Medical, Political, and Economic Considerations for the Use of MAC for Endoscopic Sedation: Big Price, Little Justification?

The last few decades of gastrointestinal (GI) endoscopy have seen phenomenal growth. In many aspects, GI endoscopy has led the field of nonsurgical interventional medicine. In many aspects, this growth is facilitated by advancements in sedation-both drugs and techniques. Unfortunately, the topic of GI endoscopy sedation is also mired in many controversies, mainly emanating from the cost of anesthesia providers. While no one debates their role in the majority of advanced endoscopic procedures, the practice of universal propofol sedation in the USA, delivered by anesthesia providers, needs a closer look. In this review, medical, political, and economic considerations of this important topic are discussed in a very frank and honest way. While such ubiquitous propofol use has increased satisfaction of both patients and gastroenterologists, there is little justification. More importantly, going by the evidence, there is even less justification for the mandated anesthesia providers use for such delivery. Unfortunately, the FDA could not be convinced otherwise. The new drug fospropofol met the same fate. Approval of SEDASYS®, the first computer-assisted personalized sedation system, was a step in the right direction, nevertheless an insufficient step that failed to takeoff. As a result, in spite of years of research and efforts of many august societies, the logjam of balancing cost and justification of propofol sedation has continued. We hope that recent approval of remimazolam, a novel benzodiazepine, and potential approval of oliceridine, a novel short-acting opioid, might be able to contain the cost without compromising the quality of sedation.

Cost-effectiveness of anesthesia maintained with sevoflurane or propofol with and without additional monitoring: a prospective, randomized controlled trial.

BACKGROUND: We compared cost-effectiveness of anesthesia maintained with sevoflurane or propofol with and without additional monitoring, in the clinical setting of ear-nose-throat surgery. METHODS: One hundred twenty adult patients were randomized to four groups. In groups SEVO and SEVO+ anesthesia was maintained with sevoflurane, in group SEVO+ with additional bispectral index (BIS) and train-of-four (TOF) monitoring. In groups PROP and PROP+ anesthesia was maintained with propofol, in group PROP+ with additional BIS and TOF monitoring. RESULTS: Total cost of anesthesia per hour was greater in group SEVO+ compared to SEVO [€ 19.95(8.53) vs. 12.15(5.32), p <  0.001], and in group PROP+ compared to PROP (€ 22.11(8.08) vs. 13.23(4.23), p <  0.001]. Time to extubation was shorter in group SEVO+ compared to SEVO [11.1(4.7) vs. 14.5(3.9) min, p = 0.002], and in PROP+ compared to PROP [12.6(5.4) vs. 15.2(4.7) min, p <  0.001]. Postoperatively, arterial blood pressure returned to its initial values sooner in groups SEVO+ and PROP+. CONCLUSIONS: Our study demonstrated that the use of BIS and TOF monitoring decreased the total cost of anesthesia drugs and hastened postoperative recovery. However, in our circumstances, these were associated with higher disposables costs. Detailed cost analysis and further investigations are needed to identify patient populations who would benefit most from additional monitoring. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02920749 . Retrospectively registered (date of registration September 2016).

Is the anesthesiologist necessary in the endoscopy suite? A review of patients, payers and safety.

The use of propofol for sedation during endoscopy has been increasing, particularly given its association with superior patient satisfaction. Propofol sedation may also allow for higher quality endoscopy exams, increased efficiency of endoscopy suites and most particularly, permit better patient compliance with colonoscopy for colorectal cancer screening. However, propofol is typically provided by anesthesia specialists via monitored anesthesia care, and is associated with significant economic burden. Given the increasing use of monitored anesthesia care, which adds significant costs to endoscopy, payers are likely to react with changes in payer policies. One alternative to monitored anesthesia care is non-anesthesiologist administered propofol, which due to safety concerns and a lack of reimbursement has not been widely adopted in the US.

Comparison between the recovery time of alfentanil and fentanyl in balanced propofol sedation for gastrointestinal and colonoscopy: a prospective, randomized study.

