LISTA DE REFERENCIAS CON LOS RESUMENES DISPONIBLES ACERCA DE ANESTESIA Y COSTOS

ESTRATEGIA DE BUSQUEDA: "Costs and Cost Analysis" and anesthesia por P Ibarra Mayo 02

Everett, L. L. (2002). "Can the risk of postoperative nausea and vomiting be identified and lowered during the preoperative assessment?" Int Anesthesiol Clin 40(2): 47-62.

Lockwood, G. G. and D. C. White (2001). "Measuring the costs of inhaled anaesthetics." Br J Anaesth 87(4): 559-63.
The cost of inhalation anaesthesia has received considerable study and is undoubtedly reduced by the use of low fresh gas flows. However, comparison between anaesthetics of the economies achievable has only been made by computer modelling. We have computed anaesthetic usage for MAC-equivalent anaesthesia with isoflurane, desflurane, and sevoflurane in closed and open breathing systems. We have compared these data with those derived during clinical anaesthesia administered using a computer-controlled closed system that measures anaesthetic usage and inspired concentrations. The inspired concentrations allow the usage that would have occurred in an open system to be calculated. Our computed predictions lie within the 95% confidence intervals of the measured data. Using prices current in our institution, sevoflurane and desflurane would cost approximately twice as much as isoflurane in open systems but only about 50% more than isoflurane in closed systems. Thus computer predictions have been validated by patient measurements and the cost saving achieved by reducing the fresh gas flow is greater with less soluble anaesthetics.

Lennox, P. H., C. Chilvers, et al. (2002). "Selective spinal anesthesia versus desflurane anesthesia in short duration outpatient gynecological laparoscopy: a pharmacoeconomic comparison." Anesth Analg 94(3): 565-8; table of contents.
We compared the cost and effectiveness of selective spinal anesthesia (SSA) with a desflurane-based general anesthetic (DES) for outpatient gynecological laparoscopy. A prospective analysis was undertaken of 10 patients randomized to receive SSA and compared with 10 patients randomized to receive DES. The groups were well matched in their demographic characteristics. The mean cost (in 2000 Canadian dollar values) of anesthesia supplies, drugs, and nursing for the SSA group of $62.31 was less than that for the DES group of $92.31 (P < 0.01). Recovery costs of both groups were similar. Time to administer anesthesia and time spent in the postanesthetic care unit were also similar. Postoperative analgesia was required by 50% of the DES group but in no patient receiving SSA (P < 0.01). SSA is a cost-effective alternative to DES in these patients. IMPLICATIONS: Small-dose spinal anesthesia is an effective alternative to a desflurane general anesthetic in terms of cost and recovery profiles in ambulatory gynecological laparoscopy.

Westphal, V. and M. R. Krogsgaard (2001). "[Diagnostic knee arthroscopy under local anesthesia in hospital. An assessment of the diagnostic reliability, course of the treatment and health care costs]." Ugeskr Laeger 164(1): 60-4.
INTRODUCTION: Outpatient knee arthroscopy under local analgesia can be performed solely as a diagnostic procedure. The aim was to estimate the diagnostic precision of such arthroscopy as compared to the diagnosis made during a secondary therapeutic operation, and to describe the flow of patients and the costs of this treatment strategy. MATERIAL AND METHODS: The records of 371 consecutive patients, who had a diagnostic knee arthroscopy performed under local analgesia, were reviewed retrospectively. The diagnosis made during the diagnostic arthroscopy (371 patients) and a later therapeutic operation (135 patients) were extracted and the patients were asked to fill in a questionnaire. RESULTS: The diagnostic arthroscopy could not be completed in 11 cases. No further operation was necessary in 188 patients. A secondary therapeutic operation was performed in 135 patients. In only 54% of these was the same diagnosis made during the diagnostic and the therapeutic operations. Only half of the 278 patients (75%) who returned the questionnaire, found that the diagnostic procedure had been pain free. DISCUSSION: With respect to the costs, the diagnostic arthroscopy cannot be recommended. Most economic was the strategy in which the diagnostic and therapeutic operations were performed together as an outpatient procedure. The relatively poor diagnostic precision of arthroscopy is surprising and should be kept in mind when patients continue to have unexplained complaints in the knee, despite a normal arthroscopy.

Tebbetts, J. B. (2002). "Achieving a predictable 24-hour return to normal activities after breast augmentation: part I. Refining practices by using motion and time study principles." Plast Reconstr Surg 109(1): 273-90; discussion 291-2.
The purpose of this study was to develop techniques to predictably return patients receiving inframammary and axillary, subpectoral breast augmentation to full normal activities within 24 hours of their primary breast augmentation. This 5-year study applies motion and time study principles to refine practices in augmentation mammaplasty to reduce perioperative morbidity and shorten patient recovery. Retrospective data for operative times, medications administered, recovery times, times to discharge, and time to return to normal activities were collected from patient chart reviews and patient contacts from 1982 to 1984 (group 1, n = 16, axillary partial retropectoral augmentations) and 1990 (group 2, n = 16, inframammary partial retropectoral augmentations). Videotapes from operative procedures of groups 1 and 2 were analyzed with macromotion and micromotion study principles, and tables of events were formulated for all operating room personnel, detailing every step of each function they performed. The events tables were then refined into detailed scripts by using motion and time study principles. Scripts were used for surgeon and personnel training and for reference during operative procedures. Extensive changes in all aspects of patient care, including patient education, preparation, operative planning, implant selection, anesthesia techniques, surgical techniques, instrumentation, and postoperative care derived from data and videotape studies of patients in groups 1 and 2 were then applied to a third group of patients (group 3), collecting prospective data over a 3-year period (1998 to 2000). Group 3 (n = 627) data included timed events, medications, and time to return to normal activities. Patients in group 3 had substantially shorter anesthesia, operation, and postanesthesia care unit times and time to discharge and time to return to normal activities compared with groups 1 and 2. Of the patients in group 3, 96 percent were able to return to normal activities, lift their arms above their heads, lift normal-weight objects, and drive their car without any narcotic medications, drains, bandages, special bras, or other adjunctive treatments within 24 hours after their partial retropectoral breast augmentation. Applying motion and time study principles to analysis and refinement of surgeon and personnel actions and surgical techniques resulted in a substantial reduction in perioperative morbidity and a simpler, shorter 24-hour return to normal activities without intercostal blocks, narcotic pain medications, drains, bandages, or other adjunctive devices in 96 percent of 627 augmentation patients.

Yagiela, J. A. (2001). "Making patients safe and comfortable for a lifetime of dentistry: frontiers in office-based sedation." J Dent Educ 65(12): 1348-56.
Conscious sedation administered in the office setting is one important method for helping people obtain necessary dental care. Patients who may benefit from sedation include the dentally fearful, young children, the behaviorally or medically challenged, and individuals who are undergoing invasive procedures or have problems with gagging or local anesthesia. In-office sedation is effective in reducing apprehension and can improve patient behavior without adversely affecting the patient's physiological status. Mortality and serious morbidity are exceedingly rare in modern practice. Although behavioral strategies are clearly more cost-effective for the patient receiving routine dental care, in-office sedation is usually the least expensive alternative for patients requiring pharmacologic management. Future advances in conscious sedation may include agents and techniques currently thought to be dangerous for nongeneral anesthesia-trained dentists because of their ability to produce rapid changes in anesthetic depth. However, delivery devices such as infusion pumps for drugs like propofol, when coupled with computers to help regulate the infusion rate and monitor the sedative effect, may provide the necessary control for safe administration of propofol and similar drugs by these individuals. A final approach to drug delivery may involve patient-controlled sedation in which the patient self-infuses small boluses incrementally until the desired effect is achieved.

White, P. F. and M. F. Watcha (2001). "Pharmacoeconomics in anaesthesia: what are the issues?" Eur J Anaesthesiol Suppl 23: 10-5.
Newer anaesthetic agents provide a faster onset, easier titration and a more rapid recovery than the older agents, but are more expensive. In assessing the financial consequences associated with their use, it is important to examine the total costs (including personnel costs) and not just the acquisition costs of new drugs. Claims of cost savings from new drugs should be subjected to close scrutiny, with studies designed to demonstrate that the preferential use of the newer drug is associated with actual decreased payments for personnel, an earlier return to normal activities by the patient and/or their caretakers, or the completion of an additional case in the same operating session. It may be necessary to alter work patterns to obtain the full benefits of the new drugs (e.g. bypass of the labour-intensive [phase I] postanaesthetic care unit). Finally, greater cost savings in the operating room can be achieved by increasing efficiency in resource utilization. A delay in starting a case, or a prolonged turnover time between cases, can negate any cost savings related to the anaesthetist's choice of drugs.

Huang, J. J., S. Fogel, et al. (2001). "Cost analysis in vitrectomy: monitored anesthesia care and general anesthesia." Aana J 69(2): 111-3.
A retrospective study was performed to compare differences in hospital charges between monitored anesthesia care with retrobulbar block and general anesthesia among patients having vitrectomy. Of 128 consecutive patients undergoing vitrectomy between July 1996 and July 1997, group 1 received general anesthesia (n = 41), group 2 received monitored care anesthesia with retrobulbar block (n = 59), and 28 patients were eliminated from the study. There were significant differences in anesthesia charges, operating room charges, pharmacy charges, and total hospital charges between groups 1 and 2. Charges associated with monitored care anesthesia with retrobulbar block are 20% less than charges associated with general anesthesia. Fewer patients in group 2 required postoperative intravenous narcotics than in group 1.

Todd, D. W. (2002). "A comparison of endotracheal intubation and use of the laryngeal mask airway for ambulatory oral surgery patients." J Oral Maxillofac Surg 60(1): 2-4; discussion 4-5.
PURPOSE: This study compared current experience with the laryngeal mask airway (LMA) to previous experience with endotracheal intubation for ambulatory patients receiving general anesthesia. PATIENTS AND METHODS: A retrospective comparison of 157 patients (50 endotracheal intubation [ET] and 107 LMA cases) was conducted. The subjects were American Association of Anesthesiologist (ASA) Class I and II patients who underwent outpatient general anesthesia for dentoalveolar surgery. Procedure time, recovery time, and cost of techniques were compared. RESULTS: The patients undergoing a variety of outpatient dentoalveolar surgical procedures under general anesthesia in the LMA group had a shorter procedure time than the ET group (40 vs 44 minutes) and had a significantly shorter recovery time (54 vs 67 minutes). In addition, compared with the cost of delivering care with ET, the LMA provided slightly lower cost per case ($20 to $30 per case compared with $35 to $80 per case), depending on the anesthetic technique used. Comparing the 2 techniques for removal of 4 impacted third molars (25 patients ET and 68 patients LMA) revealed a similar procedure time of 39 minutes for both groups, but a shorter recovery time for the LMA group (54 vs 68 minutes). CONCLUSIONS: Use of the LMA has advantages over endotracheal intubation for outpatients receiving general anesthesia for dentoalveolar surgery.

Ozkose, Z., B. Ercan, et al. (2001). "Inhalation versus total intravenous anesthesia for lumbar disc herniation: comparison of hemodynamic effects, recovery characteristics, and cost." J Neurosurg Anesthesiol 13(4): 296-302.
The clinical effects, recovery characteristics, and costs of total intravenous anesthesia (TIVA), sevoflurane, and isoflurane anesthesia have been measured in various out-patient operations, but have not been evaluated in patients undergoing laminectomy or discectomy. In the current study, the authors assessed the hemodynamic characteristics, recovery, and cost analyzes after laminectomy and discectomy operations, comparing TIVA, sevoflurane, and isoflurane anesthesia. Sixty American Society of Anesthesiologists I and II patients were randomly divided into three groups, each consisting of 20 patients. Group I received propofol-alfentanil, Group 2 received sevoflurane-N2O, and Group 3 received isoflurane-N2O. At the end of surgery, the anesthetics were discontinued, and recovery from anesthesia was assessed by measuring the time until spontaneous eye opening and the time until response to verbal commands. The drug and delivery costs were calculated in United States dollars. No significant differences were found in the demographic data. Heart rate and mean arterial pressure decreased significantly after induction of anesthesia in the TIVA group, compared to the two other groups ( P < .05 for both comparisons). The fastest recovery was seen in the TIVA group. Incidences of postoperative nausea, vomiting, and pain were significantly reduced after TIVA ( P < .05 for both comparisons). Thus, TIVA patients required fewer additional drugs and showed the lowest additional costs in the post-anesthesia care unit. However, the total cost was significantly higher in the TIVA group than in the sevoflurane and isoflurane groups (52.73 dollars, 29.99 dollars, and 24.14 dollars, respectively) ( P < .05). Total intravenous anesthesia was associated with the highest intraoperative cost but provided the most rapid recovery from anesthesia, and the least frequent postoperative side effects.

Abouleish, A. E., D. S. Prough, et al. (2001). "The impact of longer-than-average anesthesia times on the billing of academic anesthesiology departments." Anesth Analg 93(6): 1537-43, table of contents.
Academic anesthesiology departments provide clinical services for surgical procedures that have longer-than-average surgical times and correspondingly increased anesthesia times. We examined the financial impact of these longer times in three ways: 1) the estimated loss in revenue if billing were done on a flat-fee system by using industry-averaged anesthesia times; 2) the estimation of incremental operating room (OR) sites necessitated by longer anesthesia times; and 3) the estimated potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration. Health Care Financing Administration average times per anesthesia procedure code were used as industry averages. Billing data were collected from four academic anesthesiology departments for 1 yr. Each claim billed with ASA units was included except for obstetric anesthesia care. All clinical sites that do not bill with ASA units were excluded. Base units were determined for each anesthesia procedure code. The mean commercial conversion factor (US$45 per ASA unit) for reimbursement was used to estimate the impact in dollar amounts. In all four groups, anesthesia times exceeded the Health Care Financing Administration average. The loss per group in billed ASA units if a flat-fee billing system were used ranged from 18,194 to 31,079 units per group, representing a 5% to 15% decrease (estimated billing decrease of US$818,719 to US$1,398,536 per group). The number of excess OR sites necessitated by longer surgical and anesthesia times ranged from 1.95 to 4.57 OR sites per group. The potential gain in billed units if the hours of productivity of current anesthesia time were applied to surgical cases of average duration was estimated to be from 13,273 to 21,368 ASA units. Longer-than-average anesthesia and surgical times result in extra hours or additional OR sites to be staffed and loss of potential reimbursement for the four academic anesthesiology departments. A flat-fee system would adversely affect academic anesthesiology departments. IMPLICATIONS: We examined the economic impact of longer-than-average anesthesia times on four academic anesthesiology departments in three ways: the estimated loss in revenue under a flat-fee system, the excess operating room sites staffed, and the potential gain in revenue if the surgeries were of average length. These results should be considered both in productivity measurements and strategies for operating room management.

Lee, J. Y., W. F. Vann, Jr., et al. (2001). "A cost analysis of treating pediatric dental patients using general anesthesia versus conscious sedation." Anesth Prog 48(3): 82-8.
The purpose of this pilot study is to report a cost comparison of general anesthesia (GA) versus oral conscious sedation (CS) for pediatric dental patients. The study sample included 22 children whose parents or guardians selected GA care for their child. Selection criteria limited inclusion to healthy children (American Society of Anesthesiologists' classification I) aged 24-60 months. The subjects acted as their own comparison group to an estimation CS model. Models were developed to assess societal costs for treatment under GA and CS. Treatment rendered was equalized using the dental relative based value unit scale.

Chan, V. W., P. W. Peng, et al. (2001). "A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis." Anesth Analg 93(5): 1181-4.
IV regional anesthesia can offer a more favorable patient recovery profile and shorter postoperative nursing care time and hospital discharge time than an isoflurane-based general anesthetic or brachial plexus block technique for hand surgery.

Ross, I. A. (1996). "Practice guidelines, patient interests, and risky procedures." Bioethics 10(4): 310-22.
A clinical scenario is described where an anaesthetist is concerned about the seemingly high risk/benefit ratio relating to laparoscopic versus standard inguinal hernia operations. Some options for further action by the anaesthetist are introduced. The remainder of the paper explores the question of who can legitimately assess the acceptability of risk/benefit ratios, and defends the use of practice guidelines at the expense of so called clinical freedom. It is argued that respect for persons is not breached by limiting the treatment options offered to patients to those therapies which have a 'reasonable' risk/benefit ratio. This 'reasonableness' is context dependent, and should be properly decided by those with expertise in the field.

Hasaniya, N. W., F. F. Zayed, et al. (2001). "Preinsertion local anesthesia at the trocar site improves perioperative pain and decreases costs of laparoscopic cholecystectomy." Surg Endosc 15(9): 962-4.
BACKGROUND: Local anesthesia at the trocar site in laparoscopic cholecystectomy is expected to decrease postoperative pain and hence expedite recovery. The aims of this prospective randomized study were to investigate the effect of local anesthesia and to discover whether it is cost effective. METHODS: For this study, 100 patients undergoing laparoscopic cholecystectomy were randomized into two groups. The 43 study patients were injected with 0.5% bupivacaine hydrochloride at the trocar site before the trocars were inserted. They then were compared with 41 control patients who received no local anesthesia. The remaining 16 patients were excluded from the study. The postoperative pain was evaluated at the standard four trocar sites at 4 h and 24 h after surgery on a scale 1 (the mildest pain the patient had ever experienced) to 10 (the most severe pain the patient had ever experienced). Postoperative pain medications and their cost were evaluated. RESULTS: There was no difference between the two groups with regard to gender, age, weight, operative time, estimated operative blood loss, and bile culture. The patients who received bupivacaine at the trocar site clinically had less pain (p < 0.001 for all four sites) both at 4 and 24 h after surgery. The treatment group patients used less mepiridine and promethzine than the control group (p = 0.001 and 0.002, respectively) postoperatively. Overall, the patients who had local anesthesia used less postoperative pain and antiemetic medication than the control patients (p = 0.02). This afforded a significant decrease in the costs and charges of these medications (p = 0.004 and 0.005, respectively). Three patients in the study group were discharged from the hospital the day of surgery. Conclusion: Preinsertion of local anesthesia at the trocar site in laparoscopic cholecystectomy significantly reduces postoperative pain and decreases medication usage costs.

Reeves, S. W., D. S. Friedman, et al. (2001). "A decision analysis of anesthesia management for cataract surgery." Am J Ophthalmol 132(4): 528-36.
PURPOSE: To compare the trade-offs in cost and preference of various anesthesia management strategies for cataract surgery. METHODS: Six strategies, differing in sedation, local anesthetic, and monitoring approach, were chosen for comparison. For each strategy, potential complications, and conversions to different anesthesia approaches were modeled. A panel of physicians and anesthetists, well versed in the literature and practice of the anesthesia management of cataract surgery, assigned preference values to the strategies and potential outcomes (0 to 1 scale). Probability estimates were obtained from a study of 19,557 cataract surgeries and from the panel. Cost estimates were derived from several sources. The model was analyzed to determine the strategies associated with the highest expected preference and lowest expected cost. RESULTS: The strategy associated with the highest net preference was intravenous sedation with block anesthesia and an anesthesiologist present throughout the case. The expected net preference for this strategy was 19% greater than the net preference for the next most preferred strategy, oral sedation with block anesthesia and an anesthesiologist on call (0.88 versus 0.74), but the expected anesthesia costs per case were much greater ($324 versus $42). Results were sensitive to plausible variation in the preference values assigned to the six initial management strategies and to the cost of topical versus block anesthesia. CONCLUSION: This analysis emphasizes that cost and preference are important considerations when choosing an anesthesia management strategy for cataract surgery. For some surgeries, substantial cost savings may be available for a small change in preference.

