Financial Implications of Intravenous Anesthetic Drug Wastage in Operation Room

Scoping review for the SAGES EAES joint collaborative on sustainability in surgical practice

BACKGROUND

Surgical care in the operating room (OR) contributes one-third of the greenhouse gas (GHG) emissions in healthcare. The European Association of Endoscopic Surgery (EAES) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) initiated a joint Task Force to promote sustainability within minimally invasive gastrointestinal surgery.

METHODS

A scoping review was conducted by searching MEDLINE via Ovid, Embase via Elsevier, Cochrane Central Register of Controlled Trials, and Scopus on August 25th, 2023 to identify articles reporting on the impact of gastrointestinal surgical care on the environment. The objectives were to establish the terminology, outcome measures, and scope associated with sustainable surgical practice. Quantitative data were summarized using descriptive statistics.

RESULTS

We screened 22,439 articles to identify 85 articles relevant to anesthesia, general surgical practice, and gastrointestinal surgery. There were 58/85 (68.2%) cohort studies and 12/85 (14.1%) Life Cycle Assessment (LCA) studies. The most commonly measured outcomes were kilograms of carbon dioxide equivalents (kg CO2eq), cost of resource consumption in US dollars or euros, surgical waste in kg, water consumption in liters, and energy consumption in kilowatt-hours. Surgical waste production and the use of anesthetic gases were among the largest contributors to the climate impact of surgical practice. Educational initiatives to educate surgical staff on the climate impact of surgery, recycling programs, and strategies to restrict the use of noxious anesthetic gases had the highest impact in reducing the carbon footprint of surgical care. Establishing green teams with multidisciplinary champions is an effective strategy to initiate a sustainability program in gastrointestinal surgery.

CONCLUSION

This review establishes standard terminology and outcome measures used to define the environmental footprint of surgical practices. Impactful initiatives to achieve sustainability in surgical practice will require education and multidisciplinary collaborations among key stakeholders including surgeons, researchers, operating room staff, hospital managers, industry partners, and policymakers.

The environmental impacts of anesthesia

PURPOSE OF REVIEW

The healthcare sector has a substantial environmental footprint, and the delivery of anesthesia contributes significantly. Inhaled anesthetics themselves are potent greenhouse gases, unused intravenous medication exert toxic effects on the environment, and the increasing reliance on single-use devices has led to an ever-growing amount of solid waste produced in operating rooms. This review discusses many of these environmental impacts and suggests practices to mitigate the environmental footprint of anesthetic practice.

RECENT FINDINGS

The choice of anesthesia maintenance has significant environmental implications, with nitrous oxide and desflurane having the highest carbon footprint of all anesthetic agents. Using low fresh gas flows and supplementing or replacing inhalational agents with propofol leads to a significant reduction in emissions. Many intravenous anesthetic agents pose a risk of environmental toxicity, and efforts should be made to decrease medication waste and ensure appropriate disposal of unused medications to minimize their environmental impacts. Additionally, consideration should be given to replacing single-use devices in the operating rooms with reusable alternatives that are often both environmentally and economically superior. And solid waste generated in the operating room should be segregated thoughtfully, as processing regulated medical waste is a highly energy-intensive process.

SUMMARY

Significant opportunities exist to improve the environmental footprint of anesthesia practice, and with the rapidly worsening climate crisis, the importance of implementing changes is greater than ever.

Anesthetics drug wastage and preventive strategies: Systematic review

BACKGROUND

Surgical Patients and hospitals are now facing financial strain due to direct anesthetic demand as a result of the development of new anesthetic drugs, equipment, and techniques. Up to 15% of a hospital's pharmacy budget is currently allocated to anesthetic drug expenses. Drug wastage during anesthesia practice is a widespread hidden source of healthcare waste that leads to anesthetic drug shortages as well as poor operating room efficiency. On the other hand, despite the fact that it is preventable in the vast majority of cases, it is well described that drug wastage is routinely observed, including in developing countries where the consequences significantly affect both hospitals and patients.

METHODS

This review aims to review the prevalence of anesthetic drug waste across the world and systematically formulate and describe preventive strategies. Relevant publications were identified using systematic searches on databases including Google Scholar, Medline (PubMed), the Cochrane Library, and Embase. In addition, papers were detected and then selected through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria guidelines and the inclusion and exclusion criteria. Using the predetermined terms and dates from the searching databases, a total of 504 articles were identified. Based on the screening criteria, 16 papers were considered eligible and included in the final review. In addition, the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis was used for evaluating the quality of selected articles. This study is registered on PROSPERO, number CRD42024497044.

RESULTS

Of the sixteen publications from eleven different nations that were considered suitable for inclusion, only two of them addressed the waste of inhalational anesthetics. In more than half of eligible articles, propofol was the frequently wasted drug that contributed to increased financial loss through drug waste. The first most significant factor contributing to the waste of intravenous and inhalational anesthetics was the disposal of multidrug vials following their use for a single patient and high fresh gas flow, respectively.

CONCLUSION

Anesthetic medication waste is a common occurrence worldwide, despite the fact that it is expensive and has a significant negative impact on operating room efficiency. Because the majority of drug waste is avoidable, preventive measures may lower drug waste and improve patient and hospital efficiency.

