Ready-to-use pre-filled syringes of atropine for anaesthesia care in French hospitals - a budget impact analysis.

BACKGROUND: Patient safety is improved by the use of labelled, ready-to-use, pre-filled syringes (PFS) when compared to conventional methods of syringe preparation (CMP) of the same product from an ampoule. However, the PFS presentation costs more than the CMP presentation. OBJECTIVE: To estimate the budget impact for French hospitals of switching from atropine in ampoules to atropine PFS for anaesthesia care. METHODS: A model was constructed to simulate the financial consequences of the use of atropine PFS in operating theatres, taking into account wastage and medication errors. The model tested different scenarios and a sensitivity analysis was performed. RESULTS: In a reference scenario, the systematic use of atropine PFS rather than atropine CMP yielded a net one-year budget saving of €5,255,304. Medication errors outweighed other cost factors relating to the use of atropine CMP (€9,425,448). Avoidance of wastage in the case of atropine CMP (prepared and unused) was a major source of savings (€1,167,323). Significant savings were made by means of other scenarios examined. The sensitivity analysis suggests that the results obtained are robust and stable for a range of parameter estimates and assumptions. STUDY LIMITATIONS: The financial model was based on data obtained from the literature and expert opinions. CONCLUSION: The budget impact analysis shows that even though atropine PFS is more expensive than atropine CMP, its use would lead to significant cost savings. Savings would mainly be due to fewer medication errors and their associated consequences and the absence of wastage when atropine syringes are prepared in advance.

Fundamentos de farmacoeconomía y su aplicación en anestesia clínica / Pharmacoeconomics: basic concepts and applications to clinical anesthesia

La evaluación económica de medicamentos y tecnologías sanitarias es una disciplina en auge en nuestros tiempos. Los recursos sanitarios son limitados y debemos aprovecharlos del mejor modo posible. La Farmacoeconomía se encarga especificamente del análisis de la mejor opción farmacológicaterapéutica, para aplicar a un determinado paciente o población con el objetivo de obtener un efecto deseado. Hay fundamentalmente cuatro tipos de estudios empleados en Farmacoeconomía: los estudios de minimización de costes, análisis coste-beneficio, análisis coste-efectividad y análisis costeutilidad. En el presente artículo se revisan sus características y ejemplos de su aplicación en Anestesiología, un campo aun incipiente en nuestra especialidad(AU)

The economic evaluation of medications and health care technology has gained importance in recent years. Health care resources are limited and their use must be optimized so that we can take the greatest possible advantage. Pharmacoeconomics seeks to analyze the best therapeutic drug choices to obtain the desired outcome in specific cases or in populations. The 4 approaches used in pharmacoeconomics are cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. This review examines the characteristics of each type of study using examples from anesthesiology, a field in which pharmacoeconomics is beginning to play a role(AU)

Analysis of the cost-effectiveness of remifentanil-based general anesthesia: a survey of clinical economics under the Japanese health care system.

PURPOSE: Remifentanil has been available in Japan for 3 years. The use of this new opioid is considered a useful adjuvant to general anesthesia. Knowing the exact cost-effectiveness of remifentanil should lead to improved anesthetic outcomes with a reasonable cost. METHODS: This single-blinded, prospective, randomized study compared the cost of remifentanil-based general anesthesia combined with isoflurane, sevoflurane, or propofol with fentanyl-based conventional techniques in 210 women who underwent breast surgeries. RESULTS: Remifentanil-based general anesthesia was no more expensive than fentanyl-based conventional anesthesia. Postoperative nausea and vomiting was significantly less frequent after remifentanil-based than fentanyl-based anesthesia. CONCLUSION: This study shows that remifentanil-based general anesthesia is no more expensive than conventional fentanyl-based anesthesia under the Japanese health care system because of the small difference in price between remifentanil and fentanyl.

Procedural sedation in children for magnetic resonance imaging--comparison between ketamine diazepam combination with midazolam fentanyl combination.