BACKGROUND: There is increasing interest in balanced propofol sedation (BPS) titrated to moderate sedation (conscious sedation) for endoscopic procedures. However, few controlled studies on BPS targeted to deep sedation for diagnostic endoscopy were found. Alfentanil, a rapid and short-acting synthetic analog of fentanyl, appears to offer clinically significant advantages over fentanyl during outpatient anesthesia.It is reasonable to hypothesize that low dose of alfentanil used in BPS might also result in more rapid recovery as compared with fentanyl. METHODS: A prospective, randomized and double-blinded clinical trial of alfentanil, midazolam and propofol versus fentanyl, midazolam and propofol in 272 outpatients undergoing diagnostic esophagogastroduodenal endoscopy (EGD) and colonoscopy for health examination were enrolled. Randomization was achieved by using the computer-generated random sequence. Each combination regimen was titrated to deep sedation. The recovery time, patient satisfaction, safety and the efficacy and cost benefit between groups were compared. RESULTS: 260 participants were analyzed, 129 in alfentanil group and 131 in fentanyl group. There is no significant difference in sex, age, body weight, BMI and ASA distribution between two groups. Also, there is no significant difference in recovery time, satisfaction score from patients, propofol consumption, awake time from sedation, and sedation-related cardiopulmonary complications between two groups. Though deep sedation was targeted, all cardiopulmonary complications were minor and transient (10.8%, 28/260). No serious adverse events including the use of flumazenil, assisted ventilation, permanent injury or death, and temporary or permanent interruption of procedure were found in both groups. However, fentanyl is New Taiwan Dollar (NT$) 103 (approximate US$ 4) cheaper than alfentanil, leading to a significant difference in total cost between two groups. CONCLUSIONS: This randomized, double-blinded clinical trial showed that there is no significant difference in the recovery time, satisfaction score from patients, propofol consumption, awake time from sedation, and sedation-related cardiopulmonary complications between the two most common sedation regimens for EGD and colonoscopy in our hospital. However, fentanyl is NT$103 (US$ 4) cheaper than alfentanil in each case. TRIAL REGISTRATION: Institutional Review Board of Buddhist Tzu Chi General Hospital (IRB097-18) and Chinese Clinical Trial Registry (ChiCTR-TRC-12002575).

Comparison of propofol-remifentanil versus propofol-ketamine deep sedation for third molar surgery.

This study aimed to compare continuous intravenous infusion combinations of propofol-remifentanil and propofol-ketamine for deep sedation for surgical extraction of all 4 third molars. In a prospective, randomized, double-blinded controlled study, participants received 1 of 2 sedative combinations for deep sedation for the surgery. Both groups initially received midazolam 0.03 mg/kg for baseline sedation. The control group then received a combination of propofol-remifentanil in a ratio of 10 mg propofol to 5 µg of remifentanil per milliliter, and the experimental group received a combination of propofol-ketamine in a ratio of 10 mg of propofol to 2.5 mg of ketamine per milliliter; both were given at an initial propofol infusion rate of 100 µg/kg/min. Each group received an induction loading bolus of 500 µg/kg of the assigned propofol combination along with the appropriate continuous infusion combination . Measured outcomes included emergence and recovery times, various sedation parameters, hemodynamic and respiratory stability, patient and surgeon satisfaction, postoperative course, and associated drug costs. Thirty-seven participants were enrolled in the study. Both groups demonstrated similar sedation parameters and hemodynamic and respiratory stability; however, the ketamine group had prolonged emergence (13.6 ± 6.6 versus 7.1 ± 3.7 minutes, P = .0009) and recovery (42.9 ± 18.7 versus 24.7 ± 7.6 minutes, P = .0004) times. The prolonged recovery profile of continuously infused propofol-ketamine may limit its effectiveness as an alternative to propofol-remifentanil for deep sedation for third molar extraction and perhaps other short oral surgical procedures, especially in the ambulatory dental setting.

Comparative cost analysis of three different anesthesia methods in gynecological laparoscopic surgery.