Visser, K., E. A. Hassink, et al. (2001). "Randomized controlled trial of total intravenous anesthesia with propofol versus inhalation anesthesia with isoflurane-nitrous oxide: postoperative nausea with vomiting and economic analysis." Anesthesiology 95(3): 616-26.
BACKGROUND: To assess the incidence of postoperative nausea and vomiting after total intravenous anesthesia (TIVA) with propofol versus inhalational anesthesia with isoflurane-nitrous oxide, the authors performed a randomized trial in 2,010 unselected surgical patients in a Dutch academic institution. An economic evaluation was also performed. METHODS: Elective inpatients (1,447) and outpatients (563) were randomly assigned to inhalational anesthesia with isoflurane-nitrous oxide or TIVA with propofol-air. Cumulative incidence of postoperative nausea and vomiting was recorded for 72 h by blinded observers. Cost data of anesthetics, antiemetics, disposables, and equipment were collected. Cost differences caused by duration of postanesthesia care unit stay and hospitalization were analyzed. RESULTS: Total intravenous anesthesia reduced the absolute risk of postoperative nausea and vomiting up to 72 h by 15% among inpatients (from 61% to 46%, P < 0.001) and by 18% among outpatients (from 46% to 28%, P < 0.001). This effect was most pronounced in the early postoperative period. The cost of anesthesia was more than three times greater for propofol TIVA. Median duration of stay in the postanesthesia care unit was 135 min after isoflurane versus 115 min after TIVA for inpatients (P < 0.001) and 160 min after isoflurane versus 150 min after TIVA for outpatients (P = 0.039). Duration of hospitalization was equal in both arms. CONCLUSION: Propofol TIVA results in a clinically relevant reduction of postoperative nausea and vomiting compared with isoflurane-nitrous oxide anesthesia (number needed to treat = 6). Both anesthetic techniques were otherwise similar. Anesthesia costs were more than three times greater for propofol TIVA, without economic gains from shorter stay in the postanesthesia care unit

Thomas, D., K. Wareham, et al. (2001). "Autologous blood transfusion in total knee replacement surgery." Br J Anaesth 86(5): 669-73.
We compared allogeneic blood usage for two groups of patients undergoing total knee replacement surgery (TKR). Patients were randomized to receive either their post-operative wound drainage as an autotransfusion (n=115) after processing or to have this wound drainage discarded (n=116). Allogeneic blood was transfused in patients of either group whose haemoglobin fell below 9 g dl(-1). Only 7% of patients in the autotransfusion group required an allogeneic transfusion compared with 28% in the control group (P<0.001). There was no hospital mortality and only 3% mortality from all causes at the study completion, which spanned 6 months to 3 yr. There was a higher incidence of infection requiring intervention in the allogeneic group (P<0.036). Total patient costs were Pound Sterling 113 greater in the autotransfusion group. We conclude that in this type of surgery post-operative cell salvage is a safe and effective method for reducing allogeneic blood use.

Engoren, M., G. Luther, et al. (2001). "A comparison of fentanyl, sufentanil, and remifentanil for fast-track cardiac anesthesia." Anesth Analg 93(4): 859-64.
Cardiac surgery is estimated to cost $27 billion annually in the United States. In an attempt to decrease the costs of cardiac surgery, fast-track programs have become popular. The purpose of this study was to compare the effects of three different opioid techniques for cardiac surgery on postoperative pain, time to extubation, time to intensive care unit discharge, time to hospital discharge, and cost. Ninety adult patients undergoing cardiac surgery were randomized to a fentanyl-based, sufentanil-based, or remifentanil-based anesthetic. Postoperative pain was measured at 30 min after extubation and at 6:30 AM on the first postoperative day. Pain scores at both times were similar in all three groups (P > 0.05). Median ventilator times of 167, 285, and 234 min (P > 0.05), intensive care unit stays of 18.8, 19.8, and 21.5 h (P > 0.05), and hospital stays of 5, 5, and 5 days (P > 0.05) for the Fentanyl, Sufentanil, and Remifentanil groups did not differ. Three patients needed to be tracheally reintubated: two in the Sufentanil group and one in the Fentanyl group. Median anesthetic costs were largest in the Remifentanil group ($140.54 [$113.54-$179.29]) and smallest in the Fentanyl group ($43.33 [$39.36-$56.48]) (P < or = 0.01), but hospital costs were similar in the three groups: $7841 (Fentanyl), $5943 (Sufentanil), and $6286 (Remifentanil) (P > 0.05). We conclude that the more expensive but shorter-acting opioids, sufentanil and remifentanil, produced equally rapid extubation, similar stays, and similar costs to fentanyl, indicating that any of these opioids can be recommended for fast-track cardiac surgery. IMPLICATIONS: To conserve resources for cardiac surgery, fentanyl-, sufentanil-, and remifentanil-based anesthetics were compared for duration of mechanical ventilation, intensive care unit length of stay, hospital length of stay, and cost. The shorter-acting anesthetics, sufentanil and remifentanil, produced equally rapid extubation, similar stays, and similar costs to fentanyl; thus, any of these opioids can be recommended for fast-track cardiac surgery.

Levin, R. and L. Trivikram (2001). "Cost/benefit analysis of open tracheotomy, in the or and at the bedside, with percutaneous tracheotomy." Laryngoscope 111(7): 1169-73.
OBJECTIVES/HYPOTHESIS: (1) To determine whether percutaneous dilational tracheotomy (PDT), open tracheotomy in the operating room (OT/OR), and open tracheotomy at the bedside (OT/BS) are equally safe; and (2) to determine which procedure was most cost effective. STUDY DESIGN: Retrospective review of patient medical records and billing data. METHODS: Any adult patient (>20 y of age) on the medical or surgical services at Penn State Milton S. Hershey Medical Center who required a tracheotomy, elective or emergent, from September 1996 to July 1997 was included. The decision to perform OT in the OR, PDT, or OT at BS was made by the attending surgeon independent of this study. Each patient's course after tracheotomy was reviewed. All complications, perioperatively or postoperatively, for up to 10 days were documented. The complications were divided into two groups: major and minor. Determination of patient cost used surgical billing and OR materials staff records. The necessary equipment and staff for each procedure was determined, and an itemized cost list was retrospectively developed for a typical PDT, OT in OR, or OT at BS. The P values were calculated with the Cochran-Mantel-Haenszel (CMH) chi(2) test of association. RESULTS: All procedures were equally safe, with PDT being the most cost effective. CONCLUSION: This report confirms the results of several studies demonstrating that PDT, OT in the OR, and OT at the BS are equally safe; PDT appears to be most cost effective. Our analysis, however, does reveal several options for decreasing the cost of bedside tracheotomy to allow this procedure to be even more cost effective than PDT.

Stuart, K. A., H. Krakauer, et al. (2001). "Labor epidurals improve outcomes for babies of mothers at high risk for unscheduled cesarean section." J Perinatol 21(3): 178-85.
CONTEXT: Epidural placement for labor in the general population of laboring women is associated with increased incidence of operative deliveries, prolongation of labor, and may be associated with an increased cesarean section rate. The risks and benefits associated with epidural placement for labor in the subpopulation of mothers at high risk for cesarean section have not been studied. OBJECTIVE: To determine if a population of mothers and babies at high risk for cesarean section will have improved outcomes with labor epidural placement. DESIGN: A decision and cost analysis examining epidural placement for labor on a population of women who are at high risk for unscheduled cesarean section and may benefit from scheduled cesarean section as determined by threshold analysis was performed. Outcomes and probabilities were determined through analysis of the Department of Defense's 1996 National Quality Management Program (NQMP) Birth Product Line data set containing more than 7000 deliveries. Outcomes were defined using variables comprised of all documented conditions that occurred during the peripartum and neonatal hospitalizations. The 1997 NQMP data set was used to validate the results. SETTING: Military Treatment Facilities throughout the United States and abroad and civilian facilities in the United States providing care to military dependents. PATIENT POPULATION: Active duty and dependent pregnant women and babies. RESULTS: About 8% of mothers in this patient population were found to be at high risk for cesarean section. The decision and cost analyses showed that babies of the high risk mothers who received epidurals for labor had better clinical outcomes (p<0.05) and the procedure was cost neutral (p=0.23). The procedure did not increase the frequency of cesarean section, and there was no effect on maternal outcomes scores. These results were confirmed by the validation study. CONCLUSIONS: There is a sizable subpopulation of women at high risk for cesarean section whose babies may have better outcomes with epidural placement with no sacrifice in maternal outcomes or costs.

Bauer, M., A. Bach, et al. (2001). "[Inhalation anesthetics in financial contexts]." Anasthesiol Intensivmed Notfallmed Schmerzther 36(6): 373-7.

Splinter, W. M. and L. A. Isaac (2001). "The pharmacoeconomics of neuromuscular blocking drugs: a perioperative cost-minimization strategy in children." Anesth Analg 93(2): 339-44 , 3rd contents page.
The purpose of this investigation was to compare the costs of intermediate-acting neuromuscular blocking drugs in children during routine ambulatory surgery. We studied 200 healthy, 2-10-yr-old children undergoing elective dental restorative surgery. During Part 1 of the study, children received an inhaled anesthetic with halothane and nitrous oxide, whereas in Part 2, the anesthetic was IV propofol with nitrous oxide. The study drugs were atracurium, cisatracurium, mivacurium, rocuronium, and vecuronium. Patients were initially administered 2x the effective dose for 95% of the study drug. After recovery to 10% of baseline neuromuscular function, the neuromuscular blockade was rigidly maintained with an infusion of the study drug at about 10% of baseline function. Neuromuscular drug costs were approximated as drug usage x cost/unit. The initial drug costs were not substantially different for both Parts 1 and 2, but over time, mivacurium became the most expensive drug and cisatracurium the least expensive. In conclusion, based on current costs, cisatracurium is the least expensive intermediate-acting neuromuscular drug. IMPLICATIONS: For children undergoing minor ambulatory procedures of 1-2 h, and continuous intraoperative neuromuscular blockade is indicated, cisatracurium currently is the least expensive drug.

Smith, I. (2001). "Cost considerations in the use of anaesthetic drugs." Pharmacoeconomics 19(5 Pt 1): 469-81.
Anaesthetic drugs typically comprise approximately 5% or less of a hospital pharmacy budget, yet they are a common target for cost reduction measures. In particular, there is considerable pressure to use less costly products where alternatives exist and to limit the introduction of expensive new items. In considering strategies to reduce a departmental drug budget, or in defending against restrictions imposed from outside, it is important to consider all of the costs associated with anaesthetic drug delivery. These costs comprise not only the expense of the anaesthetic drugs themselves, but also fixed and variable costs associated with their delivery and related to their effects. Elimination of drug waste will always be beneficial, since it has no direct effect on the patient yet clearly reduces cost. Waste is by no means confined to anaesthetic drugs, however. Using less expensive drugs may appear an attractive option and can reduce costs, provided that patient outcome is in no way affected. Rarely is this the case. Once patient care is modified, through changes in recovery times or complication rates, determining the true cost of the intervention becomes essential; there may be increases in indirect costs which dwarf the apparent savings. Sometimes indirect costs will rise by a lesser amount than savings in direct costs, such that there is still an overall benefit but less than that originally anticipated. Exactly how indirect effects result in indirect costs is highly variable. The requirement for additional drugs or supplies to treat an adverse event, such as emesis, will always have an associated cost. Delayed recovery or prolonged hospital stay will waste operating room time or increase the amount of time that a patient requires nursing care, but whether this carries an associated cost depends on what the staff would otherwise have been doing. Depending on the employment method, staff may have been sent home early (with less pay) or employed at identical cost but with less to do. Many studies which purport to consider all costs either ignore such issues, or make invalid assumptions. These issues are complex, but anyone involved with decisions concerning anaesthetic costs should be familiar with the underlying principles and be able to make a rational assessment of the likely indirect costs in their own institution.

Groudine, S. B. (2001). "The costs of Medicare compliance." Anesthesiology 94(5): 937-8.

Bauer, M., A. Bach, et al. (2001). "Cost optimization in anaesthesia." Minerva Anestesiol 67(4): 284-9.
As a result of the progress which has been made in medicine and technology and the increase in morbidity associated this demographic development, the need and thus the costs for medical care have increased as well. The financial resources which are available for medical care, however, are still limited and hence the funds which are available must be distributed more efficiently. Cost optimisation measures can help make better use of the profitability reserves in hospitals. The authors show how costs can be optimised in the anaesthesiology department of a clinic. Pharmacoeconomic evaluation of the new inhalation anaesthetics shows an example of how the cost structures in anaesthesia can be made more obvious and potential ways savings be implemented. To reduce material and personnel costs, a more rational means of internal process management is presented. According to cost-effectiveness analysis, medications are not divided into the categories inexpensive and expensive but rather cost-effective or non-cost-effective. By selecting a cost-effective drug it is possible to reduce cost at a hospital. For example, sevoflurane at a fresh gas flow of below 3 l/min has been shown to be a cost-effective inhalation anaesthetic which, in terms of the economics, is also superior to intravenous anaesthesia with propofol. In addition to these measures of reducing material costs, other examples are given of how personnel costs can be reduced by optimising work procedures: e.g. effective operating theatre co-ordination, short switchover times by overlapping anaesthesia induction and the use of multifunctional personnel. The gain in productivity which is a result of these measures can positively affect profits, and by optimising the organisation of procedures to shorten the times required to carry out a procedure, costs can be reduced.

Dexter, F., R. H. Epstein, et al. (2001). "A statistical analysis of weekday operating room anesthesia group staffing costs at nine independently managed surgical suites." Anesth Analg 92(6): 1493-8.
At many surgical suites, surgeons and patients schedule elective cases on whatever future workday they choose, resulting in there being no limit on the number of cases performed each day. Staff are then scheduled in the manner that satisfies the marketing guarantee to the surgeons, satisfies labor contracts, and minimizes staffing costs. We assessed weekday nurse anesthesia group staffing at nine such suites to determine whether statistical methods can identify staffing solutions whereby all the cases are covered but for which staffing costs are less than those obtained using the staffing plans implemented by anesthesia groups' managers. Two years of operating room information system case duration and staffing data were analyzed. First- and second-shift staffing was assessed using previously published algorithms. The statistical methods identified staffing solutions with significantly decreased labor costs than those currently being used at eight of the nine surgical suites. The statistical methods relied more on overtime than second-shift staffing. The incremental decrease in staffing costs achievable by using overlapping 8-, 10-, and 13-h shifts was negligible. Overall, we found that statistical methods can identify, for some surgical suites, staffing solutions whereby all the cases are covered but for which costs are significantly less and productivity significantly more than those obtained using the plans developed by the managers based on their experience and the data. IMPLICATIONS: Statistical methods can identify, for some surgical suites, anesthesia staffing solutions whereby all the cases are covered but for which labor costs are significantly less than those obtained using the staffing plans developed by the managers based on data and their experience.

O'Connor, M. F., S. M. Daves, et al. (2001). "BIS monitoring to prevent awareness during general anesthesia." Anesthesiology 94(3): 520-2.
BACKGROUND: Unexpected awareness is a rare but well-described complication of general anesthesia that has received increased scientific and media attention in the past few years. Transformed electroencephalogram monitors, such as the Bispectral Index monitor, have been advocated as tools to prevent unexpected recall. METHODS: The authors conducted a power analysis to estimate how many patients would be needed in an appropriately powered study to demonstrate the Bispectral Index monitor reduces awareness, as well as a cost analysis to assess the cost of using the monitor for this purpose alone. RESULTS: If unexpected recall is rare (1 in 20,000), it will require a large study to demonstrate that the monitor reduces awareness (200,000-800,000 patients), and the cost of using it for this purpose alone would be high ($400,000 per case prevented). If awareness is common (1 in 100), then the number of patients needed in a study to demonstrate that the monitor works becomes tractable (1,000-4,000 patients), and the cost of using the monitor for this purpose alone becomes lower ($2,000 per case prevented). Because there are reported cases of awareness despite Bispectral Index monitoring, the authors are certain that the effectiveness of the monitor is less than 100%. As the performance of the monitor decreases from 100%, the size of the study needed to demonstrate that it works increases, as does the cost of using it to prevent awareness. CONCLUSION: The contention that Bispectral Index monitoring reduces the risk of awareness is unproven, and the cost of using it for this indication is currently unknown.

Elliot, R. A. (2001). "The economics of anaesthesia." Eur J Anaesthesiol 18(4): 205-7.

Kern-Jeandel, D., S. Sacrista, et al. (2001). "[Is the use of sevoflurane in closed circuit in pediatric anesthesia really an economy?]." Ann Fr Anesth Reanim 20(3): 305.

Pate-Cornell, E. (1999). "Medical application of engineering risk analysis and anesthesia patient risk illustration." Am J Ther 6(5): 245-55.
The engineering risk analysis method can be extended to include some human and organizational factors and can be used in the medical domain; this transfer is illustrated by a description of a study of anesthesia patient risk. This study involves first a dynamic analysis of accident risks. The model is then extended by relating the basic events of accident scenarios to the state of the practitioner described by the probability of personal problems that may affect his or her level of competence and alertness. These potential problems, in turn, are linked (by probabilistic relations) to the way the system is managed. This extension of the analytical framework allows assessment of the effect of particular types of practitioner problems and therefore of corresponding risk mitigation measures on the probability of the different accident scenarios. The risk analysis model can then be used as a management tool that permits setting priorities among patient safety measures, based either on the sole benefits of the corresponding decrease of patient risk or on a cost-to-benefit ratio. This probabilistic approach constitutes a departure from the classic risk studies exclusively based on statistical frequencies because it involves both available statistics and expert opinions. It is commonly used in engineering for systems for which there is not enough information at the time when decisions need to be made. I show here how the probabilistic model can be used in the medical field to support patient safety decisions before complete data sets can be gathered or in cases in which some key factors are not directly observable.

Koch, T. (2001). "[Effectiveness and cost-benefit ratio of regional anesthesia procedures]." Anasthesiol Intensivmed Notfallmed Schmerzther 36(3): 178-80.

Dexter, F. and A. Macario (2001). "Optimal number of beds and occupancy to minimize staffing costs in an obstetrical unit?" Can J Anaesth 48(3): 295-301.
PURPOSE: We describe how the science of analyzing patient arrival and discharge data can be used to determine the optimal number of staffed OB beds to minimize labour costs. METHODS: The number of staffed beds represents a balance between having as few staffed beds as possible to care properly for parturients vs having enough capacity to assure available staff for new admissions. The times of admission and discharge of patients from the OB unit can be used to calculate an average census. From this average census, and the properties of the Poisson distribution, the optimal number of staffed beds can be estimated. This calculation requires specification of the risk of having all in-house and on-call staff caring for patients, such that additional staff are unavailable should another parturient arrive. As an example, patient admission and discharge times were obtained for 777 successive patients cared for at an obstetrical unit. The numbers of patients present in the OB unit each two-hour period were calculated and analyzed statistically. PRINCIPAL FINDINGS: There was variation in the average census among hours of the day and days of the week. Poisson distributions fit the data for each of four periods throughout the week. Simply benchmarking the current average occupancy and comparing it to a desired occupancy would have been inadequate as this neglected consideration of the risk of being unable to appropriately care for an additional patient. CONCLUSIONS: The optimal number of beds and occupancy of an OB unit to minimize staffing costs can be determined using straightforward statistical methods.