A deeper level of sedation by an anaesthesiologist is requirement for magnetic resonance imaging (MRI) in paediatric populations and sedation of children is different from sedation of adults. The purpose of the study was to compare the efficacy, safety, tolerability and cost effectiveness of ketamine, diazepam combination to midazolam, fentanyl combination for sedation of children during MRI. One hundred twenty children of both sex, age between 1-10 years, American Society of Anesthesiologist (ASA) physical status I and II were distributed into two groups. Group A (n=60) were sedated with 1.5 mg/kg body weight ketamine and 0.1 mg/kg body weight diazepam intravenously. Group B (n=60) were sedated with midazolam 0.05 mg/kg bodyweight and fentanyl 1 microg/kg body weight intravenously. Both groups showed satisfactory sedating condition for MRI. Incidences of side effects of drug regimens during sedation and recovery were recorded in both groups; those were transient and minor inconveniences. Pulse, blood pressure and respiration were within normal range in both groups. Mean procedure time was almost same in both groups and mean recovery time was more in group A than group B and the difference was statistically significant (p<0.05). Every child of both groups was discharged to home. Sedation regimen of group B found 5 times more costly than group A. Both the regimens were found safe and effective for paediatric sedation during MRI but ketamine, diazepam combination found more cost effective which, is a considerable matter in Bangladesh.

Transrectal-HIFU as primary minimally-invasive option for localized prostate cancer. Is spinal anaesthesia cost-effective? A single centre experience in over 100 patients.

INTRODUCTION: The management of Prostate cancer (PC), since PSA testing has been introduced in the clinical practice, has been significantly spoiled by a "leading-time bias" effect. As a consequence, this has brought to a dramatic diagnosis anticipation at the 4th-5th decade of life in sexually active and otherwise asymptomatic men. Standard options as radical prostatectomy or EBRT are hampered by a significant negative impact on patient's QoL. More recently several alternative minimally-invasive ablative treatment modalities have been proposed with promising results. Among these, TR-HIFU (Trans-Rectal High Intensity Focused Ultrasound) is playing a growing role in the treatment of localized low-intermediate risk PC, although long-term oncologic outcome are still awaited. In order to achieve an optimal result, a specific TR-HIFU's requirement is given by an unchanging target throughout the whole procedure. Therefore, the ideal anaesthesia should be either minimally-invasive and allow to get a motionless target up to 3-4 hours. A retrospective evaluation of efficacy and safety of a spinal anaesthesia in this patient's setting was done. MATERIAL AND METHODS: 107 patients with localized prostate cancer treated in our institution from October 2004 to December 2007 with TR-HIFU procedure received a subarachnoidal anaesthesia with combined administration of 0.5% normobaric racemic bupivacaine (15 to 17.5 mg) and sufentanil 5 microg. RESULTS: This technique allowed covering the whole TR-HIFU procedure (analgesia and motor blockade up to 4-5 hours). It was well tolerated by patients who only rarely required additional sedative or analgesics. A low anaesthesia-related side effects rate, as arterial hypotension, nausea and vomiting, and no severe side effects of intrathecal opioids, as deep sedation, bradycardia, myosis, bradypnea and oxygen desaturation, occurred. Intraoperative employment of sedatives and postoperative need of analgesics was low. CONCLUSIONS: Using a low-dose intrathecal sufentanil an effective spinal block either on the sensitive and motor pathways was provided. Patients' tolerance to the procedure was good and the side-effect rate low. No adverse reactions to intrathecal sufentanil 5 microg were observed. In our experience TR-HIFU can be performed with neuraxial block in most of the cases and it's associated to a favorable cost-benefit rate.

Comparative cost-analysis of a propofol-cisatracurium-based anesthesia with remifentanil or fentanyl for laparoscopic surgery.

To compare the intraoperative costs of intravenous propofol-based anesthesia for laparoscopic cholecystectomy, a total of 42 patients were randomly assigned to receive remifentanil or fentanyl as adjuvant using the bispectral index anesthesia monitoring. The average anesthesia calculated costs per hour (and per minute) were 79.45 (1.32) in the fentanyl group and 65.36 (1.09) in the remifentanil group. The calculated mean cost per patient was 76.56 in the fentanyl group and 58.86 in the remifentanil group. In conclusion, for propofol-cisatracurium-based anesthesia for laparoscopic surgery, when applying the bispectral index to guide the administration of hypnotic anesthetic drugs and ensure an adequate and stable depth of anesthesia, the cost of anesthesia is lower using remifentanil as an adjuvant rather than fentanyl. The clinical relevance is that it could be the intravenous anesthesia technique of choice in laparoscopic surgery for cholecystectomy from a cost-minimization standpoint.

