The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses.

BACKGROUND: Although approximately 2,000 medical practice guidelines have been proposed, few have been successfully implemented and sustained. We hypothesized that we could develop and institute practice guidelines to promote more appropriate use of costly anesthetics, to generate and sustain widespread compliance from a large physician group, and to decrease costs without adversely affecting clinical outcomes. METHODS: A prospective before and after comparison study was performed at a tertiary care medical center. Clinical outcomes data and times indicative of perioperative patient flow were collected on the first of two sets of patients 1 month before discussion of practice guidelines. Practice guidelines were developed by the physicians and their associated care team for the intraoperative use of anesthetic drugs. A drug distribution process was developed to aid compliance. Clinical outcomes data and times indicative of perioperative patient flow were collected on the second set of patients 1 month after institution of practice guidelines. Hospital drug costs and adherence to guidelines were noted throughout the study period and for each of the following 9 months by querying the database of an automated anesthesia record keeper. RESULTS: A total of 1,744 patients were studied. Drug costs decreased from 56 dollars per case to 32 dollars per case as a result of adherence to practice guidelines. Perioperative patient flow was minimally affected. Time (mean +/- SD) from end of surgery to arrival in the post-anesthesia care unit (PACU) increased from 11 +/- 7 min before the authors instituted practice guidelines to 14 +/- 8 min after practice guidelines (P < 0.0001). Admission of inpatients to the PACU receiving monitored anesthesia care increased from 6.5 to 12.9% (P < 0.02). Perioperative patient flow and clinical outcomes were not otherwise adversely affected. Compliance and cost savings have been sustained. CONCLUSIONS: This study is an example of a successful physician-directed program to promote more appropriate utilization of health care resources. Cost savings were obtained without any substantial changes in clinical outcomes. Institution of similar practice guidelines should result in pharmaceutical savings in the range of 50% at tertiary care centers around the country, with a slightly smaller degree of savings expected at institutions with more ambulatory surgery.

A comparison of mivacurium dosage requirements during isoflurane and desflurane anesthesia.

STUDY OBJECTIVE: To evaluate the dose requirement and recovery characteristics of mivacurium infusions during anesthesia with equipotent concentrations of either desflurane or isoflurane. DESIGN: Randomized, open-study comparing the effects of desflurane and isoflurane on mivacurium-induced neuromuscular blockade. SETTING: Operating suite of a university-affiliated medical center. PATIENTS: 41 ASA status I, II, and III adult patients, requiring more than 45 minutes of neuromuscular blockade for surgery. INTERVENTIONS: Following a standardized induction sequence and established steady desflurane-nitrous oxide (DES group) or isoflurane-nitrous oxide (ISO group) anesthesia at 1 minimum alveolar concentration (MAC), an intubating dose of 0.2 mg/kg of mivacurium chloride was administered. Ventilation was maintained with a face mask until the first twitch (T1) of the evoked train-of-four (TOF) reached 10% or less of control when tracheal intubation was performed. T1 was allowed to return to 10% of its control value. An infusion of mivacurium at the initial rate of 5 micrograms/kg/min was then started and adjusted to maintain T1 at 10% +/- 2% of control. Within 20 minutes of completion of surgery, the mivacurium infusion was stopped, and the time for the evoked electromyograph (EMG) to return to 25% and 75% of the original baseline was noted. MEASUREMENTS AND MAIN RESULTS: Neuromuscular function was monitored continuously by an evoked EMG. The average infusion rate was 5.7 +/- 2.4 micrograms/kg/min (mean +/- SD) for DES group (n = 20) and 6.6 +/- 2.7 micrograms/kg/min for ISO group (n = 21) (p = NS). There was no change in the infusion rate of mivacurium over time for both groups. However, there was an inverse relationship in both groups between the time to recovery following a bolus dose and the subsequent mean infusion rate of mivacurium (correlation coefficient = -5.0; p < 0.005). The spontaneous recovery index (T25-75) for the two groups was identical, 11.5 +/- 4.9 min (mean +/- SD) for DES group and 11.5 +/- 7.9 min for ISO group (p = NS). CONCLUSION: There were no differences in the dose requirement and recovery indices of mivacurium during either desflurane or isoflurane-based anesthesia. Patients who took longer to recover from the bolus dose in both groups showed a subsequent reduction in dose requirements of mivacurium.