Chilvers, C. R., A. Goodwin, et al. (2001). "Selective spinal anesthesia for outpatient laparoscopy. V: pharmacoeconomic comparison vs general anesthesia." Can J Anaesth 48(3): 279-83.
PURPOSE: To compare the cost and effectiveness of small-dose spinal anesthesia (SP) with general anesthesia (GA) for outpatient laparoscopy. METHODS: A retrospective record analysis of 24 patients who received SP were compared with 28 patients who received GA in our Daycare centre. The costs of anesthesia and recovery were calculated, from an institutional perspective, using 1997 Canadian Dollar values. Effectiveness was measured in terms of time for anesthesia and recovery, and postoperative antiemetic and analgesic requirements. RESULTS: Both groups were well matched for age, weight, duration and type of surgery. The mean total cost for the SP group of $53.45 +/- 10.40 was no different from that for the GA group of $48.92 +/- 10.25 (95% CI -10.3, 1.2). Time to administer anesthesia was longer in the SP group with a mean time of 18 +/- 8 min compared with 10 +/- 3 min in the GA group (CI -11.3, -4.7). Recovery time in the PACU was longer in the SP group 123 +/- 51 min compared with 94 +/- 48 min (CI -56.6,-1.4). Postoperative antiemetic requirements were similar: 8% in SP group vs 14% in GA group, whereas analgesic requirements were less in the SP group with 25% receiving analgesia compared with 75% in the GA group (P < 0.05). CONCLUSION: The total cost of anesthesia and recovery using SP is similar to that for GA when used for outpatient laparoscopy. Spinal anesthesia was less effective than GA in time to administer anesthesia and in duration of recovery. Postoperative analgesic requirements were reduced using SP.

Reinelt, H., T. Marx, et al. (2001). "Xenon expenditure and nitrogen accumulation in closed-circuit anaesthesia." Anaesthesia 56(4): 309-11.
The high price of xenon has prevented its use in routine, clinic anaesthetic practice. Xenon therefore has to be delivered by closed-circuit anaesthesia. The accumulation of nitrogen is a significant problem within the closed circuit and necessitates flushing, which in turn increases gas expenditure and costs. In previous investigations, nitrogen concentrations between 12% and 16% have been reported in closed-circuit anaesthesia. In order to avoid such nitrogen accumulation, we denitrogenised seven pigs using a non-rebreathing system and connected the animals to a system primed with a xenon/oxygen mixture. In comparison, seven pigs were anaesthetised with xenon using a standard low-flow anaesthetic procedure. Anaesthesia time was 2 h. Nitrogen concentrations in the closed system ranged from 0.08 to 7.04% and were not significantly different from those observed during low-flow anaesthesia. Closed-circuit anaesthesia reduced the xenon expenditure 10-fold compared with low-flow anaesthesia.

Epple, J., J. Kubitz, et al. (2001). "Comparative analysis of costs of total intravenous anaesthesia with propofol and remifentanil vs. balanced anaesthesia with isoflurane and fentanyl." Eur J Anaesthesiol 18(1): 20-8.
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.

Yeo, K. S., S. W. Kua, et al. (2001). "The use of thiopentone/propofol admixture for laryngeal mask airway insertion." Anaesth Intensive Care 29(1): 38-42.
An admixture of thiopentone and propofol was evaluated against propofol for laryngeal mask airway (LMA) insertion. Eighty-one ASA 1 and 2 18- to 65-year-old patients, premedicated with 7.5 mg midazolam orally were assigned randomly to receive either propofol 1% or an admixture of thiopentone and propofol (1.25% and 0.5% respectively), both at a dose of 0.25 ml x kg(-1). Satisfactory conditions for insertion were achieved with the admixture, which was comparable to propofol (73% vs 85%, P>0.05). There was no statistical difference in the incidence or severity of gagging, coughing, inadequate jaw relaxation and laryngospasm. The incidence of hypotension was lower in the admixture group (51% vs 78%, P=0.02). The duration of apnoea was not different between the admixture and propofol group (mean 103s vs 109s respectively, P>0.05). We conclude that thiopentone/propofol admixture can be a suitable alternative to propofol for LMA insertion, producing less hypotension while allowing cost savings of up to 45%. An admixture of thiopentone and propofol (1.25% and 0.5% respectively) can produce suitable conditions compared to propofol 1%, for laryngeal mask insertion. In addition to cost containment, the admixture also produces less hypotension.

Naraynsingh, V., D. Maharaj, et al. (2001). "Cost-effective carotid endarterectomy." Br J Surg 88(3): 469-70.

Gress, F., C. Schmitt, et al. (2001). "Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience." Am J Gastroenterol 96(2): 409-16.
OBJECTIVE: In our previous randomized trial, we suggested a possible role for endoscopic ultrasound (EUS) guided celiac plexus block in the treatment of abdominal pain associated with chronic pancreatitis. The purpose of this study was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed to chronic pancreatitis, including follow-up on response rates and complications. METHODS: All subjects enrolled had documented chronic pancreatitis by ERCP and EUS criteria and presented with chronic abdominal pain unresponsive to current treatment options. All were treated with EUS-guided celiac plexus block under the guidance of linear array endosonography using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) inserted on each side of the celiac area, followed by injection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg) triamcinolone on each side of the celiac plexus. Individual pain scores, based on a visual analog scale (0-10), were determined preblock and postblock by a nurse at 2, 7, 14 days and monthly thereafter. Subjects also rated their overall comfort level during the EUS procedure. RESULTS: EUS-guided celiac plexus block was performed in 90 subjects (40 males, 50 females) having a mean age of 45 yr (range 17-76 yr) between July 1, 1995 and December 30, 1996. A significant improvement in overall pain scores occurred in 55% (50/90) of patients. The mean pain score decreased from 8 to 2 post EUS celiac block at both 4 and 8 wk follow-up (p < 0.05). In 26% of patients there was persistent benefit beyond 12 wk, and 10% still had persistent benefit at 24 wk, including three patients who were pain-free between 35 and 48 wk. Younger patients (<45 yr of age) and those having previous pancreatic surgery for chronic pancreatitis were unlikely to respond to the EUS-guided celiac block. Three patients experienced diarrhea post EUS celiac block, which resolved in 7-10 days; however, it is unclear whether this diarrhea was due to the block or to refractory disease. A cost comparison between the EUS ($1200) and CT ($1400) techniques shows the EUS celiac block to be less costly and perhaps more cost efficient in a subset of subjects. CONCLUSIONS: EUS-guided celiac plexus block appears to be safe, effective, and economical for controlling pain in some patients with chronic pancreatitis. Younger patients (<45 yr) and those having prior pancreatic surgery for chronic pancreatitis do not appear to benefit from this technique. Prophylactic antibiotics should be considered if acid suppressing agents are being taken.

Kleinschmidt, S., U. Grundmann, et al. (2000). "[Anesthesia with remifentanil combined with desflurane or sevoflurane in lumbar intervertebral disk operations]." Anaesthesiol Reanim 25(6): 151-7.
Recovery characteristics, haemodynamic profile, analgesic requirement and costs were evaluated and compared in patients undergoing elective lumbar discectomy with remifentanil-based anaesthesia using either desflurane or sevoflurane as the volatile anaesthetic agent. Sixty-two patients (ASA I/II status) were randomly assigned to receive either desflurane and remifentanil or sevoflurane and remifentanil (in oxygen/air) for anaesthesia. After induction with 0.5 microgram/kg/min remifentanil, 4 to 5 mg/kg thiopentone and 0.5 mg/kg atracurium, the patients received 0.25 microgram/kg/min remifentanil and 0.5 +/- 0.05 MAC of one of the volatile anaesthetic agents for further maintenance of anaesthesia. At the end of surgery, early emergence from anaesthesia was recorded by assessing the time to sufficient spontaneous respiration, eye opening and tracheal extubation. The total demand of piritramide in the postoperative period was determined using patient-controlled analgesia (PCA device). Quality of pain therapy was assessed via a verbal ranking scale (VRS). Side-effects such as postoperative nausea, vomiting or shivering were recorded in the postanaesthetic care unit. In both groups, the haemodynamic profile was nearly identical. Mean arterial pressure (-18%) and heart rate (-23%) were significantly reduced throughout anaesthesia in both groups. All recovery parameters were significantly shorter in the desflurane group in comparison with the sevoflurane group (e.g. time to tracheal extubation: 8.5 +/- 3.0 min vs. 11.9 +/- 4.6 min). No significant differences between the groups were observed concerning the amount of piritramide required, side-effects such as nausea and vomiting or the total cost of anaesthesia. In conclusion, both anaesthetic techniques provide adequate haemodynamic stability and postoperative pain control in a surgical procedure with minimal trauma. Incidence and severity of side-effects such as nausea, vomiting or shivering did not differ between the groups and were acceptable under clinical conditions. Costs for desflurane were significantly higher than those for sevoflurane, but total costs were not different between the groups. Concerning recovery profile, desflurane/remifentanil seems to have small advantages over sevoflurane/remifentanil in patients undergoing lumbar vertebral disc resection.

Vaagenes, P., D. Helgo, et al. (2000). "[Day surgery of hernia]." Tidsskr Nor Laegeforen 120(28): 3386-9.
INTRODUCTION: Reduced economic resources have been a stimulus for increased day-case surgery, and an incentive for improving surgical technique and anaesthetic methods. In hernia surgery it is important to avoid recurrence and reoperation, which seems to be more easily achieved by the use of mesh prosthetics. For anaesthesia, costs may possibly be reduced by the use of spinal blockade instead of general anaesthesia, but also local infiltration anaesthesia is regaining popularity. We found it appropriate to evaluate and compare relevant factors associated with the use of these two anaesthetic techniques in our day-case surgery. MATERIAL AND METHODS: Evaluation and analysis of the anaesthetic and postoperative notes on 413 adult patients with inguinal hernia operated in local anaesthesia and 121 patients operated in spinal anaesthesia. RESULTS: Cardiovascular, respiratory and neurological problems were more frequent and more severe in the spinal than in the local anaesthesia group, whereas the need for extra analgesia and sedation perioperatively was higher in the local group. Time spent in the operating room was shorter, and early ambulation appeared to lead to less discomfort in the local anaesthesia group. INTERPRETATION: The results indicate that local infiltration is a safe, simple and effective technique when used for operations of abdominal hernias in adult patients, and can be recommended for day-case surgery of reducible inguinal hernias.

Oral, H., B. P. Knight, et al. (2000). "Cost analysis of transthoracic cardioversion of atrial fibrillation with and without ibutilide pretreatment." J Cardiovasc Pharmacol Ther 5(4): 259-66.
BACKGROUND: Ibutilide may result in chemical cardioversion of atrial fibrillation and facilitates transthoracic cardioversion by lowering the defibrillation energy requirement. Whether routine pretreatment with ibutilide increases or decreases the cost of cardioversion is unknown. The purpose of this study was to compare the cost of outpatient transthoracic cardioversion of atrial fibrillation with and without ibutilide pretreatment. METHODS: Using a model based on published literature and hospital accounting information, a hypothetical group of 100 patients with atrial fibrillation and a left ventricular ejection fraction >0.30 underwent 2 strategies of outpatient cardioversion: transthoracic cardioversion with and without routine pretreatment with 1 mg ibutilide, and with and without involvement of an anesthesiologist for sedation. If transthoracic cardioversion was unsuccessful in patients who did not receive ibutilide, transthoracic cardioversion was repeated after administration of ibutilide. RESULTS: If an anesthesiologist was involved, transthoracic cardioversion with ibutilide was associated with incremental cost-savings as the efficacy of ibutilide alone in restoring sinus rhythm increased above the critical values of 20%, 27%, and 35% when the efficacy of transthoracic cardioversion alone was 60%, 80%, and 100%, respectively. In the absence of an anesthesiologist, routine pretreatment with ibutilide increased the cost of cardioversion at all success rates of transthoracic cardioversion. CONCLUSIONS: In the presence of an anesthesiologist, whether or not routine pretreatment with ibutilide lowers the mean cost of cardioversion is determined by the success rates of chemical cardioversion with ibutilide and transthoracic cardioversion. In the absence of an anesthesiologist, ibutilide pretreatment increases the cost of cardioversion.

Tazi, K., S. M. Moudouni, et al. (2000). "[Percutaneous nephrostomy: indications, techniques and results. Retrospective study of 81 cases]." Ann Urol (Paris) 34(6): 391-7.
A retrospective study has been made of 81 cases of percutaneous nephrostomy (PCN) which were treated during the period 1989-1998. The mean patient age was 41 years (age range: 21-66 years). The reasons for the diversion via nephrostomy catheter were oligoanuria (43 cases), pyonephrosis (34 cases), and evaluation of renal function (four cases). The initial disease was found to be malignant in 23.25% of cases of oligoanuria, with six cancers of the cervix, three bladder cancers and one prostate cancer. Lithiasis was the main etiology in subjects with benign disease, and was the causative factor of oligoanuria in 55.8% and pyonephrosis in 67.6% of cases, i.e., a total of 47 cases (58%). PCN catheter placement was successfully carried out in 100% of cases, and resulted in improved renal function, and/or in the treatment of the initial infectious syndrome in the majority of cases. PCN is an excellent technique for upper urinary tract drainage due to its simplicity, efficacy, ease of insertion, low cost and satisfactory results. It is a minimally invasive technique, which necessitates only the use of a local anesthetic, a sound knowledge of the human anatomy involved, a trained operator and a minimum of material.

Thomson, I. R., G. Harding, et al. (2000). "A comparison of fentanyl and sufentanil in patients undergoing coronary artery bypass graft surgery." J Cardiothorac Vasc Anesth 14(6): 652-6.
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.

Beers, R. A., J. R. Calimlim, et al. (2000). "A comparison of the cost-effectiveness of remifentanil versus fentanyl as an adjuvant to general anesthesia for outpatient gynecologic surgery." Anesth Analg 91(6): 1420-5.
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.

Edomwonyi, N. P., M. O. Obiaya, et al. (2000). "A study of co-induction of anaesthesia U.B.T.H. experience." West Afr J Med 19(2): 132-6.
Co-induction is the concurrent administration of two or more drugs that facilitate induction of anaesthesia. Some combinations have been shown to have pharmacological advantages. In addition to the safety and comfort of the patient, it is also important to find a cost effective combination in view of the rather stringent economy of the times. This project was undertaken to study the response of Nigerian patients to co-induction (midazolam and propofol) by comparison with the traditional thiopentone or propofol alone, and to study the cost implications. 45 patients who came in for various surgical procedures were randomly assigned to three different groups. The first group was induced with thiopentone alone. The second group had a combination of midazolam and propofol and the third group had propofol alone. In all other respects except for the surgery the patients had the same treatment. The induction was satisfactory in all groups. The cardiovascular and respiratory changes were within clinically acceptable limits but the emergence was best with propofol, followed by midazolam/propofol and thiopentone in that order. Although thiopentone was the cheapest in terms of absolute cost, the combination of midazolam and propofol was most cost-effective.

Kendell, J., J. A. Wildsmith, et al. (2000). "Costing anaesthetic practice. An economic comparison of regional and general anaesthesia for varicose vein and inguinal hernia surgery." Anaesthesia 55(11): 1106-13.
A computerised database of operating theatre activity was used to estimate the costs of regional and general anaesthesia for varicose vein and inguinal hernia surgery. Data retrieved for each procedure included the anaesthetic technique and drugs used, and the duration of anaesthesia, surgery and recovery. The costs of anaesthetic drugs and disposables, salary costs of the anaesthetic personnel and maintenance costs for anaesthetic equipment were considered. Drugs and disposables accounted for approximately 25% of the total cost of an anaesthetic. Anaesthetic times were 5 min longer for regional anaesthesia, but recovery times were 10 min shorter following regional anaesthesia for varicose vein surgery. Staff costs were dependent on the length of time each staff member spent with the patient. Although the number of cases was small, provision of a field block and sedation for inguinal hernia repair was considerably cheaper than other anaesthetic techniques.

Biddle, C. (2000). "The cost effectiveness of anesthesia workforce models: the creation of a procrustean bed." Anesth Analg 91(5): 1312-3.

Martin-Sheridan, D. (2000). "The cost effectiveness of anesthesia workforce models: a critique." Anesth Analg 91(5): 1312.

Brodner, G., N. Mertes, et al. (2000). "Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients." Eur J Anaesthesiol 17(9): 566-75.
An acute pain service (APS) was set up to improve pain management after operation. We attempted to reduce the length of stay in the intensive care unit (ICU) of patients undergoing major surgery and to improve their homeostasis and rehabilitation using a multimodal approach (pain relief, stress reduction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus blockade (BPB) was used for surgery of the upper limbs. A computer based documentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management techniques, and (c) cost-effectiveness. Patients receiving PCEA (n = 5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacaine 0.2%, with 1 microg sufentanil mL(-1) added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n = 634) an initial bolus of 7.5-15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was titrated to a dynamic visual analogue scale (VAS) scores < 40. The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5.0 days. In the case of PCEA, the quality of pain relief, vigilance and satisfaction were superior compared with the PCIA method, which resulted in greater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of Euro 91,620 for the year 1998 obviating the need for an ICU stay totalling 433 days. Provided that PCEA is part of a fast-track protocol employing early tracheal extubation and optimal perioperative management, the associated initial higher costs will be recouped by the benefits to patients of better pain relief after surgery and fewer days subsequently spent in the ITU.

Ortega, A., C. Sarobe, et al. (2000). "Cost analysis of neuromuscular blocking agents in the operating room: cisatracurium, atracurium, vecuronium and rocuronium." Pharm World Sci 22(3): 82-7.
Cisatracurium (C), Atracurium (A), Rocuronium (R) and Vecuronium (V) are four neuromuscular blockers (NMB) used in the operating room with similar efficacy, defined as adequate muscle relaxation, but different pharmacokinetics. C and A have organ-independent elimination, A is associated with histamine release and R has a shorter onset time. The objective of this study was to economically compare these four NMB from the hospital point of view in order to facilitate drug selection. A cost analysis was performed. Only direct costs were considered and data were collected through a retrospective chart review. A total of 151 patient charts were randomly selected. Differences between patients receiving one of the four NMB were evaluated by ANOVA or Kruskal-Wallis tests. Then a multiple linear regression analysis was conducted. In the chart review, no significant difference was observed between the four groups of patients in age, weight or surgery duration (p > 0.05). Multiple regression analysis revealed that atracurium was on average PTA 237 (1 Euro = PTA 166) cheaper per surgery than any other NMB after adjusting for other factors (p < 0.01) and there is no significant difference in cost between the other three NMBs (p > 0.1). We recommend the use of rocuronium when a quick onset is needed and the patient does not have hepatic failure, cisatracurium when a haemodynamic instability is possible and atracurium in the remaining cases. If just one NMB can be included in the drug formulary we would select cisatracurium due to its pharmacological advantages over atracurium with a small increment in cost.

Khalfaoui, F., N. Gharbi, et al. (2000). "[Plastic surgery in ambulatory practice]." Tunis Med 78(4): 251-3.
We have analysed 283 patient studies operated of ambulatory during the last two years. These patients represent only 12% of the patient group. It's especially a matter of patients operated urgently. The local anaesthesia in the regional local was practised in terms of 90% of cases. The complications where exceptional. We wanted to insist on the necessary guidelines and pitfalls to forget during the practice of that surgery and we wanted to focus on its advantages.