In the current study, we assessed and evaluated the costs and benefits of three popular methods of general anesthesia practiced in our department for gynecological laparoscopic surgery in recent years. Sixty adult female patients who underwent elective gynecological laparoscopic surgery under general anesthesia were randomly divided into three groups: group V, group I and group C. In group V, anesthesia was induced intravenously with midazolam, remifentanil, propofol and vecuronium, and maintained with continuous infusion of propofol and remifentanil. In group I, anesthesia was intravenously induced with midazolam, fentanyl, propofol and vecuronium, and maintained with inhaled isoflurane and intravenous bonus of fentanyl. In group C, anesthesia was induced as in group I, but maintained with isoflurane inhalation combined with propofolremifentanil infusion. All patients received vecuronium for muscle relaxation. Perioperative incidences of complications and total anesthesia costs for patients in all groups were recorded. In addition, postoperative satisfaction of the patients was also noted, and similar outcomes of the satisfaction were reported in all 60 patients. Although there was no statistical significance among groups, the incidence of postoperative nausea and vomiting were higher in group C, and the rates of shivering and the needs for analgesics were higher in group V. Anesthesia costs in group I were the lowest. Therefore, it is concluded that the costs of anesthesia induced with midazolam, fentanyl, propofol, vecuronium, and maintained with isoflurane, fentanyl and vecuronium are cheapest, and there is no significant difference in patients' satisfaction and safety among the three above-mentioned methods of anesthesia in our department.

Efficacy and cost analysis of transrectal ultrasound-guided prostate biopsy under monitored anesthesia.

Sedation may result in reduction in pain during transrectal ultrasound (TRUS)-guided prostate biopsies. We aimed to evaluate the efficacy and safety of a combination of propofol and remifentanil infusion during TRUS-guided prostate biopsy and the related increases in health care costs. From January to September 2010, 100 men undergoing a transrectal prostate biopsy were randomized into two groups. In Group 1, 50 patients received a combined infusion of propofol and remifentanil; in Group 2, 50 patients received lidocaine jelly. After TRUS-guided biopsies were performed, pain and patient satisfaction were evaluated by a 10-point visual analog scale (VAS), and a cost-related patient satisfaction questionnaire was completed by all patients. Patients were also asked whether they would be willing to undergo repeat biopsy by the same method. Patients in Group 1 showed a significantly lower VAS score than those in Group 2 (mean VAS score: 0.9±1.1 versus 6.3±2.5; P<0.001). In addition, the patient satisfaction scale was significantly higher in Group 1 (P=0.002). Although the overall cost was significantly higher in Group 1 (P=0.006), patient satisfaction scales considering cost were also higher in this group (P=0.009). A combination of propofol and remifentanil is a safe and effective way to decrease patient pain and increase patient satisfaction during TRUS-guided prostate biopsy. Although the costs were higher in the group that received sedation, as expected, the patients exhibited heightened satisfaction and willingness to repeat biopsies by the same method.

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.

Endoscopist-directed administration of propofol: a worldwide safety experience.

BACKGROUND & AIMS: Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation. METHODS: We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death. RESULTS: A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million. CONCLUSIONS: EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Low fresh gas flow balanced anesthesia versus target controlled intravenous infusion anesthesia in laparoscopic cholecystectomy: a cost-minimization analysis.

