Using hydrofluoroether solvents to replace HCFC-141b, Part II.

The use of hydrochlorofluocarbon (HFC) solvents is banned from the end of 2001. Part of this article assessed the merits of using hydrofluoroethers as replacement solvents. Alternatives to HFCs are more expensive. Part II looks at how to reduce the cost of conversion.

Pharmacoeconomic analysis of sevoflurane versus isoflurane anesthesia in elective ambulatory surgery.

This study investigated the economic aspects of sevoflurane and isoflurane anesthesia in 47 healthy women undergoing elective ambulatory surgery, as part of a randomized, prospective clinical trial. Patient records were analyzed for anesthetic; duration of surgery, anesthesia, and recovery room stay; and associated charges. Sevoflurane is shorter acting than isoflurane, but it was not associated with a shorter duration of anesthesia or surgical unit stay, or earlier hospital discharge. Total charges associated with sevoflurane anesthesia were greater than those for isoflurane ($2641 and $2230, respectively) and primarily related to prolonged anesthesia and surgical unit stay. A minor decrease in recovery room charges ($15) associated with earlier discharge was observed with sevoflurane (p>0.05), but the agent was not associated with lower hospital charges. Larger trials and assessment of other patient populations may show sevoflurane to be more pharmacoeconomically advantageous than isoflurane.

Sevoflurane use in Veterans Affairs medical centers: utility, safety, and cost-effectiveness.

It has long been realized that the Veterans Affairs (VA) patient has a high incidence of multiorgan system diseases, especially diseases of the pulmonary and cardiovascular systems. The typical Birmingham VA Medical Center patient presenting for surgery is male, with a national mean age of 60 years. More than one half of these patients have a significant history of current or prior tobacco abuse, and many have cardiovascular impairments. When sevoflurane became available, a careful review of the characteristics of the drug, as well as cost comparisons of inhaled agents, was done by our department of anesthesia. Sevoflurane appears to be an ideal inhaled anesthetic for the veteran patient population. If used appropriately, sevoflurane can be administered safely at a cost comparable to desflurane.

[Economic aspects of modern inhalation anesthetics with sevoflurane as an example]. / Okonomische Aspekte beim Einsatz moderner Inhalationsanästhetika am Beispiel des Sevofluran.

The economic impact of the new German health care laws requires an awareness of cost-effectiveness when using newer drugs. The main goal in patient care, i.e., effective treatment, must be achieved by the rational use of restricted resources at a maximum degree of effectiveness. Economic aspects of the new inhalational anaesthetics such as sevoflurane are discussed in this article. The cost of inhalational anaesthetic agents accounts for up to 5% of all the running expenses of an anaesthesia department. The consumption and cost of an inhalational agent depend on fresh gas flow, vapour setting, and duration of anaesthesia. Comparing the cost for 1 MAC-h of anaesthesia, desflurane is more expensive at current market prices than sevoflurane and isoflurane. However, at low or minimal fresh gas flows, the price for one MAC-h is almost the same for these volatile anaesthetics. Total intravenous anaesthesia using propofol is even more expensive, partly due to wastage, i.e., opened ampoules with a remainder of propofol that has to be discarded after each case. When choosing an anaesthetic agent, the price of 1 ml liquid anaesthetic is an important factor. However, the overall cost-effectiveness analysis must balance the cost of the agent with its pharmacodynamic advantages such as more rapid recovery from anaesthesia. Furthermore, the indirect costs of side effects have to be taken into account. For example, nausea and vomiting lead to a prolonged stay in the recovery room after anaesthesia for outpatient surgery, which in turn incurs additional costs for antiemetic drugs and the extra time for nursing care. Therefore, a lower incidence of nausea and vomiting and a more rapid recovery from anaesthesia leading to earlier discharge from the recovery room may compensate for the higher price. Volatile agents account for up to 1% of the total intraoperative costs. In analysing the costs of 1 h of anaesthesia, other products such as plasma substitutes and blood products account for a much higher proportion than anaesthetic agents, and reductions or increases in costs pertaining to these products have a bigger impact on overall costs than do volatile anaesthetics. We conclude that volatile anaesthetics account for only a minor portion of the anaesthesia department budget and the cost of anaesthesia delivery. The higher market price of the new agents may be compensated for by the economic impact of fewer side effects and a shorter post-anaesthesia stay in the hospital. In analysing data for sevoflurane, this agent may be cost-effective, for example, for outpatient anaesthesia.

The role of sevoflurane in outpatient anesthesia.

Sevoflurane appears to have several properties that make it an attractive alternative to the currently available anesthetics for outpatient anesthesia. The relative low solubility of sevoflurane, as well as an impressive lack of airway irritation, makes it a very useful anesthetic for inhalation induction of anesthesia. This feature is likely to make sevoflurane a population choice for pediatric outpatient anesthesia. For adult outpatients, the relatively low solubility of sevoflurane permits rapid alterations in alveolar concentration during the maintenance period (even when administered at relatively low flow rates of 2-3 L/min), thereby improving control of the depth of anesthesia. Low solubility should also allow for a more predictable emergence from anesthesia (versus isoflurane), thereby facilitating patient turnover in a busy ambulatory surgery center. The commercial development of sevoflurane has been slow because of concerns regarding the potential toxicity of its metabolites and breakdown products (24). However, the large body of clinical experience from Japan and the worldwide Phase II and III clinical development programs suggests that these concerns may be unfounded. The short duration of exposure in the outpatient setting should further decrease the risk of nephrotoxicity. The relatively low solubility of sevoflurane will facilitate its use with total gas flow rates of 2-3 L/min. In the final analysis, clinicians will have to balance the cost of sevoflurane (versus halothane, enflurane, isoflurane, and desflurane) against its potential advantages in the ambulatory surgery population. Although the search for anesthetics that are more ideally suited for use in the outpatient setting will continue, sevoflurane clearly represents a step in the right direction (3).