Vallejo, M. C., G. L. Mandell, et al. (2000). "Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients." Anesth Analg 91(4): 916-20.
This prospective, blinded, randomized study compares the incidence of postdural puncture headache (PDPH) and the epidural blood patch (EBP) rate for five spinal needles when used in obstetric patients. One thousand two women undergoing elective cesarean delivery under spinal anesthesia were recruited. We used two cutting needles: 26-gauge Atraucan and 25-gauge Quincke, and three pencil-point needles: 24-gauge Gertie Marx (GM), 24-gauge Sprotte, and 25-gauge Whitacre. The needle for each weekday was chosen randomly. Cutting needles were inserted parallel to the dural fibers. The incidences of PDPH were, respectively, 5%, 8.7%, 4%, 2.8%, and 3.1% for Atraucan, Quincke, GM, Sprotte, and Whitacre needles (P = 0.04, chi(2) analysis), and the corresponding EBP rates in those with PDPH were 55%, 66%, 12.5%, 0%, and 0% (P = 0.000). The Quincke needle had a more frequent PDPH rate than the Sprotte or the Whitacre needle (P = 0.02) and a more frequent EBP rate than the GM, Sprotte, or the Whitacre needle (P = 0.01). The Atraucan needle had a more frequent EBP rate than the Sprotte or Whitacre needle (P = 0.05). Neither the PDPH rate nor the EBP rates differed among the pencil-point needles. The cost of EBP must be taken into consideration when choosing a spinal needle. We conclude that pencil-point spinal needles should be used for subarachnoid anesthesia in obstetric patients.

Song, D., N. B. Greilich, et al. (2000). "Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy." Anesth Analg 91(4): 876-81.
The use of an ilioinguinal-hypogastric nerve block (IHNB) as part of a monitored anesthesia care (MAC) technique has been associated with a rapid recovery profile for outpatients undergoing inguinal herniorrhaphy procedures. This study was designed to compare the cost-effectiveness of an IHNB-MAC technique with standardized general and spinal anesthetics techniques for inguinal herniorrhaphy in the ambulatory setting. We randomly assigned 81 consenting outpatients to receive IHNB-MAC, general anesthesia, or spinal anesthesia. We evaluated recovery times, 24-h postoperative side effects and associated incremental costs. Compared with general and spinal anesthesia, patients receiving IHNB-MAC had the shortest time-to-home readiness (133+/-68 min vs. 171+/-40 and 280+/-83 min), lowest pain score at discharge (15+/-14 mm vs. 39+/-28 and 34+/-32 mm), and highest satisfaction at 24-h follow-up (75% vs. 36% and 64%). The total anesthetic costs were also the least in the IHNB-MAC group ($132.73+/-33.80 vs. $172.67+/-29.82 and $164.97+/-31.03). We concluded that IHNB-MAC is the most cost-effective anesthetic technique for outpatients undergoing unilateral inguinal herniorrhaphy with respect to speed of recovery, patient comfort, and associated incremental costs.

Suttner, S. and J. Boldt (2000). "Low-flow anaesthesia. Does it have potential pharmacoeconomic consequences?" Pharmacoeconomics 17(6): 585-90.
Healthcare reform has placed increasing pressure on anaesthetists to consider the costs of current anaesthesia strategies. Although the cost of anaesthesia constitutes only a small proportion of total healthcare costs, anaesthetic drug expenditures have been a focus of cost-containment efforts. Low-flow anaesthesia is a simple method of reducing the fresh gas flow rate for anaesthetic gases during inhalational anaesthesia. A knowledge of the pharmacokinetic behaviour of inhaled anaesthetics and the use of modern equipment and monitoring technology meet the requirements for safe application of this anaesthetic technique. Millions of patients receive general anaesthesia each year, and thus the use of this technique could generate substantial savings in anaesthetic drug expenditure without reducing the patient's comfort or increasing adverse events. The new inhaled anaesthetics desflurane and sevoflurane, which have low tissue solubility, provide promising options when used in low-flow anaesthesia. Apart from the economic advantages, low-flow anaesthesia helps to reduce environmental pollution and is associated with several physiological benefits for the patient. Low-flow anaesthesia is a simple but highly effective method of cost minimisation that can be applied to a large number of patients without any compromise in patient care or safety.

McFarlane, M. E. (2000). "Analgesia-sedation for day-case inguinal hernia repair. A review of patient acceptance and morbidity." West Indian Med J 49(2): 158-60.
The objective of this study was to determine whether analgesia-sedation improved patient acceptance of day-case herniorrhaphy and to evaluate the extent of patient morbidity. A total of 98 patients (mean age 34 years, range 17-75 years) were studied before and after herniorrhaphy to determine their response to the procedure. All patients were unpremedicated and underwent herniorrhaphy using a Bassini repair technique with a standard local anaesthetic block. Sedation was obtained with titrated intravenous midazolam(Hypnovel, Roche Products Ltd.) without narcotic analgesia. Patients were evaluated with a simple questionnaire after surgery. The maximum dose of midazolam used was 5 mg (median dose 3.5 mg). Monitoring of vital signs with pulse oximetry during the operative period was routine though oxygen therapy was not required. All patients were able to walk without assistance and were discharged under responsible supervision. Operative morbidity was low (5%). Adverse reactions to the procedure such as nausea, vomiting and headache were not seen. In conclusion, conscious sedation allows amnesia to be achieved with low morbidity in the majority of patients undergoing local anaesthetic procedures. This should result in increased patient acceptance.

Eger, E. I., P. F. White, et al. (2000). "Clinical and economic factors important to anaesthetic choice for day-case surgery." Pharmacoeconomics 17(3): 245-62.
Clinical and economic factors that are important to consider when selecting anaesthesia for day-case surgery can differ from those for inpatient anaesthesia. Patients undergoing day-case surgery tend to be healthier and have shorter durations of surgery. They expect less anxiety before surgery, amnesia for the surgical experience, a rapid return to normal (normal mentation with minimal pain and nausea) after surgery, and lower expenses. However, the latter 2 expectations can conflict; older generic drugs have lower acquisition costs but often impose longer recovery times. Longer recovery periods can increase costs by prolonging the time to discharge from labour-intensive areas such as the operating suite or the post-anaesthesia recovery unit. The challenge for today's anaesthetist is to use newer drugs judiciously to minimise their expense without compromising the rate or quality of recovery. Several approaches can secure these aims. Most apply the least anaesthetic needed. 'Least anaesthetic' may mean the particular form of anaesthetic (e.g. local infiltration with monitored anaesthesia care versus a general anaesthetic), or may mean the delivery of the smallest effective dose, perhaps guided by anaesthetic monitors such as end-tidal analysers or the bispectral index. For patients requiring general anaesthesia, a combination of several drugs usually secures the closest approach to the ideal. Drug combinations used usually include a short-acting properative anxiolytic (e.g. midazolam), intravenous propofol (a short-acting potent anxiolytic and amnestic agent) for induction of anaesthesia (and sometimes for maintenance) and primary maintenance of anaesthesia with inhaled nitrous oxide combined with a poorly soluble (low solubility produces rapid recovery; the least soluble is desflurane) potent inhaled anaesthetic delivered at a low inflow rate (to minimise cost). Although old, nitrous oxide is inexpensive and has favourable pharmacokinetic and cardiovascular advantages; however, it is limited in its anaesthetic/amnestic potency, and has the capacity to increase nausea. In children, induction of anaesthesia is often accomplished with sevoflurane rather than desflurane; although sevoflurane is modestly more soluble than desflurane, it is non-pungent whereas desflurane is pungent. Moderate- or short-acting opioids (fentanyl is popular) or nonsteroidal anti-inflammatory agents (especially ketorolac), or local anaesthetics are added to secure analgesia during and after surgery. Similarly, when needed, moderate- or short-acting muscle relaxants are selected. Before the end of anaesthesia, an intravenous antiemetic may be given. With this drug combination, patients usually awaken within minutes after anaesthesia and can often move themselves to the vehicle for transport to the recovery unit. These combinations of anaesthetics and techniques minimise use of expensive drugs while expediting recovery (again minimising cost) with minimal or no compromise in the quality of recovery.

Morris, K. T., R. F. Pommier, et al. (2000). "Office-based wire-guided open breast biopsy under local anesthesia is accurate and cost effective." Am J Surg 179(5): 422-5.
BACKGROUND: Mammographic abnormalities found to be malignant by stereotactic biopsy still require a wire-guided biopsy (WGB) in most cases. We have previously described a simplified method of WGB that allows the procedure to be done with a minimum of dissection and under local anesthesia in the office setting. We hypothesized that this procedure can be used to produce cost-effective, office-based breast preservation therapy (BPT). METHODS: We reviewed our recent experience with this WGB method to determine applicability and accuracy in the office setting. A cost-effectiveness analysis was also performed to determine potential charge reductions when this method is used to avoid operating room (OR) usage for either lumpectomy or lumpectomy plus sentinel lymph node biopsy (SLNB). RESULTS: Of the 164 biopsies reviewed, 114 (70%) were performed in the office setting under local anesthesia and 50 (30%) were performed in the OR. The most common reasons for choosing the OR setting included performance of biopsy during an unrelated procedure requiring the OR (16 cases), patient preference (12), deep lesions (6), and the inability of the patient to cooperate with local anesthesia (5). The complication rates were similar between the two settings (7% for office-based and 4% for OR; P = 0.697), and in neither setting were any lesions missed. A cost-effectiveness analysis using our Current Procedure Terminology (CPT)-based charges revealed a potential per-case charge reduction of $4,632 for office-based lumpectomy and $4306 for office-based lumpectomy/SLNB, using our method of WGB and local anesthesia, compared with the OR setting. CONCLUSIONS: Office-based WGB using our previously described method is accurate and can be applied to at least 70% of patients. Based on the favorable results of our cost analysis and rising support for SLNB, we anticipate increased utilization of the clinic setting and local anesthesia for BPT in the future.

Baum, J., B. Sievert, et al. (2000). "[Nitrous oxide free low-flow anesthesia]." Anaesthesiol Reanim 25(3): 60-7.
The routine use of nitrous oxide as a component of the carrier gas has been unanimously called into question in recent surveys, in fact, its use is now recommended in indicated cases only. Whereas a lot of contraindications are listed in the surveys, precise definitions of justified indications are not given. In clinical routine practice, there are absolutely no problems in carrying out inhalational anaesthesia without nitrous oxide. The missing analgetic effect can be compensated for by moderately increasing the additively used amount of opioids, while the missing hypnotic effect can be achieved by raising the expired concentration of the inhalational anaesthetic by not more than 0.2-0.25 x MAC. Thus, when isoflurane is used, an expired concentration of 1.2 vol% is desired, in the case of sevoflurane of 2.2 vol% and with desflurane of 5.0 vol%. In addition, doing without nitrous oxide facilitates the performance of low flow anaesthetic techniques considerably. Since the patient only inhales oxygen and the volatile anaesthetic, the total gas uptake is reduced significantly. Washing out nitrogen is no longer necessary. This means that the initial phase of low flow anaesthesia, during which high fresh gas flows have to be used, can be kept short. Its duration is now determined by the wash-in of the volatile anaesthetic. Since there is no uptake of nitrous oxide, a considerably greater volume of gas is circulating within the breathing system, minimizing the possibility of accidental gas volume deficiency. Thus, if anaesthesia machines with highly gas-tight breathing systems are used, even the performance of non-quantitative closed system anaesthesia becomes possible in routine clinical practice. The carrier gas flow can be reduced to just that amount of oxygen which is really taken up by the patient. This oxygen volume can be roughly calculated by applying the Brody's formula. Using fresh gas flows as low as 0.25 l/min, however, will result in a significant decrease of the output of conventional vaporizers outside the circuit. Thus, it becomes nearly impossible to maintain an expired isoflurane concentration of 1.2 vol%. With respect to their pharmcokinetic properties, the newer low soluble volatile agents sevoflurane and desflurane are better suited for use with flows corresponding to the basal oxygen uptake. Our own clinical experience, gained in the last six months from a trial involving over 1,800 patients, shows that the increase in opioid consumption resulted in additional costs of about 0.25-0.50 DM per patient. The increased concentration of inhalational agents brought additional costs of 3.00 to 5.00 DM for a two-hour anaesthesia. On the other hand, doing without nitrous oxide saved 2.61 DM per one-hour anaesthesia, whereby our consumption of nitrous oxide is extremely low as minimal flow anaesthesia is performed consistently. Furthermore, these calculations disregard the cost of the technical maintenance fo the central gas piping system and of the regular measurement of workplace contamination with nitrous oxide by a certified institute, which in Germany, ad least, is obligatory. The additional costs of nitrous oxide-free inhalational anaesthesia seem to be balanced by the savings. Given the numerous justified arguments against the routine use of nitrous oxide, the lack of precisely-defined indications and the clinical experience showing that doing without nitrous oxide is uncomplicated, self-financing and ecologically beneficial, the use of nitrous oxide should be given up completely.

Fernandez-Gonzalez, F., F. Seijo, et al. (2000). "[Neurophysiological monitoring in the treatment of pain]." Rev Neurol 30(6): 567-76.
INTRODUCTION: The concept of transynaptic deafferentation secondary to a lesion is the basis of the therapeutic criteria of functional neurosurgery. DEVELOPMENT: Pain due to deafferentation requires clinical neurophysiological techniques for characterization, and when appropriate, for localization of the level of the lesion and the ectopic focus or foci which cause the pain syndrome. However, monitoring therapeutic interventions in the pain clinic is an ever increasing need, and obliges the clinical neurophysiologist to master the range of techniques involved in his specialty, so that he can use the most suitable techniques and methods as required by each condition and/or case. The use of techniques such as micro-recordings of the unitary or multiunitary activity of the nerves or nuclei, intracerebral evoked potentials, nociceptive evoked potentials, reflexology, polysomnography and topography, together with techniques such as percutaneous objective localization of deep nerves, allows quantitative evaluation pre-, intra- and postoperative. CONCLUSION: The development of neuromodulation, and in particular of acute or long-term neurostimulation by use of percutaneous techniques, offers an effective therapeutic option in the field of clinical neurophysiology.

Whyman, R. A. (2000). "Dental care for children under general anaesthesia by private dental practitioners in New Zealand." N Z Dent J 96(423): 14-7.
An overall reduction of approximately one-third in the availability of private dental care under general anaesthesia in New Zealand has occurred in the past 5 years. Private dentists providing dental care under general anaesthesia are disproportionately located in Auckland. Specialist anaesthetists or general medical practitioners are used to provide almost all the general anaesthetics; approximately half the dentists providing this service continue to use their dental surgeries for the procedure. Private dentists provide approximately one-third of the dental care under general anaesthesia for children each month in New Zealand, but utilise a greater number of sessions per month than the public-sector hospitals. Fees associated with dental care under general anaesthesia for children provided by private dentists are predominantly privately funded. Barriers to dental care for children provided by private dentists are primarily cost, difficulties for the dentists and anaesthetists to fit a general anaesthetic session into the practising day, and difficulties providing care for children under 3 years of age and for those with medical problems and disabilities.

Suttner, S., J. Boldt, et al. (2000). "Economic aspects of different muscle relaxant regimens." Anasthesiol Intensivmed Notfallmed Schmerzther 35(5): 300-5.
OBJECTIVE: At a time of cost reduction in medical care efforts to manage the ever-increasing costs of new pharmaceutical drugs become increasingly important. Costs of four different muscle relaxant regimens including the new intermediate-acting neuromuscular blocking drugs (NMBD) cisatracurium and rocuronium will be analyzed. METHODS: Eighty patients undergoing laparoscopic cholecystectomy were prospectively studied. All patients received standardized general anaesthesia with desflurane/fentanyl. Muscle relaxation was achieved with atracurium, cisatracurium, vecuronium, or rocuronium with 20 patients in each group. Intraoperatively muscle relaxants were added to maintain two twitches of the train-of-four (TOF) assessment. RESULTS: There were no differences among the four groups regarding biometric data, duration of surgery and anesthesia, number of patients with reversal of neuromuscular blockade, and time of extubation. Length of stay in the postanesthesia care unit (PACU) and the incidence of side effects were similar in all groups. Total costs of used drugs were significantly lowest in the atracurium-treated patients (per patient: 18.27 Euro) and significantly highest in the cisatracurium group (26.71 Euro) compared with the other groups (vecuronium: 22.61 Euro; rocuronium: 22.63 Euro). CONCLUSION: It is summarized that the use of cisatracurium was associated with higher costs compared to a standard muscle relaxant regimen using atracurium, whereas patient outcome was the same in all study groups. The routine use of the newer NMBDs can only be justified economically, if considerable improvements to clinical practice can be demonstrated.

Movaghar, M., S. Kodsi, et al. (2000). "Probing for nasolacrimal duct obstruction with intravenous propofol sedation." J Aapos 4(3): 179-82.
BACKGROUND: Nasolacrimal duct obstruction occurs in 5% to 6% of neonates. Many studies advocate the probing of nasolacrimal duct obstruction under general inhalational anesthesia in patients at a late age (12 to 13 months) because a high percentage will resolve spontaneously. Others support early surgical intervention in patients aged younger than 6 to 9 months without anesthesia. We present late nasolacrimal duct probing under intravenous propofol sedation as an alternative approach to the treatment of nasolacrimal duct obstruction with a decrease in cost and time compared with probing under general inhalational anesthesia. METHODS: We made a retrospective review of patient charts of children who underwent nasolacrimal duct probing with intravenous propofol sedation from April 1996 to September 1997. Procedure time and cost of procedure were compared for patients who had probings under propofol sedation to patients who had probings under general anesthesia. RESULTS: A total of 22 patients (31 eyes) underwent nasolacrimal duct probing with propofol sedation; the patients' ages ranged from 11.5 to 39 months (average age, 17.8 months). Twenty-six (84%) of 31 eyes had resolution of the symptoms. The average total time for procedure under propofol sedation was 10.5 minutes, compared with 43.6 minutes under general inhalational anesthesia. The average total recovery time under propofol sedation was 13.6 minutes, compared with 121.1 minutes with general inhalational anesthesia. The cost of probing under propofol sedation was one third less than the cost of probing under general inhalational anesthesia. DISCUSSION: Late probing for nasolacrimal duct obstruction under intravenous propofol sedation is comparable in efficacy to late probing under general inhalational anesthesia with a shorter time for the procedure and decreased expense.

Petrou, S., D. Coyle, et al. (2000). "Cost-effectiveness of a delayed pushing policy for patients with epidural anesthesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group." Am J Obstet Gynecol 182(5): 1158-64.
OBJECTIVE: The purpose of this study was to estimate the economic efficiency of a policy of delayed pushing for nulliparous women who have full dilatation while they are under epidural anesthesia.Study Design: A cost-effectiveness evaluation was based on a randomized controlled trial. Resource use and clinical effectiveness data were collected for 1862 women who were randomly allocated to either a delayed pushing group (n = 936) or an early pushing group (n = 926). Costs (in 1997 Canadian dollars) were collected for each item of resource use. Sensitivity analysis was used to examine the robustness of the main results. RESULTS: Delayed pushing was effective at reducing the number of difficult deliveries (relative risk, 0.79; 95% confidence interval, 0.66 to 0.95). The mean cost of intrapartum care was significantly higher in the delayed pushing group ($625.86 vs $557.64; P <.0005). There were no significant differences in mean costs of postnatal care ($2146.67 vs $2133.54; P =.871) or total hospital care ($2772.53 vs $2691.18; P =.324). The incremental cost per difficult delivery prevented was estimated at $1743.06. The incremental cost-effectiveness ratio remained fairly robust with variations in the values of key parameters incorporated into the sensitivity analysis. CONCLUSIONS: The results of this economic evaluation should inform decision makers determining whether to advocate a policy of delayed pushing for nulliparous women who have full dilatation while they are under epidural anesthesia.