Cu2O nanoparticles anchored on carbon for the efficient removal of propofol from operating room wastewater via peroxymonosulfate activation: efficiency, mechanism, and pathway

Anesthetic drug wastage has increasingly become the main resource of operating room sewage, which poses a great risk to the safety of humans and other organisms. Propofol is the most widely used anesthetic drug in the world, and also occupies the largest proportion of the total anesthetic wastage in the operating room. In this work, a 2D Cu2O anchored carbon catalyst (Cu2O@NC) was prepared by the assembly-pyrolysis process and successfully applied to peroxymonosulfate (PMS) activation. We took propofol as a typical example and investigated the removal activity through heterostructure-enhanced advanced oxidation processes (AOPs). Through the degradation process, propofol can be removed from 20 ppm to ultralow levels within 5 min using the PMS/Cu2O@NC system. The degradation pathway of propofol was deduced through quantum chemical calculation and LC/GC-MS results. The final products were verified as CO2 and H2O. Moreover, sulfate radicals (SO4˙-) proved to be the dominant reactive oxidation species by radical scavenger experiments and ESR results. In addition, it has great universality for various pharmaceuticals such as tetracycline (TC), amoxicillin (AMX), cephalexin (CPX), and norfloxacin (NFX). Our work provided the possibility to treat operation room sewage in a rapid, high-efficiency, and feasible way.

Reducing Medication Waste While Improving Access to Sugammadex: A Quality Improvement Project in Medication Stewardship

The relatively high cost of sugammadex compared to neostigmine limits its widespread use to reverse neuromuscular blockade, despite its faster onset and more complete clinical effect. While ensuring timely access to sugammadex is important in improving perioperative safety, it is also vital to control unnecessary spending. We describe a quality improvement initiative to reduce excess spending on sugammadex while improving access for anesthesia providers. Monthly spending on sugammadex decreased by 52% ($70,777 vs $33,821), while medication access increased via automated medication dispensers in each operating room. Clinical usage decreased by one-third, with presumed increased adherence to dosing guidelines.

The Wastage and Economic Effects of Anaesthetic Drugs and Consumables in the Operating Room

Objective

Anaesthesia is a branch in which new anaesthetic drugs, devices, instruments and new treatment methods have been developed. Because of these innovations, health expenditures have escalated. Anaesthetic drugs and consumables constitute the majority of these expenses. Some waste of used drugs and consumables in the operating room is unavoidable. However, excessive drug wastage can be controlled. One of the ways to reduce the financial burden of this wastage is to know the loss cost. This study aimed to discuss the effect of the wastage of drugs and consumables.

Methods

This prospective observational study was conducted in a hospital operating room over a six-week period. At the end of each operation and at the end of each operation day, the amount of wasted and consumables was recorded. The total wastage of the drugs and consumables was calculated by multiplying unit prices.

Results

Data of 363 cases were collected during the study period. The total loss cost calculated during the study period was 2545.77 TL. The highest total loss cost was rocuronium (29.95%) and propofol (27.99%). The least loss was neostigmine (0.06%). The consumption rate of consumables was lower than that of drugs.

Conclusion

A significant amount of drug wastage was recorded during the study period. This can be reduced by simple means. These applications vary from physician behavioural change to the preparation of standard doses of single-dose preparations. Cost training programmes at regular intervals can also be used as a cost-reduction strategy.

A Collaborative Initiative for Reducing Operating Room Waste of Unused Refrigerated Medication

BACKGROUND

Inappropriate management of anesthetic medications requiring refrigeration creates waste and increases costs of intraoperative care. At Tampa General Hospital, pharmacy personnel refill medications in cardiovascular operating rooms (CVOR) nightly and noticed large amounts of unattended medications at room temperature for unknown periods of time. Per protocol, these medications were disposed.

OBJECTIVE

To effectively decrease pharmaceutical waste in the CVOR.

METHODS

A pharmacy-led anesthesia committee identified the most used intraoperative medications requiring refrigeration and implemented changes to decrease waste. As a result, norepinephrine intravenous piggyback (IVPB), norepinephrine vials, nitroglycerin vials, and epinephrine IVPB were physically relocated into preexisting mini-refrigerators inside each CVOR. Vasopressin vials and phenylephrine syringes/vials were relocated into automated anesthesia cabinets. Amounts and cost of wasted medication were analyzed before and after protocol implementation.

RESULTS

Average weekly cost of wasted medication was significantly reduced (preintervention: US$1188.59 vs postintervention: US$322.96; P < .001), despite a consistent caseload.

CONCLUSION

Recorded weekly savings of US$865.63 (∼annual savings of >US$45 000) reflect only the explicit cost of waste. True savings are higher when including opportunity costs such as salary of pharmacy personnel and supplies needed to replace wasted medications. We demonstrate the benefits of a collaborative approach to improving inefficiencies in health care.

Optimization of the Surgical Field in Endoscopic Sinus Surgery: an Evidence-Based Approach

PURPOSE OF REVIEW

The advent of endoscopic sinus surgery (ESS) has enabled the development of minimally invasive surgical procedures in Rhinology. However, proficiency with ESS techniques can still be hampered by poorly controlled bleeding limiting visibility of the surgical field (VSF). This can lead to increased operating time and, more importantly, increased risk of major and minor complications. To optimize the VSF and mitigate the risk of complications, many strategies have been explored.

RECENT FINDINGS

This is a narrative review of the relative risks and benefits of pre- and intra-operative interventions aimed at optimizing intraoperative conditions during ESS. The value of these interventions is determined based on their impact on intraoperative blood loss, time of surgery, and the VSF, and weighed against their adverse event profile. This review provides a comprehensive overview of the evidence relating to the safety and efficacy of interventions used to improve intraoperative conditions during ESS.