Avaliação pré-anestésica e redução dos custos do preparo pré-operatório / Preanesthesia evaluation and reduction of preoperative care costs / Evaluación preanestésica y reducción de los costes de la preparación del preoperatorio

JUSTIFICATIVA E OBJETIVOS: A avaliação pré-anestésica (APA) é fundamental no preparo do paciente cirúrgico. Entre suas muitas vantagens, destaca-se a redução dos custos com o preparo pré-operatório. Embora estudos prévios tenham constatado esse benefício, não é certo que ele se aplique adequadamente em nosso meio. O objetivo deste estudo foi comparar os custos do preparo pré-operatório realizado pelo cirurgião com os custos estimados a partir da APA. Paralelamente, comparou-se a classificação do estado físico da American Society of Anesthesiologists (ASA) determinada pelo anestesiologista ou por outros especialistas. MÉTODO: Duzentos pacientes candidatos a procedimentos cirúrgicos ou diagnósticos eletivos, cujo preparo pré-operatório foi orientado pelo cirurgião, foram submetidos à APA após internação hospitalar. O anestesiologista determinou os exames complementares ou as consultas especializadas e necessárias a cada paciente. Foram comparados o número e os custos dos exames ou consultas indicados pelo anestesiologista com aqueles realizados no preparo pré-operatório. Comparou-se também a classificação da ASA determinada pelo anestesiologista ou pelo médico que realizou a consulta especializada. RESULTADOS: Dos 1.075 exames complementares realizados, 55,8 por cento não estavam indicados, o que equivaleu a uma fração de 50,8 por cento do custo total com exames. O anestesiologista considerou que 37 pacientes (18,5 por cento) não precisariam realizar exames. O custo do preparo orientado pelo cirurgião foi 25,11 por cento maior do que o custo estimado a partir da avaliação pré-anestésica, sendo essa diferença estatisticamente significante (p < 0,01). Houve discordância na classificação da ASA em 9,3 por cento dos pacientes avaliados pelo especialista. CONCLUSÕES: O preparo pré-operatório baseado na avaliação pré-anestésica criteriosa pode resultar em significativa redução dos custos quando comparado ao preparo orientado pelo cirurgião. Observou-se boa concordância na determinação do escore da ASA.

BACKGROUND AND OBJECTIVES: Preanesthesia evaluation (PAE) is fundamental in the preparation of a surgical patient. Among its advantages is the reduction of preoperative care costs. Although prior studies had observed this benefit, it is not clear whether it can be taken into consideration among us. The objective of the present study was to compare the costs of preoperative care performed by the surgeon with estimated costs based on PAE. In parallel, we compared the American Society of Anesthesiologists (ASA) physical status classification determined by the anesthesiologist with that estimated by other specialists. METHODS: Two hundred patients scheduled for elective surgery or diagnostic procedures whose preoperative care was made by the surgeon underwent PAE after hospital admission. The anesthesiologist determined which ancillary exams or referrals necessary for each patient. The number and cost of ancillary exams or referrals requested by the anesthesiologist were compared with those of the preoperative preparation. The ASA classification according to the anesthesiologist was also compared to that of the physician in charge of the consultation. RESULTS: Out of 1,075 ancillary exams performed, 55.8 percent were not indicated, which corresponded to 50.8 percent of the total cost of exams. The anesthesiologist considered that 37 patients (18.5 percent) did not require exams. The cost of surgeon-oriented preoperative care was higher than that based on the preanesthesia evaluation and this difference in costs was statistically significant (p < 0.01). In 9.3 percent of the patients discordance in ASA classification according to the specialist was observed. CONCLUSIONS: Preoperative care based on judicious preanesthesia evaluation can result in significant reduction in costs when compared to that oriented by the surgeon. Good concordance in ASA classification was observed.