Absalom, A. and A. Troy (2000). "Costs of sevoflurane and propofol anaesthesia." Br J Anaesth 84(3): 417-8.

Lake, C. L. (2000). "Fast tracking the paediatric cardiac surgical patient." Paediatr Anaesth 10(3): 231-6.

Miguel, R. (2000). "Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder?" Cancer Control 7(2): 149-56.
BACKGROUND: For most patients with cancer pain, the World Health Organization's three-step analgesic ladder provides adequate management with oral or transdermal options. However, some cancer patients are not well palliated with these approaches. METHODS: The author reviews interventional options that include nerve blocks, spinal administration of local anesthetics, opioids, alpha-2 agonists, spinal cord stimulation, and surgical interventions. RESULTS: Numerous interventional options are readily accessible and most can be performed on an outpatient basis. They can be used as sole agents for the control of cancer pain or as useful adjuncts to supplement analgesia provided by opioids, thus decreasing opioid dose requirements and side effects. CONCLUSIONS: Cancer-related pain can be controlled with several interventions when oral or transdermal opioids are inadequate. A risk:benefit ratio should be considered before implementing invasive analgesic methods.

Rozenberg, P., F. Goffinet, et al. (2000). "External cephalic version with epidural anaesthesia after failure of a first trial with beta-mimetics." Bjog 107(3): 406-10.
OBJECTIVE: To assess the efficacy, tolerance, and cost of external version under epidural anaesthesia and beta-mimetic tocolysis after the failure of an initial attempt with tocolysis alone. DESIGN: Prospective open study. PARTICIPANTS: Sixty-eight women with breech presentation at around 36 weeks of gestation and an attempted external cephalic version under salbutamol that failed, who consented to try a second attempt under epidural anaesthesia. RESULTS: The overall success rate under epidural anaesthesia was 39.7% (27/68), and complications occurred in two cases. The total cost of attempting external version was higher than the cost of expectant management. CONCLUSIONS: The efficacy of external cephalic version under epidural reduces the rate of caesarean sections associated with breech presentation, but its relative safety remains in question. Moreover, our economic analysis discourages the hope of lowered costs suggested by earlier reports that this technique is more expensive than expectant management, except in institutions with a policy of systematic caesarean sections when version fails.

Kanellis, M. J., P. C. Damiano, et al. (2000). "Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia." J Public Health Dent 60(1): 28-32.
OBJECTIVE: This paper examines the cost to the Iowa Medicaid program of hospitalizing young children for restorative dental care under general anesthesia, and describes the dental services received in this setting. METHODS: Medicaid dental claims for young children receiving restorative dental care under general anesthesia during fiscal year 1994 were matched with corresponding hospital and anesthesia claims. RESULTS: The total cost to the Medicaid program of treating a child in the hospital under general anesthesia was $2,009 per case. Less than 2 percent of Medicaid-enrolled children under 6 years of age who received any dental service accounted for 25 percent of all dollars spent on dental services for this age group, including hospital and anesthesia care. The most frequent type of procedure was stainless steel crowns (SSCs), with an average of almost six per case. CONCLUSIONS: Early identification, prevention, and intervention are critically important to prevent the costly treatment of children with ECC in hospital operating rooms.

Kovac, A. L. (2000). "Prevention and treatment of postoperative nausea and vomiting." Drugs 59(2): 213-43.
Pain, nausea and vomiting are frequently listed by patients as their most important perioperative concerns. With the change in emphasis from an inpatient to outpatient hospital and office-based medical/surgical environment, there has been increased interest in the 'big little problem' of postoperative nausea and vomiting (PONV). Currently, the overall incidence of PONV is estimated to be 25 to 30%, with severe, intractable PONV estimated to occur in approximately 0.18% of all patients undergoing surgery. PONV can lead to delayed postanaesthesia care unit (PACU) recovery room discharge and unanticipated hospital admission, thereby increasing medical costs. The aetiology and consequences of PONV are complex and multifactorial, with patient-, medical- and surgery-related factors. A thorough understanding of these factors, as well as the neuropharmacology of multiple emetic receptors [dopaminergic, muscarinic, cholinergic, opioid, histamine, serotonin (5-hydroxy-tryptamine; 5-HT)] and physiology [cranial nerves VIII (acoustic-vestibular), IX (glossopharyngeal) and X (vagus), gastrointestinal reflex] relating to PONV are necessary to most effectively manage PONV. Commonly used older, traditional antiemetics for PONV include the anticholinergics (scopolamine), phenothiazines (promethazine), antihistamines (diphenhydramine), butyrophenones (droperidol) and benzamides (metoclopramide). These antiemetics have adverse effects such as dry mouth, sedation, hypotension, extrapyramidal symptoms, dystonic effects and restlessness. The newest class of antiemetics used for the prevention and treatment of PONV are the serotonin receptor antagonists (ondansetron, granisetron, tropisetron, dolasetron). These antiemetics do not have the adverse effects of the older, traditional antiemetics. Headache and dizziness are the main adverse effects of the serotonin receptor antagonists in the dosages used for PONV. The serotonin receptor antagonists have improved antiemetic effectiveness but are not as completely efficacious for PONV as they are for chemotherapy-induced nausea and vomiting. Older, traditional antiemetics (such as droperidol) compare favourably with the serotonin receptor antagonists regarding efficacy for PONV prevention. Combination antiemetic therapy improves efficacy for PONV prevention and treatment. In the difficult-to-treat PONV patient (as in the chemotherapy patient), suppression of numerous emetogenic peripheral stimuli and central neuroemetic receptors may be necessary. This multimodal PONV management approach includes use of: (i) multiple different antiemetic medications (double or triple combination antiemetic therapy acting at different neuroreceptor sites); (ii) less emetogenic anaesthesia techniques; (iii) adequate intravenous hydration; and (iv) adequate pain control.

Lee, J. Y., W. F. Vann, et al. (2000). "A cost analysis of treating pediatric dental patients using general anesthesia versus conscious sedation." Pediatr Dent 22(1): 27-32.
PURPOSE: The purpose of this pilot study is to report a cost comparison of general anesthesia (GA) versus oral conscious sedation (CS) for the treatment of pediatric dental patients. METHODS: The study sample included 22 children whose parents/guardian selected GA care for their child. Selection criteria limited inclusion to healthy children (ASA I) ages 24-60 m.o. The subjects acted as their own comparison group to an estimation CS model. Models were developed to assess societal costs for treatment under GA and CS. Treatment rendered was equalized using the dental Relative Based Value Units Scale (RBVU). RESULTS: Ordinary Least Squares Regression analysis techniques showed the association of RBVU to the total societal costs of GA and CS to be significant (P < 0.01) with an adjusted R2 of .64 and .78 respectively. When regression lines were plotted, the intersection represented RBVU level at which societal costs of GA and CS were the same. CONCLUSION: Under the conditions of this pilot study, it is concluded that CS costs exceed GA costs at a RBVU level of 66.4, which would equate to more than three CS appointments.

Saidman, L. J. (2000). "Inappropriate statements can lead to misleading conclusions." Anesth Analg 90(3): 765-6.

Glance, L. G. (2000). "The cost effectiveness of anesthesia workforce models: a simulation approach using decision-analysis modeling." Anesth Analg 90(3): 584-92.
The objective of this study was to evaluate the incremental cost effectiveness of anesthesia workforce staffing scenarios, as a function of skill mix, by using the technique of decision analysis. A decision tree model was constructed to compare the incremental cost effectiveness of alternative delivery systems for anesthesia care from the perspective of the payer. Five different staffing scenarios, ranging from physician-intensive to nurse-intensive, were modeled. In the nurse-intensive model, low- and intermediate-risk patients were cared for by solo certified registered nurse anesthetists (CRNAs) and high-risk patients were cared for by physicians. In the physician-intensive model, physicians anesthetized all patients. In the first-, second-, and third-team models, all high-risk patients were cared for by physicians working alone, and all intermediate-risk patients were cared for using an anesthesia care team approach with a ratio of one physician to two CRNAs. The low-risk patients were managed by using an anesthesia care team approach with physician to CRNA ratios of 1:2, 1:4, and 1:8 in the first-, second-, and third-team models, respectively. The findings of this decision-analysis model suggest that physician-only anesthesia is not cost effective. However, the third-team model is cost effective when compared with the nurse-intensive model. IMPLICATIONS: An anesthesia care-team approach with a physician to certified registered nurse anesthetist (CRNA) ratio of 1:2 is the preferred staffing scenario for intermediate-risk patients. Although medical direction of CRNAs caring for low-risk patients is cost-effective, the small improvement in outcome resulting from increasing the physician to CRNA ratio from 1:8 to 1:4 may not be justified by the added cost.

Heidvall, M., A. Hein, et al. (2000). "Cost comparison between three different general anaesthetic techniques for elective arthroscopy of the knee." Acta Anaesthesiol Scand 44(2): 157-62.
INTRODUCTION: We compared three anaesthetic techniques for elective knee arthroscopy with special reference to cost-effectiveness. METHOD: Seventy-five ASA I-II patients having elective arthroscopy of the knee joint were randomised to receive an anaesthetic technique based on propofol, fentanyl for induction followed by sevoflurane in oxygen:nitrous oxide (1:2 l/min) for maintenance of one of two intravenous techniques: propofol alfentanil or propofol-remifentanil infusions in combination with oxygen in air. RESULTS: All patients had an uncomplicated course. No differences were seen with regard to emergence, postoperative pain or emesis or time to discharge. The anaesthetic technique based on sevoflurane was associated with the lowest cost US$ 14.7 as compared to US$ 18 for the propfol/alfentanil and US$ 19.9 for the propofol/remifentanil technique, including both cost for wastage as well as premedication and other fixed drug costs. Looking only at the anaesthetic drugs consumed, the cost per minute was US$ 0.56 for sevoflurane/nitrous oxide as compared to US$ 0.68 and 0.63 per minute for the propofol/alfentanil and proprofol/remifentanil, respectively. When the cost for wastage was taken into account, the difference in mean anaesthetic drug cost was more pronounced: the sevoflurane anaesthetic technique US$ 0.58, the propofol/alfentanil US$ 0.74 and the propofol/remifentanil US$ 0.84 per minute respectively. CONCLUSION: From a cost-minimisation point of view, anaesthesia based on sevoflurane in oxygen:nitrous oxide is the technique of choice.

Vassilopoulos, P. P. and N. Kelessis (2000). "Continent gastrostomy." J Surg Oncol 73(2): 115-6.

Meurisse, M. (1999). "[Thyroid and parathyroid surgery under hypnosis: from fiction to clinical application]." Bull Mem Acad R Med Belg 154(2): 142-50; discussion 150-4.
Since 1992, we have used hypnosis routinely in more than 1400 procedures in plastic surgery. Our clinical success and experience with this technique led us to test wether hypnosis using active patient collaboration, could be used as an effective adjunct to conscious intravenous sedation ("hypnosedation", (HS)) for endocrine surgery, as an alternative to general anaesthesia. On a total of 1905 cervical endocrine surgical procedures performed between 1995 and 1998, 296 thyroidectomies and 33 cervical explorations for hyperparathyroidism were conducted under HS. Conversion to GA was needed in three cases (0.9%). All patients having HS reported a very pleasant experience and had significantly less postoperative pain while analgesic use was significantly reduced in this group. Hospital stay was also significantly shorter, providing a substantial reduction of the costs of medical care. The postoperative convalescence was significantly improved after HS and full return to social or professional activity was significantly shortened. We conclude that HS is a very efficient technique that provide physiological, psychological and economic benefits to the patient.

Smith, I., P. A. Terhoeve, et al. (1999). "A multicentre comparison of the costs of anaesthesia with sevoflurane or propofol." Br J Anaesth 83(4): 564-70.
Day-case anaesthesia requires rapidly eliminated anaesthetics which are relatively expensive. This multinational, multicentre European study assessed the relative costs of propofol or sevoflurane anaesthesia in 211 patients. Anaesthesia was induced and maintained with propofol in group 1, with propofol and sevoflurane in group 2, and with sevoflurane in group 3. Drug and delivery costs were calculated in US$. Induction of anaesthesia was fastest in groups 1 and 2, although spontaneous ventilation resumed earliest in group 3. Emergence times and times at which patients were fit for discharge were similar in all groups. Group 2 had the lowest costs based on actual drug use (mean $14.2 (SEM 0.8) vs $18.7 (0.8) and $17.3 (0.8) in groups 1 and 3, respectively). Anaesthetic drug wastage and disposable costs were highest in group 1 and lowest in group 3. Consequently, total costs were highest in group 1 ($31.9 (0.9)) compared with groups 2 ($19.7 (0.9)) and 3 ($18.8 (0.9)). Although we observed increased nausea and vomiting in groups 2 and 3 and reduced patient satisfaction in group 3, these differences should be balanced against the greater cost of propofol anaesthesia.

Crozier, T. A. and D. Kettler (1999). "Cost effectiveness of general anaesthesia: inhalation vs i.v." Br J Anaesth 83(4): 547-9.

Biacabe, B., O. Laccourreye, et al. (2000). "[Replacement of tracheo-esophageal Provox prosthesis]." Ann Otolaryngol Chir Cervicofac 117(1): 34-9.
OBJECTIVES: To compare anesthesic techniques used between 1992 and 1997 at Laennec Hospital for replacement by tracheo-esophageal Provox prosthesis: local and general anesthesia. Theoretical financial cost for replacement was estimated according to anaesthetic techniques. PATIENTS AND METHODS: Provox in situ lifetime was calculated in 58 patients who underwent 115 and 49 replacements under general and local anaesthesia respectively. Age, sex, surgical and radiotherapy backgrounds, complications and anaesthetic techniques were studied as potential factors correlated with Provox in situ lifetime. Theoretical financial cost for replacement was estimated according to anaesthetic techniques. RESULTS: In 1992, 12% of Provox prosthesis were inserted under local anaesthesia and 54% in 1997. Provox in situ lifetime was either not influenced by anaesthetic techniques or other factors under analysis. The theoretical financial cost was estimated at 14, 341 FFrs and 6,048 FFrs for replacement under general and local anaesthesia respectively. CONCLUSION: Due to increased control of health care costs, we advocated local anaesthesia for Provox prosthesis replacement if control endoscopy is not required.

Lindheim, S. R., S. Kavic, et al. (2000). "Operative hysteroscopy in the office setting." J Am Assoc Gynecol Laparosc 7(1): 65-9.
STUDY OBJECTIVE: To describe the feasibility of operative hysteroscopy in the office setting. DESIGN. Descriptive study (Canadian Task Force classification II-2). SETTING: University-based private practice. PATIENTS: Women undergoing assisted reproduction in whom diagnostic evaluation revealed uterine cavity pathology. INTERVENTION: Patients were offered office hysteroscopy and allowed to choose between paracervical block anesthesia supplemented with mild intravenous sedation or full conscious sedation, administered by an anesthesiologist. A MicroSpan Hysteroscopy system or HysteroSys Flexible Hysteroscope system was used for diagnostic purposes. When pathology was identified, resection was performed with 2-mm operative instruments or a VersaPoint hysteroscopic electrosurgical electrode using bipolar coagulation through an expandable operating channel. MEASUREMENTS AND MAIN RESULTS: Of 69 women with abnormal sonohysterographic and hysterosalpingogram studies, 44 agreed to office hysteroscopy. Thirty-three (48%) underwent VersaPoint resection and/or scissors resection, which was successfully accomplished in 32 (97%). Significant cervical stenosis in one woman precluded resection because of concern of creating a false passage. Concomitant diagnostic laparoscopy and operative hysteroscopy was performed in one patient. Average operating and anesthesia times were 45.2 +/- 20.3 minutes and 67.2 +/- 28.4 minutes, respectively. One uterine perforation occurred (3.3%) during resection of intrauterine adhesions. CONCLUSION: Office hysteroscopy is a time-efficient and cost-effective procedure, made possible by the development of small instruments. Proper patient selection and training of office personnel are mandatory to minimize complications and maximize efficacy.

Harman, D. M. (2000). "Combined sedation and topical anesthesia for cataract surgery." J Cataract Refract Surg 26(1): 109-13.
PURPOSE: To determine whether lidocaine jelly is as efficacious as tetracaine drops for obtaining ocular anesthesia and to evaluate sublingual lorazepam as premedication for sedation in cataract surgery. SETTING: An ambulatory surgical center dedicated to ophthalmic surgery. METHODS: The study was divided into 2 phases. In the first, 100 patients were divided into 2 groups of 50 each. The first group received tetracaine 0.5% drops for anesthesia. The second group received lidocaine 2% jelly for topical anesthesia. In the second stage, 100 patients were divided into 2 groups of 50 each. The first 50 patients were given 1 mg of sublingual lorazepam before surgery. The second group had cataract surgery without sublingual lorazepam. All patients were operated on by the same surgeon in an ambulatory surgical center. The technique was temporal clear corneal cataract surgery with foldable intraocular lens implantation. Exclusions from the study were the need to convert to peribulbar or retrobulbar anesthesia, intraocular complications, and altered mental status. RESULTS: In the first phase of the study, lidocaine 2% jelly was as efficacious as tetracaine 0.5% drops for topical anesthesia in cataract surgery. In the second phase of the study, overall, patients in the lorazepam group had less anxiety, greater amnesia, and lower blood pressure than those not receiving lorazepam as sedation for topical anesthesia. CONCLUSIONS: Lidocaine 2% jelly combined with sublingual lorazepam provided excellent cost-effective anesthesia and sedation for topical anesthesia in cataract surgery and enhanced patient satisfaction with the procedure.

Daggan, R., A. Zefeiridis, et al. (1999). "High-quality filtration allows reuse of anesthesia breathing circuits resulting in cost savings and reduced medical waste." J Clin Anesth 11(7): 536-9.
STUDY OBJECTIVES: To determine if the new Filta-Therm filter prevents contamination and allows the reuse of breathing circuit with considerable cost and environmental savings. DESIGN: Prospective study. PATIENTS: 52 ASA physical status I, II, III, and IV patients, aged 18 to 75 years. INTERVENTIONS: Each morning a new breathing circuit was assembled. The Filta-Therm filter (Intersurgical, Inc., Liverpool, NY) elbow, and mask, but not the circuit, were changed between patients. The filter was placed between the Y-piece and the elbow of the breathing circuit. Prior to anesthesia, samples were obtained at the Y-piece, and the inspiratory and expiratory ports of breathing circuit. Following anesthesia, samples were obtained at the Murphy eye of endotrachael tube, and at the Y-piece. The samples were incubated, and the results examined at 24 and 48 hours. MEASUREMENTS AND MAIN RESULTS: Prior to anesthesia, cultures of the Y-piece and the inspired and expired ports samples showed no growth. Following anesthesia, all 52 samples obtained at the endotracheal tube were contaminated with various organisms, while all 52 Y-piece samples showed negative growth. CONCLUSIONS: The single use of Filta-Therm filter prevents bacterial contamination and allows reuse of breathing circuit at least twice, resulting in significant cost savings ($50,778 per year). Further studies are needed to establish the safety of reusing breathing circuits when appropriate bacterial filters are used.

Hess, D. (1999). "Filters and anesthesia breathing circuits: can we cut costs without harm?" J Clin Anesth 11(7): 531-3.