Under "real world" conditions, desflurane increases drug cost without speeding discharge after short ambulatory anesthesia compared to isoflurane.

PURPOSE: To compare the measured "real world" perioperative drug cost and recovery associated with desflurane- and isoflurane-based anesthesia in short (less than one hour) ambulatory surgery. METHODS: We conducted a prospective, randomized, blinded trial with patients undergoing arthroscopic meniscectomy under general anesthesia. Following iv induction, patients received either isoflurane (group I; n = 25) or desflurane (group D; n = 20) for maintenance. The primary outcome variable was total perioperative drug cost per patient in Canadian dollars. Secondary outcome variables included volatile agent consumption and cost, adjuvant anesthetic and postanesthesia care unit (PACU) drug cost, readiness for PACU discharge, and incidence of adverse events. RESULTS: Total perioperative drug cost per patient was 14.58 +/- 6.83 Canadian dollars (mean +/- standard deviation) for group I, and 21.47 +/- 5.18 Canadian dollars for group D (P < 0.001). Isoflurane consumption per patient was 6.0 +/- 3.0 mL compared to 18.6 +/- 7.7 mL for desflurane (P < 0.0001); corresponding costs were 0.83 +/- 0.42 Canadian dollars vs 7.61 +/- 3.15 Canadian dollars (P < 0.0001). There were no differences in adjuvant anesthetic or PACU drug cost. All but one patient from each group were deemed ready for PACU discharge at 15 min postoperatively (Aldrete score >or= 9). One patient in group D experienced postoperative nausea. No other adverse events were noted. CONCLUSIONS: Measured total perioperative drug cost for a short ambulatory procedure (less than one hour) under general anesthesia was higher when desflurane rather than isoflurane was used for maintenance, essentially due to volatile agent cost. Desflurane use did not translate into faster PACU discharge under "real world" conditions.

Comparative analysis of costs of total intravenous anaesthesia with propofol and remifentanil vs. balanced anaesthesia with isoflurane and fentanyl.

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.

A comparison of the cost-effectiveness of remifentanil versus fentanyl as an adjuvant to general anesthesia for outpatient gynecologic surgery.

The unique pharmacokinetic properties of remifentanil make it a potentially useful adjuvant during general anesthesia for ambulatory surgery. Fentanyl, inexpensive and easy to administer, is the most common opioid used for this purpose. As an adjuvant to general anesthesia for outpatient gynecologic surgery, we questioned if remifentanil was cost-effective as an alternative to fentanyl. Thirty-four patients undergoing gynecologic laparoscopy or hysteroscopy were prospectively and randomly assigned to a standard practice (n = 18) or a study (n = 16) group. Standard practice patients received fentanyl (3 microg/kg) before induction; study patients received remifentanil by continuous infusion (0.5 microg x kg. min(-1) at induction, then 0.2 microg x kg x min(-1)). Sevoflurane was titrated to a Bispectral index value of 40-55. We investigated recovery profiles, patient and health care professional satisfaction, and drug costs. The incidence of rescue antiemetic treatment (2 of 16 vs. 8 of 18; P = 0.013) and the nausea visual analog scale scores during second stage recovery (0.2 vs. 0.6; P = 0.044) were more frequent in the study group. However, the incidence of intraoperative adverse events and other postoperative sequelae, recovery times, pain and nausea visual analog scale scores, opioid analgesic dosage requirements in the postanesthetic care unit, and satisfaction survey responses were similar between groups. Perioperative drug costs per patient were $17.72 more in the remifentanil (vs. fentanyl) group.

A randomized, double-blind study of the use of droperidol for conscious sedation during therapeutic endoscopy in difficult to sedate patients.

BACKGROUND: Droperidol has been used in combination with narcotics and benzodiazepines to achieve conscious sedation. We performed a randomized, double-blind, study of droperidol in patients at risk for difficult sedation scheduled for therapeutic endoscopy. METHODS: Patients with regular ethanol, narcotic, or benzodiazepine usage, suspected sphincter of Oddi dysfunction, or a history of difficult sedation were eligible for the study. Patients were randomized to receive either droperidol or placebo along with midazolam and meperidine as preprocedure sedation. Time to achieve sedation, interruptions due to undersedation, medication dosages, recovery time, and subjective assessments of sedation were recorded. RESULTS: One hundred one patients were randomized. The droperidol group had significantly fewer procedure interruptions and observer ratings of difficulty with sedation and required significantly less midazolam (23%) and meperidine (16%) than the placebo group. There were no significant differences in time to achieve sedation, incomplete procedures, procedure length, recovery room time, or complications. There were significantly higher observer ratings of the quality of sedation for patients who received droperidol. CONCLUSIONS: Droperidol is a useful adjunct to conscious sedation in patients who are difficult to sedate. Its use results in significantly fewer interruptions due to poor sedation and improved sedation ratings compared with sedation using midazolam and meperidine alone.

