullaris or iliac crests were visible, the corresponding vertebral body level was recorded.

RESULTS

The level of the conus could be identified in 43 patients. The median conus level was at L1 with an interquartile range (IQR) of 0.5 vertebral levels. The level of the crests could be identified in 35 patients. The median crest height was L5 with an IQR of 0.5 vertebral levels. The difference between conus and crest levels could only be calculated in 29 patients. In the remainder of the children one of the two pieces of the data was not available. The median difference was 4 vertebral levels with an interquartile range (IQR) of 1. Two of 49 children, both of whom had tethered cords, had differences of <2 vertebral levels.

CONCLUSIONS

Our data confirmed that the iliac crests and conus medullaris were consistently related to the predicted vertebral levels in children. In the absence of a tethered spinal cord, subarachnoid puncture at L4-5 or below should present little risk of conus damage. Tuffier's line corresponded with a radiological level of L4-L5 in our study population.

Cost considerations in the use of anaesthetic drugs

Measuring the direct drug costs of an anaesthetic is relatively easy, but assessing increased expenditure in relation to clinical benefits and indirect costs is not. This review examines a number of papers that have attempted just such a task and tries to illustrate some of the difficulties inherent in this important area of cost-effective analyses.

The effects of lowering fresh gas flow during sevoflurane anaesthesia: a clinical study in patients having elective knee arthroscopy

The potential for minimising anaesthetic gas consumption with a circle absorber system is related to fresh gas flow. This study measured the actual sevoflurane consumption during elective arthroscopy of the knee in 75 ASA I-II patients randomised to three fresh gas flow rates (6, 3, and 1.5 l/min) using sevoflurane and O(2):N(2)O (1:2) after intravenous induction with fentanyl and propofol. A circle absorber system was used with a laryngeal mask airway. Anaesthetic duration, discharge time and postoperative pain did not differ between groups. Sevoflurane consumption was more than doubled with each doubling of fresh gas flow (0.07+/-0.03; 0.16+/-0.05; 0.41+/-0.12 ml sevoflurane/min; for gas flow 1.5, 3, 6 l/min; P<0.01). The hourly sevoflurane related cost decreased from 15.5 to 2.8 US$ when reducing the fresh gas flow from 6 to 1.5 l/min. Decreasing the fresh gas flow from 6 to 1.5 l/min provides good anaesthetic depth with effective reduction in anaesthetic consumption, cost and environmental burden.

Damage to the conus medullaris following spinal anaesthesia

Seven cases are described in which neurological damage followed spinal or combined spinal-epidural anaesthesia using an atraumatic spinal needle. All patients were women, six obstetric and one surgical. All experienced pain during insertion of the needle, which was usually believed to be introduced at the L2-3 interspace. In all cases, there was free flow of cerebrospinal fluid before spinal injection. There was one patchy block but, in the rest, anaesthesia was successful. Unilateral sensory loss at the levels of L4-S1 (and sometimes pain) persisted in all patients; there was foot drop in six and urinary symptoms in three. Magnetic resonance imaging showed a spinal cord of normal length with a syrinx in the conus (n = 6) on the same side as both the persisting clinical deficit and the symptoms that had occurred at insertion of the needle. The tip of the conus usually lies at L1-2, although it may extend further. Tuffier's line is an unreliable method of identifying the lumbar interspaces, and anaesthetists commonly select a space that is one or more segments higher than they assume. Because of these sources of error, anaesthetists need to relearn the rule that a spinal needle should not be inserted above L3.