JUSTIFICATIVA Y OBJETIVOS: La evaluación preanestésica (EPA), es fundamental para la preparación del paciente quirúrgico. Entre sus muchas ventajas tenemos la reducción de los costes con la preparación del preoperatorio. Aunque algunos estudios previos hayan constatado ese beneficio, no es correcto decir que él se pueda aplicar adecuadamente a nuestro medio. El objetivo de este estudio fue comparar los costes de la preparación del preoperatorio realizado por el cirujano con los costes estimados a partir de la EPA. En paralelo, comparamos la clasificación del estado físico de la American Society of Anesthesiologists (ASA) determinada por el anestesiólogo o por otros especialistas. MÉTODO: Doscientos pacientes candidatos a procedimientos quirúrgicos o diagnósticos electivos, cuya preparación preoperatoria estuvo orientada por el cirujano, se sometieron a la EPA después de su ingreso. El anestesiólogo determinó los exámenes complementarios o las consultas especializadas pertinentes para cada paciente. Se comparó el número y los costes de los exámenes o consultas indicados por el anestesiólogo con los realizados durante la preparación del preoperatorio. También comparamos la clasificación de la ASA determinada por el anestesiólogo o por el médico que realizó la consulta especializada. RESULTADOS: De los 1.075 exámenes complementarios realizados 55,8 por ciento no estaban indicados, lo que equivalió a una fracción de un 50,8 por ciento del coste total con los exámenes. El anestesiólogo consideró que 37 pacientes (18,5 por ciento) no necesitarían realizar exámenes. El coste de la preparación orientada por el cirujano fue un 25,11 por ciento mayor que el coste estimado a partir de la evaluación preanestésica, siendo ésa la diferencia entre los costes estadísticamente significantes: (p < 0,01). Se registró una discordancia en la clasificación de la ASA en 9,3 por ciento de los pacientes evaluados por el experto. CONCLUSIONES: La preparación del preoperatorio con base en la evaluación preanestésica de criterio puede resultar en una significativa reducción de los costes cuando se le compara a la preparación orientada por el cirujano. Se observó una buena concordancia en la determinación de la puntuación de la ASA.

Fast-tracking in pediatric cardiac surgery - The current standing.

Fast-tracking in cardiac surgery refers to the concept of early extubation, mobilization and hospital discharge in an effort to reduce costs and perioperative morbidity. With careful patient selection, fast-tracking can be performed in many patients undergoing surgery for congenital heart disease (CHD). In order to accomplish this safely, a multidisciplinary coordinated approach is necessary. This manuscript reviews currently used anesthetic techniques, patient selection, and available information about the safety and patient outcome associated with this approach.

Substitution of isoflurane by sevoflurane toward the end of long surgeries is cost effective

The lower solubility of sevoflurane allows a more rapid emergence from anesthesia than after anesthesia with more soluble but less expensive anesthetic isoflurane. Cost control in anesthesia is no longer an option: it is a necessity. We substitute sevoflurane for isoflurane toward the end of anesthesia lor operations longer than 3 hours in an attempt to combine the cost effectiveness of isoflurane with rapid emergence from sevoflurane. Sixty patients undergoing long abdominoplastic and ENT surgeries were randomly equally divided into three groups: group I [isoflurane group], group II [crossover group] where isoflurane was substituted by sevoflurane during the last 30 minutes of the operation and group III [sevoflurane group]. A fresh gas flow of 2 L/min as 60% N2O in 02 was used for maintenance of anesthesia. Consumption of volatile anesthetics was measured by weighing the vaporizers with a precision weighing machine and recovery variables were recorded. The times for spontaneous breathing, times to opening eyes, squeeze a finger on command, times for extubation, orientation, times to read Aidrete score >/= 9 and time to discharge from PACU: all these times were significantly longer in isoflurane group than the crossover and sevoflurane groups and no significant difference between crossover and isoflurane groups. Cost was significantly higher in sevoflurane group [1.242 EP per minute anesthesia]. The costs among the other two groups did not differ significantly [0.319 EP/min for isoflurane group and 0.344 EP/min for crossover group]. So sevoflurane based anesthesia was associated with the highest costs and faster recovery. In conclusion, by changing from isoflurane to sevoflurane toward the end of long anesthesia, we can accelerate recovery and decrease its expenditures without compromising the measured patient outcomes

Cost accounting in a surgical unit in a teaching hospital--a pilot study.