A comparison of fentanyl and sufentanil in patients undergoing coronary artery bypass graft surgery.

OBJECTIVE: To compare fentanyl and sufentanil, administered in equipotent concentrations by target-controlled infusion, as components of a balanced anesthetic in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN: A prospective, randomized, double-blind trial. SETTING: A university hospital. PARTICIPANTS: Twenty-one patients undergoing nonemergent, primary CABG surgery. INTERVENTIONS: Patients received fentanyl (group F, n = 10) or sufentanil (group S, n = 11) by target-controlled infusion throughout the pre-cardiopulmonary bypass (CPB) period. To ensure equipotency, the target effect-site concentrations employed (fentanyl, 8.1 ng/mL, and sufentanil, 0.68 ng/mL) were equal to the IC50 for electroencephalographic effect. Isoflurane was administered as needed to maintain pre-CPB hemodynamics near preoperative baseline values. MEASUREMENTS AND MAIN RESULTS: Hemodynamics and end-tidal isoflurane concentration were measured every 15 to 30 seconds. Serum opioid concentrations were measured 5 times between induction and CPB. Opioid cost was based on the number of ampules opened to provide the administered dose. The 2 groups were similar demographically. The pre-CPB serum opioid concentrations were constant and averaged fentanyl, 5.8 +/- 1.9 ng/mL, and sufentanil, 0.59 +/- 0.13 ng/mL. Pre-CPB hemodynamics were stable and similar in both groups. Pre-CPB end-tidal isoflurane requirements did not differ between groups and averaged 0.46 +/- 0.21% in group F and 0.56 +/- 0.24% in group S. The duration of post-operative endotracheal intubation was 9.1 +/- 5.0 hours in group F and 8.0 +/- 3.2 hours in group S (p = NS). The cost per patient of fentanyl (Canadian $6.12 +/- 1.04) was less than that of sufentanil (Canadian $17.47 +/- 4.65). CONCLUSIONS: When administered in a constant 10:1 concentration ratio, fentanyl and sufentanil do not differ in their ability to facilitate pre-CPB hemodynamic control. Although both opioids were relatively inexpensive, the acquisition cost of fentanyl was less than sufentanil. A recommendation regarding the opioid of choice for routine use in patients undergoing CABG surgery awaits more rigorous studies of recovery and cost after equipotent doses of fentanyl and sufentanil. When combined with isoflurane, effect-site opioid concentrations near the IC50 for electroencephalographic effect provide excellent pre-CPB hemodynamic control in patients undergoing CABG surgery.

A randomized double-blind placebo-controlled trial evaluating the cost-effectiveness of droperidol as a sedative premedication for EUS.

BACKGROUND: Droperidol is a neuroleptic agent with anti-emetic properties that produces mild sedation, reduced anxiety, and a state of mental detachment and indifference to one's surroundings. Routine premedication with droperidol has been shown to improve sedation during esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography. The purpose of this randomized double-blind placebo-controlled study was to determine whether premedication with droperidol improves sedation during routine upper endoscopic ultrasound (EUS) in a cost-effective manner. METHODS: One hundred consecutive patients referred for EUS were randomly assigned to receive either 2.5 mg or 5 mg of droperidol or placebo before the procedure. After EUS, the physician, nurse, and recovered patient scored various parameters of procedural sedation. RESULTS: In the group receiving 5 mg of droperidol there was significantly less gagging at intubation, less retching during the procedure, better patient cooperation, less need for physical restraint, and improved nurses' and physician's impression of sedation. Significantly less meperidine and less midazolam were required for sedation, making medication costs significantly lower in the group receiving 5 mg droperidol. CONCLUSIONS: A 5 mg dose of droperidol given as premedication for routine upper EUS improves sedation during the procedure while significantly decreasing the overall cost of sedation.