BACKGROUND: Laparoscopic surgery is widely recognized as a well-tolerated and effective method for cholecystectomy. It is also considered cost saving because it has been associated with a decreased hospital length of stay. Variables that might lead to increased costs in laparoscopic surgery are the technique and drugs used in anesthesia. OBJECTIVE: The goal of this study was to compare the costs of 2 anesthetic techniques used in laparoscopic cholecystectomy (LC)--balanced versus IV anesthesia--from the standpoint of an outpatient surgical department, with a time horizon of 1 year. METHODS: Patients scheduled to undergo elective LC were enrolled in this prospective case study. Patients were randomly allocated to receive balanced anesthesia, administered as low fresh gas flow (LFGF) with inhalational sevoflurane and IV sufentanil in a target controlled infusion (LFGF SS group), or IV anesthesia, administered as IV propofol/sufentanil in a target controlled infusion (TCI group). We used a microcosting procedure to measure health care resource utilization in individual patients to detect treatment differences. The costs of medications used for the induction and maintenance of anesthesia during surgery were considered for LFGF SS and TCI. Other end points included duration of anesthesia; mean times to early emergence, tracheal extubation, orientation, and postanesthesia discharge (PAD); pain intensity before first analgesia; number of analgesics required in the first 24 hours after surgery; and prevalences of nausea, vomiting, and agitation. RESULTS: A total of 60 patients were included in this analysis (male/female ratios in the LFGF SS and TCI groups: 11/19 and 12/18, respectively; mean [SD] ages, 48 [7.9] and 47 [8.6] years; and mean [SD] body mass indexes, 26 [2.0] and 26 [3.0] kg/m2). The costs of anesthetics were significantly lower with LFGF SS compared with TCI (euro17.40 [euro2.66] vs euro22.01 [euro2.50] [2006 euros]). Times to early emergence and tracheal extubation were significantly shorter with LFGF SS than TCI (5.97 [1.16] vs 7.73 [1.48] minutes and 7.57 [1.07] vs 8.87 [1.45] minutes, respectively). There were no significant between-group differences in mean duration of anesthesia; times to orientation and PAD; pain intensity before first analgesia; number of analgesics required in the first 24 hours; or prevalences of nausea, vomiting, and agitation. Because no clinically significant differences in the anesthetic results were observed, a cost-minimization analysis was conducted and found that using LFGF SS, the outpatient surgical department could realize a budget savings of euro454 per 100 patients. For the nearly 1000 expected patients per year, the savings for the department was calculated as euro4540. CONCLUSION: The results from this cost analysis in these patients who underwent elective LC suggest that the use of sevoflurane through the LFGF technique would be cost saving in this outpatient surgical department.

Nurse-administered propofol sedation compared with midazolam and meperidine for EUS: a prospective, randomized trial.

BACKGROUND: The utility of nurse-administered propofol sedation (NAPS) compared with midazolam and meperidine (M/M) for EUS is not known. OBJECTIVE: To compare recovery times, costs, safety, health personnel, and patient satisfaction of NAPS and M/M for EUS. DESIGN: Prospective, randomized, single-blinded trial. SETTING: Tertiary-referral hospital in Indianapolis, Indiana. PATIENTS: Outpatients referred for EUS. INTERVENTIONS: Sedation with M/M or NAPS. The patient and recovery nurse were blinded; however, the sedating nurse, endoscopist, and recording research nurse were unblinded to the sedatives used. A capnography, in addition to standard monitoring, was used. A questionnaire and visual analog scale assessed patient, endoscopist, and sedating nurse satisfaction. MAIN OUTCOME MEASUREMENTS: Recovery times, costs, safety, health personnel, and patient satisfaction in both groups. RESULTS: Eighty consecutive patients were randomized to NAPS (n = 40) or M/M (n = 40). More patients in the propofol group were current tobacco users; patient demographics, procedures performed, mean procedure length, and the overall frequency of adverse events were otherwise similar. Compared with M/M, NAPS was associated with a faster induction of sedation (2.3 vs 5.7 minutes, respectively; P = .001) and full recovery time (29 vs 49 minutes, respectively; P = .001), higher postprocedure patient satisfaction, and quicker anticipated return to baseline function. At discharge, total costs (recovery plus medications) were similar between the propofol ($406) and M/M groups ($399; P = .79). LIMITATION: Low-risk patient population. CONCLUSIONS: Compared with M/M, NAPS for an EUS offered a faster sedation induction and full recovery time, higher postprocedure patient satisfaction, and a quicker anticipated return to baseline function. Total costs were similar between the groups.

Cost minimisation and cost effectiveness in anaesthesia for total hip replacement surgery, in Belgium? A study comparing three general anaesthesia techniques.

The aim of the prospective randomised study is to compare the cost effectiveness of three general anaesthesia techniques for total hip replacement surgery and the cost minimisation by use of anaesthetics. For induction propofol was used in the three techniques. For maintenance, we used desflurane, or sevoflurane, or propofol. There was no significant difference in consumption of drugs for pain treatment, treatment of nausea and vomiting or cost of hospital stay or total cost for pharmacy. In terms of cost-effectiveness we can consider that the three techniques are similar. The cost of an i.v. technique was always higher than inhaled anaesthetics. The major cost in anaesthesia is the fee for the anaesthesiologist. But all in, the cost of anaesthesia was only 15.1% of the total cost of the procedure. Cost of inhaled or i.v. anaesthetics was 0.55% to 1.0% of the total cost. There was a discrepancy between the measured consumption of inhaled anaesthetics and the consumption (and cost) on the invoice. Cost minimisation based on anaesthetic medication is ridiculously by small considering the total cost of the procedure.