Cold, C. J. and R. S. Van Howe (1999). "Re: Postneonatal circumcision with local anesthesia: a cost-effective alternative." J Urol 162(6): 2104-5.

Ries, C. R., A. Azmudeh, et al. (1999). "Cost comparison of sevoflurane with isoflurane anesthesia in arthroscopic menisectomy surgery." Can J Anaesth 46(11): 1008-13.
PURPOSE: To determine the "real world" cost of sevoflurane compared with isoflurane in balanced general anesthesia for daycare arthroscopic menisectomy, we prospectively investigated perioperative drug requirement and expense as well as recovery time. METHODS: Following intravenous induction, 40 consenting adult patients randomly received either sevoflurane- or isoflurane-based anesthesia with a standardized gas inflow rate of 3 l x min. Recovery was assessed in the postanesthetic recovery room (PARR) in a double-blind manner at 15 min intervals using the Aldrete scoring system until patients met discharge criteria. RESULTS: Patient demographics, anesthetic duration, volatile potency and adjunct drug requirements were similar in the two groups. Total perioperative drug cost per patient was CAN$38.10+/-10.13 (mean +/- SD) for the sevoflurane group and $23.87+/-6.59 for the isoflurane group (P<0.01). Although the nonvolatile drug cost was comparable between the two groups, the volatile drug cost per patient was $19.40+/-8.80 for sevoflurane and $4.50+/-1.90 for isoflurane (P<0.01). This four-fold sevoflurane-to-isoflurane cost difference was the product of two ratios, both based on the volume of liquid anesthetic: the ratio of consumption, 2.1; and the ratio of institutional price, 2.1. Intraoperative hemodynamic response, time until discharge from the PARR and incidences of postoperative nausea and vomiting did not significantly differ between the two groups. CONCLUSIONS: When used to maintain equipotent balanced general anesthesia for daycare arthroscopic menisectomy, volatile consumption and cost were greater for sevoflurane compared with isoflurane. Nonvolatile perioperative drug cost and recovery times were similar, however, in the two groups.

Dexter, F., A. Macario, et al. (1999). "Forecasting surgical groups' total hours of elective cases for allocation of block time: application of time series analysis to operating room management." Anesthesiology 91(5): 1501-8.
BACKGROUND: Allocation of the correct amount of operating room (OR) "block time" can provide surgeons with access to sufficient OR time to complete their elective cases while optimally matching staffing with the elective case workload (to maximize labor productivity). To evaluate how to predict accurately total hours of elective cases performed by a surgical group using data from surgical services information systems, the authors addressed the following questions: (1) How many previous 4-week periods of data should be used to minimize error in forecasting a surgical group's total hours of elective cases? (2) Using the number of 4-week periods from question #1, can we detect trends or correlations between successive periods that could be used to improve forecasting accuracy? (3) How can results from questions #1 and #2 be used to calculate an upper prediction bound (upper limit) for the total hours of elective cases that will be completed in a future period? Prediction bounds can be used to budget staffing accurately. METHODS: Time series analysis was performed on total hours of elective cases over 39 consecutive 4-week periods from 17 surgical groups. RESULTS: The average of 12 consecutive periods' total hours of elective cases had an appropriate error profile. The observations within each series of 12 consecutive 4-week periods followed a normal distribution, with each observation of total hours of elective cases not correlated with the subsequent observation. CONCLUSIONS: The average of the most recent 12 4-week periods can be used to predict surgical groups' future use of block time.

Bay-Nielsen, M., M. S. Knudsen, et al. (1999). "[Cost analysis of inguinal hernia surgery in Denmark]." Ugeskr Laeger 161(38): 5317-21.

Nakata, Y., T. Goto, et al. (1999). "Cost analysis of xenon anesthesia: a comparison with nitrous oxide-isoflurane and nitrous oxide-sevoflurane anesthesia." J Clin Anesth 11(6): 477-81.
STUDY OBJECTIVE: To determine the cost of xenon (Xe) anesthesia in relation to the anesthetic duration by conducting a cost analysis of this relatively expensive inhaled anesthetic. DESIGN: Cost analysis based on the literature on Xe anesthesia. SETTING: Anesthetic simulation based on data obtained in the operating rooms at a university hospital. PATIENTS: A 40-year-old, ASA physical status I adult patient model weighing 70 kg, undergoing elective minor surgery with endotracheal intubation and mechanical ventilation. INTERVENTIONS: Anesthesia was given in the following four techniques: 1) closed-circuit technique with Xe; 2) closed-circuit technique with nitrous oxide (N2O)-isoflurane; 3) semi-closed technique with N2O-isoflurane; and 4) semi-closed technique with N2O-sevoflurane. MEASUREMENTS AND MAIN RESULTS: Cost of each anesthetic technique was compared in U.S. dollars. The cost of Xe anesthesia was consistently higher than that of N2O-isoflurane or N2O-sevoflurane (for 240-min anesthesia; $356 with Xe, $52 with closed-circuit N2O-isoflurane, $94 with semi-closed N2O-isoflurane, and $84 with semi-closed N2O-sevoflurane). The major cost of Xe anesthesia was a result of the cost of priming and flushing; the cost of Xe used for its anesthetic effects was comparable with the other semi-closed techniques after 240 minutes. CONCLUSIONS: For Xe to be widely used in routine anesthesia, the methods of minimizing the amount of Xe necessary for priming and flushing must be developed.

Darvas, K., M. Janecsko, et al. (1999). "[Anesthesia ambulatory one-day surgery]." Orv Hetil 140(37): 2035-40.
The spreading of the cost-benefit attitude is a considerable help in the progress of the one day surgery. The patient selection, the preoperative patient preparations and the preoperative examination has done in the anaestesiologic ambulance. Aims of ambulatory anaesthesia are to achieve sedation, hypnosis, analgesia, amnesia and muscle relaxation during the operation, to preserve preoperative mental and physiologic state, analgesia and to make early postoperative nourishing possible. Besides personnel and equipment of anaesthesia and reanimation, monitoring of circulation, respiration and neuromuscular transmission is needed. Anaesthetic methods: local, regional and general anaesthesia or sedation. Ways of general anaesthesia are intravenous, inhalation or combined. Intravenous anaesthetic drugs (barbiturates, ketamine, etomidate, midazolam, propofol and eltanolon) can be used in monotherapy or in combination with each other or opioids (morphine, alfentanil, fentanyl, sufentanil, remifentanil). Among inhalatic agents N2O isoflurane, desflurane, sevoflurane are advisable. Recommended non depolarising muscle relaxants are the short-acting atracurium, mivacurium, vecuronium and rocuronium. Methods for loco-regional anaesthesia are infiltration, peripheral nerve blockade, epidural and intradural anaesthesia which can be used with additional vigil sedation. Blockades with local analgetics, intraoperative opioids, non-steroid anti-inflammatory drugs, sedatives, pre-emptiv analgesia and patient controlled analgesia can be used for postoperative pain relief. Besides the patient and intervention type selection the adequate perioperative anaesthesiologic work and the prudent specifications of leaving conditions is the most important terms of the safety of one-day surgery and anaesthesia.

Meurisse, M., T. Defechereux, et al. (1999). "Hypnosis with conscious sedation instead of general anaesthesia? Applications in cervical endocrine surgery." Acta Chir Belg 99(4): 151-8.
Between April 1994 and June 1997, 197 thyroidectomies and 21 cervical explorations for hyperparathyroidism were performed under hypnosedation (HYP) and compared to the operative data and postoperative courses of a closely-matched population (n = 121) of patients operated on under general anaesthesia (GA). Conversion from hypnosis to GA was needed in two cases (1%). All surgeons reported better operating conditions for cervicotomy using HYP. All patients having HYP reported a very pleasant experience and had significantly less postoperative pain while analgesic use was significantly reduced in this group. Hospital stay was also significantly shorter, providing a substantial reduction of the medical care costs. The postoperative convalescence was significantly improved after HYP and full return to social or professional activity was significantly shortened. We conclude that HYP is a very efficient technique providing physiological, psychological and economic benefits to the patient.

Baker, C. E. and I. Smith (1999). "Sevoflurane: a comparison between vital capacity and tidal breathing techniques for the induction of anaesthesia and laryngeal mask airway placement." Anaesthesia 54(9): 841-4.
Sixty unpremedicated adult day-case patients were randomly assigned to either vital capacity or tidal breathing inhalational induction techniques. End points assessed included loss of eyelash reflex, time to drop a weighted syringe, time to jaw relaxation and time to the end of laryngeal mask airway insertion. Complications occurring during the induction of anaesthesia were recorded. The data show that there is no statistical or clinical difference between the two induction techniques. Patient acceptance of both techniques was similarly high. When the time taken to prime the anaesthetic breathing system is taken into consideration, the vital capacity technique is more expensive for induction of anaesthesia. These results therefore question the need for the vital capacity induction technique with sevoflurane 8%.

Pollard, J. B. and L. Olson (1999). "Early outpatient preoperative anesthesia assessment: does it help to reduce operating room cancellations?" Anesth Analg 89(2): 502-5.
Increased understanding of the high cost associated with operating room (OR) cancellations has led to efforts by healthcare providers to decrease case cancellations on the day of surgery. To investigate whether preoperative evaluations within 24 h of surgery were associated with more frequent OR cancellations than those completed 2-30 days before surgery, we prospectively studied OR cancellations for 3 mo. Of the 529 patients in the study, 166 were seen within 24 h of surgery (standard group), and the remaining 363 patients were seen 2-30 days before surgery (early group). There were 70 OR cancellations on the day of surgery, and the largest single group of cancellations was related to administrative problems. The standard group and the early group were similar in terms of gender, age, ASA physical status, and percentage of patients undergoing major surgery. The OR cancellation rates were also comparable between groups: 13.3% for the standard group and 13.2% for the early group. These data suggest that patients can be evaluated in an outpatient preoperative evaluation clinic in a timeframe that is convenient for the patient without adversely affecting the cancellation rate on the day of surgery. Implications: The operating room cancellation rate for outpatients evaluated 2-30 days before surgery was compared with the cancellation rate for outpatients who received their anesthesia evaluation within 24 h of surgery. Because both groups had similar rates, outpatients may be seen at a convenient time without adversely affecting operating room cancellations.

Sun, R., M. F. Watcha, et al. (1999). "A cost comparison of methohexital and propofol for ambulatory anesthesia." Anesth Analg 89(2): 311-6.
Methohexital is eliminated more rapidly than thiopental, and early recovery compares favorably with propofol. We designed this study to evaluate the recovery profile when methohexital was used as an alternative to propofol for the induction of anesthesia before either sevoflurane or desflurane in combination with nitrous oxide. One hundred twenty patients were assigned randomly to one of four anesthetic groups: (I) methohexital-desflurane, (II) methohexital-sevoflurane, (III) propofol-desflurane, or (IV) propofol-sevoflurane. Recovery times after the anesthetic drugs, as well as the perioperative side effect profiles, were similar in all four groups. A cost-minimization analysis revealed that methohexital was less costly for the induction of anesthesia. At the fresh gas flow rates used during this study, the costs of the volatile anesthetics for maintenance of anesthesia did not differ among the four groups. However, at low flow rates (< or = 1 L/min), the methohexital-desflurane group would have been the least expensive anesthetic technique. In conclusion, methohexital is a cost-effective alternative to propofol for the induction of anesthesia in the ambulatory setting. At low fresh gas flow rates, the methohexital-desflurane combination was the most cost-effective for the induction and maintenance of general anesthesia. Implications: Using methohexital as an alternative to propofol for the induction of anesthesia for ambulatory surgery seems to reduce drug costs. When fresh gas flow rates < or = 1 L/min are used, the combination of methohexital for the induction and desflurane for maintenance may be the most cost-effective general anesthetic technique for ambulatory surgery.

Tang, J., L. Chen, et al. (1999). "Recovery profile, costs, and patient satisfaction with propofol and sevoflurane for fast-track office-based anesthesia." Anesthesiology 91(1): 253-61.
BACKGROUND: Office-based surgery is becoming increasingly popular because of its cost-saving potential Both propofol and sevoflurane are commonly used in the ambulatory setting because of their favorable recovery profiles. This clinical investigation was designed to compare the clinical effects, recovery characteristics, and cost-effectiveness of propofol and sevoflurane when used alone or in combination for office-based anesthesia. METHODS: One hundred four outpatients undergoing superficial surgical procedures at an office-based surgical center were randomly assigned to one of three general anesthetic groups. In groups I and II, propofol 2 mg/kg was administered for induction followed by propofol 75-150 microg x kg(-1) x min(-1) (group I) or sevoflurane 1-2% (group II) with N2O 67% in oxygen for maintenance of anesthesia In group m, anesthesia was induced and maintained with sevoflurane in combination with N2O 67% in oxygen. Local anesthetics were injected at the incision site before skin incision and during the surgical procedure. The recovery profiles, costs of drugs, and resources used, as well as patient satisfaction, were compared among the three treatment groups. RESULTS: Although early recovery variables (e.g., eye opening, response to commands, and sitting up) were similar in all three groups, the times to standing up and to be "home ready" were significantly prolonged when sevoflurane-N2O was used for both induction and maintenance of anesthesia. The time to tolerating fluids, recovery room stay, and discharge times were significantly decreased when propofol was used for both induction and maintenance of anesthesia. Similarly, the incidence of postoperative nausea and vomiting and the need for rescue antiemetics were also significantly reduced after propofol anesthesia. Finally, the total costs and patient satisfaction were more favorable when propofol was used for induction and maintenance of office-based anesthesia CONCLUSION: Compared with sevoflurane-N2O, use of propofol-N2O for office-based anesthesia was associated with an improved recovery profile, greater patient satisfaction, and lower costs. There were significantly more patients who were dissatisfied with the sevoflurane anesthetic technique.

Klinck, J. R. (1999). "Quality of care in anaesthetic practice: how should it be measured?" Acta Anaesthesiol Belg 50(1): 13-8.

Johnstone, R. E. (1999). "From economics to ethics: values-based anesthesia." J Clin Anesth 11(1): 1-3.

Onaka, M., H. Yamamoto, et al. (1999). "[Economical benefit of continuous total intravenous anesthesia]." Masui 48(5): 548-55.
Total intravenous anesthesia (TIVA) has been recommended in view of avoiding air pollution. However, intermittent administration of anesthetic agents has a large disadvantage of delayed emergence. We reported that continuous TIVA with propofol, ketamine, vecuronium and buprenorphine (PKBp) could bring rapid emergence. In this study, we calculated and compared the cost of anesthesia in the subjects who had undergone general anesthesia either with continuous PKBp or nitrous oxide-oxygen-sevoflurane. In group PKBp subjects, after induction with propofol, ketamine, vecuronium and buprenorphine, anesthesia was maintained with continuous intravenous administration of propofol corresponding to the patient's age using twice step down method; ketamine (240 micrograms.kg-1.h-1), vecuronium (80 micrograms.kg-1.h-1) and buprenorphine (0.4 microgram.kg-1.h-1). Group GOS subjects, after the same induction method, received nitrous oxide, sevoflurane and vecuronium. Moreover, the group GOS subjects were divided to two groups; the high flow GOS (N2O:O2:sevoflurane = 4 l:2 l:30 ml) and the low flow GOS (N2O:O2:sevoflurane = 2 l:1 l:15 ml). Continuous PKBp group showed lower cost than the high flow GOS group. The PKBp group showed lower cost than the low flow GOS group except in patients weighing more than 100 kg. Furthermore, we calculated the cost of continuous PKBp anesthesia in Japan, U.S.A. and U.K. The U.S.A. cost of PKBp was higher than the Japanese and the U.K., because the cost of ketamine in U.S.A. is higher than in the other countries. Continuous PKBp is more economical than the high flow GOS, and continuous PKBp in Japan is more economical than in U.S.A.

Bevan, D. R. (1999). "The new relaxants: are they worth it?" Can J Anaesth 46(5 Pt 2): R88-100.

Flynn, M. K. and J. M. Niloff (1999). "Outpatient minilaparotomy for ovarian cysts." J Reprod Med 44(5): 399-404.
OBJECTIVE: To design an operative procedure for the ambulatory management of ovarian cysts using classical surgical techniques. STUDY DESIGN: One hundred consecutive patients 55 years old or younger with 115 persistent or complex ovarian cysts less than 10 cm in diameter were managed as outpatients by minilaparotomy. Minilaparotomy is defined as a transverse or vertical incision 3-5 cm in length. The procedure and anesthetic were dictated by each clinical situation. Bupivacaine HCl with epinephrine was injected in the wound preemptively, and ketorolac was administered systemically perioperatively. Operative times, complications and pathology were determined for each case. RESULTS: The procedures (unilateral cystectomy, 65; bilateral cystectomy, 9; unilateral salpingo-oophorectomy, 20; and bilateral salpingo-oophorectomy, 6) were performed under general endotracheal anesthesia in 89, laryngeal mask anesthesia in 5 and spinal block in 6. Mean operative time was 46 minutes. Estimated blood loss in 96% of cases was < 50 mL, and none was > 100 mL. Pathology in two cases revealed adenocarcinoma of borderline malignancy. Remaining histology included endometrioma, 40; dermoid, 25; serous cystadenomas, 14; hemorrhagic corpus luteum, 9; mucinous cystadenoma, 8; cystadenofibroma, 7; follicular cyst, 3; fibrothecoma, 2; and peritoneal inclusion cyst, 1. Ninety-six of 100 patients were discharged on the day of surgery. Two were admitted for urinary retention, one for severe nausea and vomiting, and one for diabetes control. CONCLUSION: Minilaparotomy is a safe, rapid procedure for the management of ovarian cysts on an ambulatory basis. It can be performed under regional anesthesia, avoids intraperitoneal spill and requires only basic operative techniques and instrumentation. Minilaparotomy is also a cost-effective technique for outpatient management of ovarian cysts.

Puura, A. I., M. G. Rorarius, et al. (1999). "The costs of intense neuromuscular block for anesthesia during endolaryngeal procedures due to waiting time." Anesth Analg 88(6): 1335-9.
The goal of this double-blinded, prospective study was to compare the costs incurred by waiting time of intense neuromuscular block while posttetanic count (PTC) was maintained at 0-2 during jet ventilation. Fifty patients were randomized into five groups to receive atracurium (ATR), mivacurium (MIV), rocuronium (ROC), vecuronium (VEC), and succinylcholine (SUCC). PTC < or =2 was maintained until completion of laryngomicroscopy by administering additional doses of relaxants or by adjusting the speed of the infusion of SUCC. We compared waiting time, i.e., onset time and recovery time, and costs of intense neuromuscular block. The expenses due to waiting time were calculated based on the average costs in the otorhinolaryngological operating room in Tampere University Hospital: FIM 40 (approximately $8) per minute in 1997. MIV and SUCC differ favorably from ATR, ROC, and VEC when waiting time and costs are concerned. The recovery times with MIV and SUCC were considerably shorter than those with ATR, ROC, and VEC (P < 0.001 in all pairwise comparisons). Using the muscle relaxant with the longest waiting time instead of that with the shortest waiting time (difference 21.8 min) cost more than FIM 800 (approximately $160) extra per patient. IMPLICATIONS: In this randomized, double-blinded, prospective study, we evaluated the costs of intense neuromuscular block due to waiting time. Succinylcholine and mivacurium are the most economical muscle relaxants to use when intense neuromuscular block is mandatory. Using intermediate-acting muscle relaxants results in unduly prolonged recovery time and extra costs.