INTRODUCTION: Economic constraints remain one of the major limitations on the quality of health care even in industrialised countries. Improvement of quality will require optimising facilities within available resources. Our objective was to determine costs of surgery and to identify areas where cost reduction is possible. PATIENTS AND METHODS: 80 patients undergoing routine major and intermediate surgery during a period of 6 months were selected at random. All consumables used and procedures carried out were documented. A unit cost was assigned to each of these. Costing was based on 3 main categories: preoperative (investigations, blood product related costs), operative (anaesthetic charges, consumables and theatre charges) and post-operative (investigations, consumables, hospital stay). Theatre charges included two components: fixed (consumables) and variable (dependent on time per operation). RESULTS: The indirect costs (e.g. administration costs, 'hotel' costs), accounted for 30%, of the total and were lower than similar costs in industrialised nations. The largest contributory factors (median, range) towards total cost were, basic hospital charges (30%; 15 to 63%); theatre charges fixed (23%; 6 to 35%) and variable (14%; 8 to 27%); and anaesthetic charges (15%; 1 to 36%). CONCLUSION: Cost reduction in patients undergoing surgery should focus on decreasing hospital stay, operating theatre time and anaesthetic expenditure. Although definite measures can be suggested from the study, further studies on these variables are necessary to optimise cost effectiveness of surgical units.

Farmaeconomía: una materia que nos atañe a todos ¿Qué son los costos? / Pharmaco-economy: a subject that involves all of us. What are costs?

La búsqueda continua de drogas más seguras, más eficaces y con efectos adversos mínimos es una preocupación constante de la industria farmacéutica y de los anestesiólogos para mejorar el cuidado del paciente. Este proceso puede costar más de 200 millones de dólares y nos da una idea global del costo del proceso de desarrollo de una nueva droga. Nuestra economía es afectada por una crisis cuya más dramática expresión son los hospitales públicos. La administración de esos recursos no es atribución exclusiva de sus directivos. Cada profesional debe conocer el costo de los insumos que requiere y colaborar para su eficiente utilización. Se hacen propuestas para incrementar el rendimiento de tan valioso recurso, mediante motivación del personal y mayor información acerca del costo de dichos insumos, a fin de disminuir los gastos, sin comprometer la seguridad del paciente y del médico. Los costos de la anestesia están relacionados con los recursos consumidos para proporcionar un servicio o prestación difíciles de medir. Además de los costos directos de las drogas es necesario un estudio adecuado de los gastos indirectos o aquellos que resulten de un mayor cuidado del paciente (cuidados especiales, externación tardía, pérdida de días de trabajo, menor satisfacción del cliente). Los costos también deben estar relacionados con mediciones de calidad de resultados en los pacientes a un costo lo más razonable posible.

Análisis de costos en anestesia hospitalaria / Costs analysis in hospitalary anesthesia

Nuestra economía es afectada por una crisis cuya más dramática expresión son los hospitales públicos. La administración de esos recursos no es atribución exclusiva de sus directivos. Cada profesional debe conocer el costo de los insumos que requiere y colaborar para su eficiente utilización. Para conocer la estructura de costos del Servicio de Anestesiología del Hospital Universitario de Caracas, realizamos un análisis técnico de sus factores esenciales, mediante la revisión de 300 historias clínicas representativas de quince procedimientos quirúrgicos frecuentes durante 1993. En ese año se realizaron 8.329 intervenciones, 82,3 por ciento de ellas bajo anestesia general, con un Costo Promedio estimado de Bs. 12.401,51 por intervención. El costo por tipo de procedimiento fue el siguiente: Tipo A; Ejemplo Hernioplastia; Frecuencia 21,64 por ciento; Costos Bs. 3.880,99. Tipo B, Ejemplo Colecistectomía; Frecuencia 54,54 por ciento; Costos Bs. 6.409,97. Tipo C; Ejemplo Herida por Arma; Frecuencia 23,78 por ciento; Costos Bs. 33.917,79. Entre los factores analizados (Medicinas, Material Descartable, Gastos Administrativos, Equipos y Personal), fue más alta la inflación para el renglon de Medicina y muy poco afectados los dos últimos rubros. Se hacen propuestas para incrementar el rendimiento de tan valioso recurso, mediante motivación del personal y mayor información acerca del costo de dichos insumos, a fin de disminuir los gastos, sin comprometer la seguridad del paciente y del médico

Custo das anestesias em um hospital universitário / Anesthesia cost in an university hospital

Em 633 anestesias do tipo geral inalatória com respiraçäo assistida e controlada, geral venosa, raquianestesia, peridural lombar e epidural sacra, foi avaliado o custo médio/hora de anestesia. A peridural lombar e a raquianestesia evidenciaram-se como as técnicas anestésicas mais econômicas, seguidas pela epidural sacra, e pelas gerais inalatórias. A anestesia geral venosa foi a de maior custo