[Propofol for paediatric patients in ear, nose and throat surgery. Practicability, quality and cost-effectiveness of different anaesthesia procedures for adenoidectomy in infants]. / Propofoleinsatz für Hals-Nasen-Ohren-Eingriffe im Kindesalter. Praktikabilität, Qualität und Kosteneffektivität verschiedener Narkoseverfahren zur Adenotomie bei Kindern.

BACKGROUND: The aim of this study was an improvement in patient comfort, reduction of anaesthesia costs and room contamination by the use of propofol for adenoidectomy. METHODS: A total of 103 infants (aged 1-5 years) undergoing elective adenoidectomy were randomized for anaesthesia with sevoflurane-nitrous oxide/oxygen (group 1), sevoflurane-air/alfentanil (group 2), alfentanil-propofol under induction with sevoflurane (group 3) or alfentanil-propofol (group 4). RESULTS: Using propofol, postoperative agitation and emesis were significantly less and the anaesthesia costs as well as the need for analgesics was reduced compared to inhalative anaesthesia. CONCLUSIONS: The use of propofol for preschool children undergoing ear, nose and throat (ENT) surgery seems to be advantageous because of less postoperative agitation, emesis and costs.

Efficacy and costs of 3 anesthetic regimens in the prevention of postoperative nausea and vomiting.

STUDY OBJECTIVE: The aim of the study was to compare the antiemetic efficacy and costs associated with 3 different anesthesia regimens used in gynecologic laparoscopy. DESIGN: This was a randomized, controlled study. SETTING: The study was conducted at a university hospital. PATIENTS: We studied 150 ASA physical status I or II patients, undergoing elective gynecologic laparoscopy with general anesthesia. INTERVENTION: Patients were allocated into the following 3 groups: group P-preoperative placebo tablet, propofol induction, propofol-air/O2 maintenance; group I + O-preoperative 8-mg ondansetron tablet, thiopental induction, isoflurane-N2O maintenance; group I (control)-preoperative placebo tablet, thiopental induction, isoflurane-N2O maintenance. MEASUREMENTS: The frequency of postoperative nausea and vomiting (PONV), number needed to treat to prevent PONV, and the costs of the anesthetic drugs to prevent PONV in one additional patient were evaluated. MAIN RESULTS: The frequency of PONV within the 24-hour study period was lowest in group I + O (P, 38%; I + O, 33%; and I, 59%; P < 0.05 I + O vs I). The number needed to treat was 5 in group P and 4 in group I + O, compared with group I. The median costs of anesthetic drugs to prevent PONV in one additional patient were $65 in group P and dollar 68 in group I + O, compared with group I. CONCLUSIONS: We conclude that in gynecologic laparoscopy, propofol-air/O2 anesthesia alone, and isoflurane-N2O anesthesia combined with an oral 8-mg dose of ondansetron had similar efficacy and costs to prevent PONV. Isoflurane-N2O anesthesia without ondansetron was less expensive, but was also less efficacious.

[Comparison of a propofol-based anesthesia regimen using optimated-target-controlled-infusion (OTCI) and manually-controlled infusion (MCI) technique]. / Propofol-Anästhesie mittels Target-Controlled-Infusion (TCI). Ein Vergleich der Verfahren: Optimated-Target-Controlled Infusion (OTCI) und Manually-Controlled-Infusion (MCI).