Lain, J., C. Young, et al. (1998). "Improving efficiencies and reducing costs in adult cardiac surgery: a team approach." Qual Manag Health Care 6(4): 37-41.
The article reviews a team effort to reduce operating room costs by 25 percent. The team achieved this goal by participating in the Institute for Healthcare Improvement Breakthrough Series on adult cardiac surgery. The process improvements included standardizing practices, reevaluating equipment, and reducing operating room cycle time.

Marchal Escalona, C., J. Caballero Alcantara, et al. (1999). "[Local anesthesia in meatoplasty with pediculated flap, an efficient technique in the treatment of meatal stenosis]." Actas Urol Esp 23(2): 140-8.
Meatal stricture is not an uncommon condition in the clinical practice, the classical treatment being meatotomy. The failure of the technique and the changes in the quality of the urinary stream have forced us to perform a meatoplasty procedure with pedicle flap from penial skin as described by Jordan, using intravenous local anaesthetics, thus avoiding hospitalization and reducing the overall cost of the procedure. From a total of 23 patients who (between May 1995 and April 1998) required surgery due to meatal stricture, 11 patients underwent meatoplasty and the rest meatotomy. None of the patients in the former group developed re-stenosis, and achieved a mean improvement of Q max in the flowmetry performed three months after the procedure of 23 mL/sg. vs the 10.5 mL/sg. of patients undergoing meatotomy. This difference is statistically significant at p = 0.02. Cost saving when surgery is conducted in the day hospital is 122,302 pts/procedure vs 215,182 pts/procedure if the patient had to remain in hospital for 3 or 7 days. Compared to the lower cost of meatotomy (39,308 pts/proc.) or meatoplasty (57,525 pts/proc.), it must be emphasised that the management of complications in the first case is 6,816 pts/patient vs 1,724 pts/patient required for cures in the case of Jordan's technique. It was concluded that pedicle flap meatoplasty is an efficient and definitive technique in the treatment of meatal stricture.

Barron, D. J., M. J. Tolan, et al. (1999). "A randomized controlled trial of continuous extra-pleural analgesia post-thoracotomy: efficacy and choice of local anaesthetic." Eur J Anaesthesiol 16(4): 236-45.
Controversy persists over the efficacy of intercostal nerve block administered through a tunnelled extrapleural catheter. We have undertaken a randomized, prospective double-blind trial of two different local anaesthetic regimes to evaluate the effect of this technique on post-thoracotomy pain relief and pulmonary function. Sixty-eight patients were randomized to receive bupivacaine 0.25% (n = 22), lignocaine 1% (n = 21) or 0.9% NaCl (saline) (n = 20) via an extrapleural catheter, inserted peroperatively. All patients underwent a standard posterolateral thoracotomy. Pain was assessed using a visual analogue pain score and by the requirement for opiate analgesia. Pulmonary function was measured using bedside spirometry. Pain scores were lower in the local anaesthetic groups at 24, 32 and 72 h compared with placebo (P < 0.05) and the total amount of opiate required was less than placebo for both lignocaine and bupivicaine (P < 0.05). Pulmonary function was better in the local anaesthetic groups throughout the post-operative period and was most pronounced at 24 h with a mean improvement of 30% for forced expiratory volume (FEV1), 24% for forced vital capacity (FVC) and 19% for peak expiratory flow rate (PEFR) compared with placebo. There was no significant difference between pain scores, opiate requirement or pulmonary function between lignocaine and bupivicaine. CT scanning demonstrated containment of the local anaesthetic in an extra-pleural tunnel. Extra-pleural infusion of local anaesthetics is a simple technique, with low risk of complications and provides effective pain relief as well as an improvement in post-operative pulmonary function. Lignocaine is equally as effective as bupivacaine and its use would result in some cost-saving.

Hammer, G. B. (1999). "Regional anesthesia for pediatric cardiac surgery." J Cardiothorac Vasc Anesth 13(2): 210-3.

Harper, D. M. and J. L. Cobb (1999). "Is it cost-effective to use a mucosal or paracervical block to relieve the pain and cramping from cryosurgery? A decision model." J Fam Pract 48(4): 285-90.
BACKGROUND: Cryosurgery is an effective treatment for cervical intraepithelial neoplasia, but it often causes pain and cramping. Both paracervical and mucosal blocks have been shown to provide relief from the pain and cramping associated with cryosurgery. The purpose of this article is to recommend the use of mucosal block, paracervical block, or no block on the basis of which procedure minimizes the costs of averting the pain and cramping that a woman experiences during cryosurgery. METHODS: A decision model was constructed encompassing the options (mucosal block, paracervical block, or no block) that a physician has when performing cryosurgery. The 4 possible outcomes for a patient undergoing cryosurgery were diagrammed as: (1) no pain and no cramping; (2) only cramping; (3) only pain; and (4) both pain and cramping. Each of these outcomes was measured on a 200-mm horizontal visual analog scale. Costs were derived for cryosurgery from the office perspective. Sensitivity analyses were conducted to test the robustness of the analysis. RESULTS: The base case analysis showed that the lowest cost per pain and cramping averted was for women who had a mucosal block before cryosurgery ($153.87), compared with women with a paracervical block ($183.24) and women with no block ($218.83). CONCLUSIONS: A mucosal block is the most cost-effective method to avert the pain and cramping from cryosurgery in women who have taken a nonsteroidal anti-inflammatory drug before the procedure.

Brooks, D. M. and W. R. Hand, Jr. (1999). "A cost analysis: general endotracheal versus regional versus monitored anesthesia care." Mil Med 164(4): 303-5.
A prospective study was conducted to compare the total cost of all consumable products used to perform a general endotracheal anesthetic (GETA), a regional anesthetic, and a monitored anesthetic (MAC). For 1 month, providers completed a survey for each anesthetic rendered identifying type and quantity of consumables used. The mean cost of each type of anesthetic was identified. Analysis of variance was conducted using SPSS (version 7.5.1) to compare the mean costs of the three groups. Of 936 anesthetics performed, 536 surveys were returned (57%). The breakdown by type was GETA, 60% (N = 319); regional, 35% (N = 189); and MAC, 5% (N = 28). The mean cost per case type was GETA, $61.74; regional, $34.99; and MAC, $26.27. The cost of rendering a GETA was significantly greater (p < 0.0005) than that of either regional or MAC. Clinical practice guidelines were established to address areas in which cost savings could be realized and were provided to all anesthesia practitioners to assist in providing the safest and most cost-effective method of rendering an anesthetic.

Jakobsson, I., M. Heidvall, et al. (1999). "The sevoflurane-sparing effect of nitrous oxide: a clinical study." Acta Anaesthesiol Scand 43(4): 411-4.
BACKGROUND: We studied the sevoflurane-sparing effect of nitrous oxide in a prospective randomised study. METHODS: Forty-two ASA I-II patients scheduled for elective knee arthroscopy under general anaesthesia were randomly assigned to a fresh gas flow consisting of oxygen in air or oxygen in nitrous oxide 1:2. All patients received a standardised anaesthesia consisting of induction with fentanyl and propofol and maintenance with sevoflurane adjusted according to clinical signs. The sevoflurane consumption was studied by means of weighing the vaporiser before and after every anaesthesia. RESULTS: The mean sevoflurane consumption was reduced from 0.62 to 0.25 g/min, a 60% reduction, by the use of oxygen in nitrous oxide 1:2 in the fresh gas flow. The emergence was faster for the patients receiving nitrous oxide. No major differences were observed during recovery. CONCLUSION: Nitrous oxide was found to be cost-effective for use during short ambulatory knee arthroscopy.

Body, S. C., J. Fanikos, et al. (1999). "Individualized feedback of volatile agent use reduces fresh gas flow rate, but fails to favorably affect agent choice." Anesthesiology 90(4): 1171-5.
BACKGROUND: Cost reduction has become an important fiscal aim of many hospitals and anesthetic departments, despite its inherent limitations. Volatile anesthetic agents are some of the few drugs that are amenable to such treatment because fresh gas flow rate (FGFR) can be independent of patient volatile anesthetic agent requirement. METHODS: FGFR and drug use were recorded at the temporal midpoint of 2,031 general anesthetics during a 2-month preintervention period. Staff and residents were provided with their preintervention individual mean FGFR, their peer group mean, and educational material regarding volatile agent costs and low-flow anesthesia. FGFR and drug use were remeasured over a 2-month period (postintervention) immediately after this information (N = 2,242) and again 5 months later (delayed follow-up), for a further 2-month period (N = 2,056). RESULTS: For all cases, FGFR decreased from 2.4+/-1.1 to 1.8+/-1.0 l/min (26% reduction) after the intervention and increased to 1.9+/-1.1 l/min (5% increase of preintervention FGFR) at the time of delayed follow-up. Use of more expensive volatile agents (desflurane and sevoflurane) increased during the study period (P < 0.01). In a subgroup of 44 staff members with more than five cases in all study periods, 42 members decreased their mean FGFR after intervention. At delayed follow-up, 30 members had increased their FGFR above postintervention FGFR but below their initial FGFR. After accounting for other predictors of FGFR, the effectiveness of the intervention was significantly reduced at follow-up (28% reduction), but retained a significant effect compared to preintervention FGFR (19% reduction). CONCLUSIONS: Although individual feedback and education regarding volatile agent use was effective at reducing FGFR, effectiveness was reduced without continued feedback. Use of more expensive volatile agents was not reduced by education regarding drug cost, and actually increased.

Payne, J. H., Jr. (1997). "Outpatient laparoscopy: can we? Should we? How are we to know?" Bull Am Coll Surg 82(6): 24-8.

Hsu, S. H. and S. J. Shalansky (1995). "Pharmacoeconomics of propofol versus thiopental for induction of anaesthesia in short procedures." Can J Hosp Pharm 48(4): 208-13.
This study compared the costs and benefits of using propofol/fentanyl versus thiopental/fentanyl for induction of anaesthesia in short procedures. A prospective, cohort trial was conducted in conjunction with a patient survey. The study population included a consecutive sample of American Society of Anaesthesiologists. Class I or II patients who underwent short operative procedures and who were given one of the studied anaesthetic regimens. Insoflurane/N2O was used for maintenance of anaesthesia in all cases. Propofol patients showed a significantly shorter time to eye opening (p = 0.0025); orientation to date of birth, place, and day of week (p = 0.0002); time to consciousness (p = 0.0019); and time in recovery room (p = 0.013); but not time to tolerating 50 mL of oral fluid (p = 0.06). Nausea and vomiting occurred in 41% of thiopental patients and 19% of propofol patients (difference 22%; 95% C.I., -1% to 44%). Based on survey results, propofol patients subjectively reported fewer side effects upon returning home and were able to resume daily activities earlier than thiopental patients. With the current staffing and patient load at our institution, an estimated 4.8 hours of nursing time per day would be made available if propofol were used in place of thiopental for induction of anaesthesia in these procedures. If propofol were used for all daycare surgery patients in our institution, the annual acquisition cost is projected to be $60,331.28 versus $8,079.68 for thiopental.(ABSTRACT TRUNCATED AT 250 WORDS)

Ezeh, U. I., S. Shepherd, et al. (1999). "Morbidity and cost-effectiveness analysis of outpatient analgesia versus general anaesthesia for testicular sperm extraction in men with azoospermia due to defects in spermatogenesis." Hum Reprod 14(2): 321-8.
The outcome and costs of testicular sperm extraction under outpatient local analgesia or general anaesthesia were compared in men with non-obstructive azoospermia. Nineteen consecutive patients were allocated to receive general anaesthesia, while the subsequent 21 consecutive patients received outpatient analgesia in the form of i.v. midazolam sedation, lignocaine spray, scrotal infiltration with local anaesthetic and spermatic cord block. Blood pressure, pulse rate and respiratory rate were determined. Sedation and testicular pain were assessed by subjective scoring. Both groups showed haemodynamic stability with little alteration in blood pressure, pulse rate and oxygen saturation. Toxic symptoms of local anaesthetic were not encountered in the outpatient group. No relationship was found between testicular size and the duration of the operation. The median postoperative pain intensity, sedation scores and analgesic requirements were significantly less in the outpatient group (P < 0.05). These advantages led to a shorter recovery time (P < 0.0001), 3-fold cheaper care and greater patient satisfaction (P < 0.0001) in the outpatient group.

Byun, M. Y., N. A. Fine, et al. (1999). "The clinical outcome of abdominoplasty performed under conscious sedation: increased use of fentanyl correlated with longer stay in outpatient unit." Plast Reconstr Surg 103(4): 1260-6.
The objective of this study was to present data supporting the effectiveness of performing mini and full abdominoplasties under conscious sedation with local anesthesia. The authors performed 20 such operations between 1994 and 1996, using a combination of midazolam (Versed) and fentanyl instead of general anesthesia (without an anesthesiologist or nurse anesthetist present). At 5- to 10-minute intervals, the surgeon would order the injection of 1 cc (1 mg/ml) of midazolam and 1 cc (50 microg/ml) of fentanyl. The amount and the interval varied based on the patient's level of sedation. Blood pressure, oxygen saturation, and the patient's response to verbal and physical stimuli were used to assess the sedation level. Average operating time was 147.5 minutes, and mean length of stay in the outpatient recovery room was 235.5 minutes. The average amounts of midazolam and fentanyl used were 9.4 mg (6 to 12.5 mg) and 532 microg (300 to 800 microg), respectively. The average age of patients in this group was 41.7 years (28 to 63 years). Nineteen patients were discharged the same day. There were no surgical complications and no complication related to the sedation (such as respiratory or cardiac compromise). The average follow-up of these patients was 1.2 years (range, 3 to 21 months). Correlation coefficient rates and regression rates were calculated. The longer the procedure, the more midazolam was used intraoperatively (r = 0.5, p = 0.03). However, there was no correlation between the length of the procedure and the amount of fentanyl used. Rather, there was a positive correlation demonstrating that patients who received more fentanyl stayed longer in the outpatient recovery area after surgery (r = 0.6, p < 0.01). The age of the patients and the amount of midazolam did not correlate with how fast they went home from the outpatient area. In conclusion, full and mini abdominoplasties can be performed safely using conscious sedation without compromising patient care or surgical outcome. Second, the survey revealed that patient satisfaction with these procedures performed under conscious sedation was very high. Third, the increased use of fentanyl, not midazolam, resulted in a longer stay in the outpatient unit after surgery. Nausea is a known side effect of narcotic analgesics, and it correlated with a higher dose of fentanyl administration in the patients. The authors are now routinely administering a dose of either droperidol or odansetron (Zofran) preoperatively (both are antiemetics). Previously, the ratio of midazolam and fentanyl injection was 1:1 every 5 to 10 minutes, but now it is 2: 1 to 4: 1 every 5 to 10 minutes (a smaller dose of fentanyl is administered). The conscious sedation technique should be an option for patients and plastic surgeons in academic and community hospital settings if they desire.

Biancofiore, G., L. Bindi, et al. (1998). "[Orthotopic liver transplant. Analysis of costs related to anesthesiologic and intensive care phases]." Minerva Anestesiol 64(12): 587-91.
BACKGROUND: To evaluate anesthesia and Intensive Care Unit (ICU) costs for Orthotopic Liver Transplantation (OLT) through a point by point analysis of the entire process from anesthesia induction to ICU discharge. DESIGN: Retrospective analysis. SETTING: Regional Transplantation Centre participating to the Italian National Health Care System. METHODS: Anesthesia and ICU costs for each OLT performed during 1997 were estimated through the analysis of costs of the following categories: drugs, medical and nurse staff, blood bank, radiology, laboratory, haemoderivates. RESULTS: Forty OLTs were performed in 38 recipients during the study period. The total charges for the anesthesia and ICU management of these patients calculated in US dollars were 583.433,23 (considering the exchange rates valid in January 1998). ICU costs resulted approximately 2.5 times higher than those for anesthesia. Blood bank and drugs were the categories that had the greatest impact on the final expense whereas laboratory had the lowest. The charges referred to medical and nurse staff resulted higher in the ICU than for anesthesia. CONCLUSIONS: The Italian National Health Care System has to deal with limited resources; costs analysis of high-tech procedures as OLT is of basic importance to optimise resources allocation and to enforce money-saving actions.

Piacevoli, Q. (1998). "[Anesthesia and health economics]." Minerva Anestesiol 64(12): 541-4.

Palter, S. F. (1999). "Office microlaparoscopy under local anesthesia." Obstet Gynecol Clin North Am 26(1): 109-20, vii.
Office laparoscopy under local anesthesia is especially suited to meet the current pressures of quality versus cost in an era of managed care. It is likely that this technique will soon become a major part of the practicing gynecologist's diagnostic operative armamentarium. Advantages of office microlaparoscopy under local anesthesia are realized by the practitioner, the patient, and the managed care provider. Office microlaparoscopy under local anesthesia is a safe, effective, and less costly tool for the evaluation of patients with many different indications. To date, the procedure has been primarily used for patients with infertility, chronic pelvic pain, and tubal ligation. The ease of scheduling, reduced costs, and rapid recovery suggest that it may be the preferred initial procedure for these patients.

Eige, S., E. A. Pritts, et al. (1999). "Anesthesia for office endoscopy." Obstet Gynecol Clin North Am 26(1): 99-108, vii.
A trend is emerging in the United States whereby surgical procedures are gradually migrating to less complex environments. The demands of cost containment, pressures to limit unnecessary time delays, and desires for increased control have all conspired to promote ambulatory surgicenters, minor procedure center, and office surgical suites. Concomitant with this shift is a differing attitude toward anesthesia, with an increasing number of procedures using alternatives to general anesthesia, such as regional blocks and conscious sedation.

Jayanthi, V. R., J. E. Burns, et al. (1999). "Postneonatal circumcision with local anesthesia: a cost-effective alternative." J Urol 161(4): 1301-3.
PURPOSE: Despite the controversy regarding the need for routine neonatal circumcision, most boys in the United States are circumcised. Physicians are commonly asked to perform circumcision after the neonatal period and are often unaware of the cost factors related to the timing and location of postneonatal circumcision. MATERIALS AND METHODS: We describe the medical and financial advantages of postneonatal circumcision with local versus general anesthesia. RESULTS: During a 30-month period 245 boys 6 months to 15 years old underwent circumcision under general anesthesia in the operating room. Hospital charges (facility and equipment) averaged $1,555 and anesthesia charges averaged $250. Therefore, the average cost for circumcision in the operating room was $1,805. During the same time period 287 infants 3 days to 9 months old (20% older than 3 months) underwent circumcision under local anesthesia in an office setting. The facility and equipment charge for these office procedures averaged $196. Overall, approximately $461,783 were saved in this 30-month period ($184,713 annually) by performing circumcision with local anesthesia in an office setting rather then in the operating room with general anesthesia. There was no significant difference in complication rates between the local and general anesthesia groups (1.4 versus 1.6%). CONCLUSIONS: Circumcision with local anesthesia can be performed easily and safely during the first several months of life and has many advantages. Parents prefer this method because it is more convenient and eliminates the risk of general anesthesia. The enormous cost savings using local as opposed to general anesthesia should prompt a reexamination of the location and timing of postneonatal circumcision.