BACKGROUND: Propofol anesthesia based on target-controlled-infusion (TCI) has been shown to be superior to a manually-controlled-infusion (MCI) technique. A new optimal-target-controlled-infusion (OTCI) technique enables an individual plasma-targeted adjustment by including the concentration in the effect-compartment. This study compared practicability and costs of the new system with a conventional MCI-based propofol anesthesia regimen. METHODS: In a prospective study, 50 patients scheduled for elective surgery of nose or nasal sinuses were randomly enrolled to receive BIS-controlled anaesthesia (level: 40-55) using either OTCI (n = 25) or MCI (n = 25). Hemodynamics, extubation times and time of awaking, rate and quality of propofol adjustment, total drug requirements, costs, postanaesthetic care unit (PACU) stay, Aldrete and pain scores, and adverse effects (postoperative nausea and vomiting (PONV), shivering) were recorded. RESULTS: Demographics, hemodynamics, and perioperative data including extubation times were comparable for both study groups. Propofol consumption was similar within the first 60 min for both groups, thereafter, significantly less propofol in the OTCI group (5.03 mg/kg/h) than the MCI group (5.79 mg/kg/h) was used. Costs for propofol was significantly reduced with OTCI (0.2 vs. 0.23 Cent/anaesthesia minute/kg), the administration of other anaesthetics (fentanyl, remifentanil, cis-atracurium) did not differ between the groups. The number of infusion adjustments to BIS values were not significantly different. CONCLUSION: The new OTCI-system is a safe and easily controllable technique. The obvious advantage of this infusion system appears to be a reduction in propofol consumption and direct drug costs for anaesthesia lasting longer than 60 min.

Early recovery, cognitive function and costs of a desflurane inhalational vs. a total intravenous anaesthesia regimen in long-term surgery.

BACKGROUND: The purpose of the study was to compare time of recovery, return of cognitive function, post-anaesthetic care unit (PACU) stay and costs of a propofol/remifentanil (TIVA) with a desflurane/fentanyl-based anaesthesia (desflurane group) in surgical procedures lasting more than 150 min. METHODS: Forty-nine patients undergoing elective abdominal prostatectomy were allocated randomly to receive bispectal index (BIS)-controlled desflurane/fentanyl (n=24) or propofol/remifentanil (n=25). Awakening, clinical recovery, direct drug acquisition and post-operative pain treatment were documented. Cognitive skills were tested using the Mini-Mental Status (MMST) test. RESULTS: Extubation was significantly faster with desflurane (6.9+/-3.5 min) than with TIVA (11.2+/-4.0 min) as well as times for stating name and date of birth (desflurane: 6.1+/-3.9 and 6.6+/-4.0 min; TIVA: 12.4+/-11.5 min and 13.4+/-11.3 min). There were no significant differences in PACU discharge times or MMS scores between the groups. Significantly more patients suffered post-operative nausea and vomiting (PONV) in the desflurane (33% vs. 0%) than the TIVA group. Overall costs were significantly higher in the TIVA (58.8+/-11.6 euro) than in the desflurane group (35.0+/-5.7 euro). CONCLUSION: Patients undergoing prolonged surgical procedures showed a faster early recovery after desflurane/fentanyl than using TIVA, whereas stay in the PACU and recovery of cognitive function were similar in both groups. Costs of a TIVA regimen were significantly higher than using a desflurane-based anaesthesia technique.

An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: a double-blinded randomized study.

BACKGROUND AND OBJECTIVES: Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure. METHODS: This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared. RESULTS: Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone. CONCLUSIONS: Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.

Use of a remifentanil and propofol combination in outpatients to facilitate rapid discharge home.

The goal of our study was to evaluate whether the combination of remifentanil and propofol facilitated shorter recovery time and decreased charges compared with conventional balanced anesthesia. We studied 49 patients, aged 13 to 75 years, who underwent elective outpatient surgery. All data were analyzed using the Pearson chi2 and the Student t test; results were considered statistically significant at a P value of.05 or less. Group 1 received a remifentanil-propofol combination and group 2, a conventional balanced anesthetic. Group 1 had decreased mean operating room (dollar 280.83 vs dollar 337.42; P = .05) and operating room plus postanesthesia care unit (PACU) (dollar 442.67 vs dollar 544.62) charges (P = .02). Group 1 had less PACU time (48.26 vs 59.62 minutes) and 2 group 1 patients bypassed the PACU. We conclude that a remifentanil-propofol combination is more cost effective than conventional balanced anesthetics and enables some patients to bypass the PACU, resulting in quicker discharge. Our findings have important implications for ambulatory surgery centers and office-based practices.