Magoha, G. A. (1998). "Local infiltration and spermatic cord block for inguinal, scrotal and testicular surgery." East Afr Med J 75(10): 579-81.
This was a prospective study involving 372 male patients. Surgical procedures including simple inguinal hernia repair, inguinal lymph node biopsy, hydrocelectomy, testicular biopsy, testicular fixation, orchidectomy and scrotal exploration were performed under local anaesthesia using various quantities of 0.5% xylocaine with adrenaline depending on the procedure, in the form of spermatic cord block and local infiltration nerve blocks. No premedication was given to any patient and only five patients (1.34%) were given intraoperative sedation due to anxiety. No complication directly attributed to the anaesthetic agent used or the technique of spermatic cord and nerve blocks were reported during the study. Three hundred and sixty patients (96.77%) were operated on as outpatients and were happy and satisfied to return home on the same day. This experience confirms that spermatic cord block accompanied by local infiltration with 0.5% xylocaine with adrenaline is simple, safe and effective technique that should be used more widely in outpatient urological and general surgical settings in this locality. It provides excellent intra-scrotal and inguinal anaesthesia. Furthermore, the technique is cost effective, and personnel effective since no anaesthetist is required for the procedure which is usually carried out by the surgeon. This would enable many more people to afford the surgical procedures.

Jellish, W. S., J. P. Leonetti, et al. (1999). "Comparison of 3 different anesthetic techniques on 24-hour recovery after otologic surgical procedures." Otolaryngol Head Neck Surg 120(3): 406-11.
Intravenous propofol anesthesia is better than inhalational anesthesia for otologic surgery, but cost and intraoperative movement make this technique prohibitive. This study compares a propofol sandwich anesthetic with a total propofol or inhalational anesthetic for otologic surgery to determine which produces the best perioperative conditions and least expense. One hundred twenty patients undergoing ear surgery were randomly chosen to receive an anesthetic with either isoflurane (INHAL), total propofol (TPROP), or propofol used in conjunction with isoflurane (PSAND). Postoperative wakeup and the incidence and severity of nausea, vomiting, and pain were compared among groups. Antiemetic administration and discharge times from recovery and the hospital were also compared. The groups were similar, but anesthesia times were longer in the INHAL group. Emergence from anesthesia after PSAND or TPROP was more rapid than after INHAL. Recovery during the next 24 hours was associated with less nausea and vomiting with PSAND than with INHAL. The cost of the PSAND anesthetic was similar to that of INHAL, and both were less than TPROP. PSAND anesthesia may be similar to TPROP and better than INHAL for otologic procedures. PSAND was less expensive than TPROP and produced a similar recovery profile and antiemetic effect in the 24-hour period after surgery.

Zanghi, G., G. Brancato, et al. (1998). "[Organizational and surgical-technical aspects of the service of abdominal hernioplasty]." Ann Ital Chir 69(5): 563-74.
The authors guided by the experience matured from 1/01/94 to 30/06/97 (435 abdominal hernioplasties performed, mainly inguinal and femoral) illustrate the organizational formalities and the technical aspects of a Hernia Surgery Service. In particular, they highlight the advantages of the routine use of local anaesthesia and of tension-free techniques, carried out on a day surgery rule (immediate rehabilitation, greater facilitation to elective surgery, access to the elderly at high anaesthetic risk). Eventually, they emphasize the remarkable reduction of sanitary costs and the outstanding social, practical and didactic value of such Hernia Centers.

Nathan, N., A. Peyclit, et al. (1998). "Comparison of sevoflurane and propofol for ambulatory anaesthesia in gynaecological surgery." Can J Anaesth 45(12): 1148-50.
PURPOSE: To analyse the cost-efficiency ratio of sevoflurane compared with propofol for gynaecological ambulatory anaesthesia. METHODS: In a prospective randomised study 52 ASA I patients scheduled for ambulatory pregnancy termination were premedicated with lorazepam and received alfentanil prior to anaesthesia induction with propofol (group P, n = 26) or with sevoflurane 8% (group S, n = 26) using the single breath vital capacity technique. Anaesthesia was maintained with N2O in both groups supplemented with sevoflurane (group S) or propofol boluses (group P). RESULTS: The quality of induction and maintenance of anaesthesia was similar between groups except for the incidence of movement during anaesthesia (14/26 patients in group P and 4/26 in group S, P < 0.05). The incidence of post-operative emesis was increased in the sevoflurane group (P < 0.05) but the patients felt able to perform normal activity after a similar delay (18.4 +/- 2.9 hr vs 20.6 +/- 2.8 hr, P > 0.05). The direct cost of anaesthesia was lower in the sevoflurane group (679 FF, n = 24 vs 1153 FF, n = 2-5 in propofol group) but the weight of uterine aspiration products was higher (293 +/- 66 g, median = 230 g, Range 110-800 g, n = 13 vs 108 +/- 8 g, median = 110 g, Range 60-160 g, n = 12, group S vs group P respectively, P = 0.004). Four patients needed reoperation and ambulatory anaesthesia failed in six patients because of uterine haemorrhage. CONCLUSION: Ambulatory anaesthesia with sevoflurane offers a good alternative to propofol but further investigation concerning blood loss with sevoflurane needs to be performed in gynaecological practice.

Wong, J. and F. Chung (1998). "Economic evaluation of sevoflurane vs propofol for ambulatory anaesthesia." Can J Anaesth 45(12): 1141-3.

Schlunzen, L., M. S. Simonsen, et al. (1999). "Cost consciousness among anaesthetic staff." Acta Anaesthesiol Scand 43(2): 202-5.
BACKGROUND: Anaesthetists, like all other specialists, need to be aware of the costs of drugs, fluids and disposables commonly used in their clinical practice so that excessive costs and waste can be minimized without compromising patient care or safety. The present study describes cost consciousness among 120 anaesthetic staff members in two Danish anaesthetic departments. METHOD: A prospective study questioning 120 anaesthetic staff members (69 anaesthetic nurses, 35 senior anaesthetists and 16 junior anaesthetists) about the costs of 29 drugs, fluids and disposable used in routine anaesthetic practice. RESULTS: After the study period 107 questionnaires (90%) were available for analysis. Thirty-eight percent of all estimated costs were within 50% of the actual costs and 85% were within 100%. The costs of relatively expensive items such as isoflurane, enflurane, sevoflurane and hydroxyethyl starch were consistently underestimated, whereas cheaper items such as narcotic drugs, endotracheal tubes, intravenous tubing, plastic syringes and Quincke spinal needle were consistently overestimated. In general, the anaesthetic staff overestimated the costs by 69% (range -24% to 270%). The anaesthetic nursing group overestimated the costs by 49% (range -24% to 270%), junior anaesthetists by 94% (range 25% to 226%) and senior anaesthetists by 72% (range -14% to 135%). CONCLUSION: This study shows that the overall consciousness of the costs of anaesthetic drugs, fluids and disposables has to be improved in order to permit the staff to optimize resources.

Duh, Q. Y., A. L. Senokozlieff-Englehart, et al. (1999). "Laparoscopic gastrostomy and jejunostomy: safety and cost with local vs general anesthesia." Arch Surg 134(2): 151-6.
BACKGROUND AND HYPOTHESIS: General anesthesia is used for laparoscopic enteral access because pneumoperitoneum requires relaxation of the abdominal muscles. We wanted to determine whether these procedures could be performed with similar results and cost under local anesthesia. DESIGN: Randomized controlled study with 30-day follow-up including a cost-benefit analysis. SETTING: University-affiliated hospitals. PATIENTS: Forty-eight patients (32 men, 16 women; mean age, 67 years) undergoing laparoscopic gastrostomies (n = 32) and jejunostomies (n = 16). INTERVENTION: Twenty-four patients underwent laparoscopic gastrostomy (n = 15) and jejunostomy (n = 9) under local anesthesia with intravenous conscious sedation and monitored anesthesia care. Twenty-four patients had general anesthesia. MAIN OUTCOME MEASURES: Conversion to general anesthesia, complications, and cost. RESULTS: Ten patients under local anesthesia had periods of deep sedation and 1 required conversion to general anesthesia. One patient under general anesthesia required conversion to open gastrostomy. No patients had intraoperative aspiration; however, 4 aspirated after the procedure. One patient died of myocardial infarction during the 30-day follow-up. We found no significant difference in the total mean cost and actual procedure time. The surgeon's fee accounted for 31% of the total cost. CONCLUSIONS: Some patients undergoing laparoscopic enteral access may require deep sedation and a rare patient may require general anesthesia. Clinical conditions and surgeon preference, therefore, should determine whether local anesthesia is suitable for laparoscopic gastrostomies and jejunostomies, and in what setting, since there is no difference in success rate or complications when compared with general anesthesia. Potential savings are possible from the operating room (26% of total cost) or anesthesiologist (12% of total cost) if these procedures are performed in an endoscopy suite without monitored anesthesia care.

Rollert, M. K., R. A. Strauss, et al. (1999). "Telemedicine consultations in oral and maxillofacial surgery." J Oral Maxillofac Surg 57(2): 136-8.
PURPOSE: The purpose of this study was to evaluate the efficiency of telemedicine consultation for preoperative assessment of patients. PATIENTS AND METHODS: A retrospective study of 43 patients was done to evaluate the efficiency of telemedicine consultation in adequately assessing patients for dentoalveolar surgery with general anesthesia and nasotracheal intubation. Efficiency was defined as the ability to conduct surgery with general anesthesia at the immediately following clinic appointment without the need for further preoperative testing, evaluation, or consultation. Thirty-five of these patients were subsequently treated. RESULTS: Ninety-five percent (33) of patients were able to undergo surgery with general anesthesia at the immediate appointment, and 100% of patients were assessed correctly, using telemedicine consultation. Two of the patients were assessed as American Society of Anesthesiologists Class III during telemedicine consultation and required further evaluation before surgery could be scheduled. No surgical procedure was canceled, and there were no anesthetic complications attributable to inadequate preoperative assessment of patients during telemedicine consultation. CONCLUSIONS: This study confirms that telemedicine consultations are as reliable as those conducted by traditional methods. Because of the reorganization of health care and the ways it is financed, it may be more economical to move data from place to place than to move doctors from place to place. Telecommunication is an efficient and cost-effective mechanism to provide preoperative evaluation in situations in which patient transport is difficult or costly.

Gerancher, J. C., H. Floyd, et al. (1999). "Determination of an effective dose of intrathecal morphine for pain relief after cesarean delivery." Anesth Analg 88(2): 346-51.
Very small doses of intrathecal (i.t.) morphine (25-200 microg) have been used in an effort to provide effective postoperative pain relief while minimizing side effects after cesarean delivery. We performed a double-blinded study in 40 patients presenting for elective cesarean delivery in which i.t. morphine was administered along with oral hydrocodone/acetaminophen and other medications commonly administered after cesarean delivery. We administered i.t. morphine by up-down sequential allocation of doses. For the purposes of this study, adequate postoperative analgesia was defined as comfort not requiring i.v. morphine for 12 h after spinal anesthesia with bupivacaine, fentanyl, and morphine. In addition, a time and cost comparison was performed for study patients receiving intrathecal morphine compared with a historical group of patients receiving patient-controlled analgesia with i.v. morphine. We were unable to determine with meaningful precision a dose of i.t. morphine to provide analgesia in this context. However, very small doses of i.t. morphine combined with oral hydrocodone/acetaminophen and other medications commonly prescribed after cesarean delivery provided postoperative pain relief with no more time commitment than patient-controlled analgesia (148 +/- 61 vs 150 +/- 57 min) and with significantly less acquisition cost ($15.13 +/- $4.40 vs $34.64 +/- $15.55). Implications: When used along with oral analgesics, very small doses of spinal morphine provide adequate pain relief after cesarean delivery. Spinal anesthetics, oral analgesics, and other medications commonly prescribed to treat side effects after cesarean delivery contribute significantly to this analgesia. When small doses of spinal morphine are used in this setting, they provide adequate analgesia and patient satisfaction that is time- and cost-effective.

Yeh, C. C., J. C. Yu, et al. (1999). "Thoracic epidural anesthesia for pain relief and postoperation recovery with modified radical mastectomy." World J Surg 23(3): 256-60; discussion 260-1.
The purpose of this study was to investigate whether thoracic epidural anesthesia (TEA) provides better postoperative pain relief and recovery than general anesthesia (GA) for modified radical mastectomy (MRM) surgery. Sixty-four patients rated as American Society of Anesthesiologists (ASA) 1 to 3 who underwent MRM surgery were included in the study. In TEA group patients, 2% lidocaine (15-20 ml) was administered via the epidural route as primary anesthesia, in conjunction with midazolam (5-10 mg) and fentanyl (<250 microg) for amnesia. The GA patients were maintained with isoflurane and 50% nitrous oxide in oxygen. After operation the patients were given pethidine (1 mg/kg IM) as required for pain relief. The time to first pethidine requirement, total pethidine consumption, worst pain score, bed rest time, satisfaction score, and anesthesia-related side effects were recorded for 2 days after surgery. The results show that TEA provided a more prolonged analgesic effect than GA after operation. A longer time to first pethidine requirement (19.2 +/- 1.5 vs. 7.6 +/- 2.5 hours) (p < 0. 001) and decreased pethidine consumption (17.2 +/- 7.0 vs. 76.3 +/- 17.4 mg) (p < 0.001) were observed in the TEA group than in the GA group, respectively. A worse visual analog scale (VAS) pain score was observed in the GA group (5.7 +/- 0.6) than in TEA patients (4.3 +/- 0.4) (p < 0.01). The average bed rest time was significantly shorter in the TEA group (16.9 +/- 0.9 hours) (p < 0.01) than in the GA group (27.1 +/- 4.1 hours). Overall satisfaction scores were significantly higher in the TEA group (4.4 +/- 0.1) (p < 0.01) than in the GA group (3.5 +/- 0.2). Side effects were observed at a higher frequency in the GA group (16/32) (p < 0.0001) than in the TEA group (3/32). The frequency of pethidine injection for pain relief was significantly lower in the TEA group (8/32) (p < 0.0001) than in the GA group (24/32). The total hospital cost (NT 64,392 +/- 3,523 vs. NT 53,806 +/- 2,817) (p = 0.0342) and anesthesia cost (NT 7,968 +/- 246 vs. NT 5,268 +/- 262) (p < 0.0001) are also significantly lower in the TEA group than the GA group. In conclusion, TEA provided better postoperative pain relief and recovery and lower cost than GA for MRM surgery.

Khan, M. L., M. M. Hossain, et al. (1998). "Lateral femoral cutaneous nerve block for split skin grafting." Bangladesh Med Res Counc Bull 24(2): 32-4.
Wound with loss of skin needs grafting for early healing and to prevent deformity and disability. For skin grafting lateral femoral cutaneous nerve block can be used as regional anesthesia. The efficacy of 55 lateral femoral cutaneous nerve block was assessed in 52 patients of 10 to 70 years of age. The nerve block was found effective in all cases. 90.91% showed excellent results. The procedure seemed to be easy, safe and less costly for the purpose of skin grafting.

Cheng, D. C. (1998). "Impact of early tracheal extubation on hospital discharge." J Cardiothorac Vasc Anesth 12(6 Suppl 2): 35-40; discussion 41-4.
Economic realities of the continuing increased utilization of cardiac surgery in the 1990s have led to the practice of early tracheal extubation and shortening of the length of intensive care unit and hospital stays. In this era of cost-containment and physician report cards, we are held accountable for patients' outcome in terms of mortality, morbidity, quality of life, length of stay, and cost of care. This report outlines the factors that influence costs of cardiac surgery. These include patient risk, anesthesia, surgical, intensive care unit, and health care systems or hospital factors. The current literature on outcome, utilization, and cost implications of early tracheal extubation in cardiac surgery is summarized and discussed. It has been demonstrated that early extubation anesthesia is safe and cost-effective and can improve resource utilization in cardiac surgery, but to achieve a maximum cost benefit from fast-track or early extubation anesthesia in cardiac patients, team organization of a fast-track cardiac surgery program must be implemented. A perioperative clinical pathway management in fast-track cardiac surgery is presented.

Rosenberg, A. D. (1998). "Ensuring early discharge following major surgery: orthopedic surgery." J Cardiothorac Vasc Anesth 12(6 Suppl 2): 7-10; discussion 41-4.
Managed care, critical pathways, and length of stay issues have a major impact on current hospital policy and patient care. In orthopedic surgery, significant strides have been made in improving efficiency, decreasing costs, and reducing length of stay. Use of vertical pathways, especially the first day of admission, the day of surgery, is important for efficient patient care. As anesthesiologists involved in the process, we must be certain that patient care is not compromised in an attempt to save money or achieve early discharge. In many studies, pain management, type of anesthesia, and amount of blood loss are not significant factors in length of hospital stay. These factors must be approached as quality-of-life issues and appropriate decisions made.

Stonemetz, J. (1999). "Cost per unit." Anesthesiology 90(1): 331-2.

Atkin, D. H. (1999). "Benchmarking anesthesia costs." Anesthesiology 90(1): 330; discussion 331-2.

Suttner, S., J. Boldt, et al. (1999). "Cost analysis of target-controlled infusion-based anesthesia compared with standard anesthesia regimens." Anesth Analg 88(1): 77-82.
With the development of new computer-assisted target-controlled infusion (TCI) systems and the availability of short-acting anesthetics, total IV anesthesia (TIVA) has become increasingly popular. The aim of this study was to compare costs of TCI-based anesthesia with two standard anesthesia regimens. Sixty patients undergoing elective laparoscopic cholecystectomy were randomly divided into three groups. Group 1 (TIVA/TCI) received TIVA using a propofol-based TCI system and continuous administration of remifentanil; Group 2 (isoflurane) underwent inhaled anesthesia with isoflurane, fentanyl, and N2O; Group 3 (standard propofol) received fentanyl and N2O and a continuous infusion of propofol using a standard delivery system. Maintenance doses for anesthetics were adjusted according to the patient's need. Isoflurane consumption was measured by weighing the vaporizer by using a precision weighing machine. Duration of surgery and of anesthesia was similar in the three groups. Time from stopping administration of anesthetics until tracheal extubation (6+/-2 min) and stay in the postanesthesia care unit (PACU; 70+/-12 min) were shorter in Group 1 than in the Groups 2 (15+/-3 and 87+/-13 min, respectively) and 3 (10+/-4 and 81+/-14 min, respectively) (P < 0.05). Episodes of postoperative nausea and vomiting in the PACU and on the surgical ward were less common in Group 1 than in the other two groups. Intraoperative costs were higher in Group 1 ($62.19/patient; $0.55/min of anesthesia) than in Groups 2 ($16.97/patient; $0.13/min of anesthesia) and 3 ($34.68/patient; $0.32/min of anesthesia). Cost for discarded anesthetic drugs accounted for almost 18% of total intraoperative costs in Group 1. We conclude that TIVA/TCI anesthesia using propofol/remifentanil was associated with the highest intraoperative costs but the fewest postoperative side effects. An overall cost-effectiveness analysis of new anesthetic regimens must balance the direct cost of anesthetics and beneficial effects leading to improved patients' comfort. IMPLICATIONS: In today's climate of cost-consciousness, careful economic evaluation of new anesthetic regimens is necessary. A target-controlled infusion (TCI)-based total IV anesthesia (TIVA) regimen using propofol and remifentanil was compared with a standard propofol anesthesia regimen and an inhaled anesthetic technique using isoflurane. Target-controlled infusion/total IV anesthesia was associated with the largest intraoperative costs but allowed the most rapid recovery from anesthesia, was associated with fewest postoperative side effects, and permitted earlier discharge from the postanesthesia care unit.

Rosen, N. B. and H. J. Hoffberg (1998). "Conservative management of low back pain." Phys Med Rehabil Clin N Am 9(2): 435-72, ix.
The importance of using appropriate conservative care in the management of low back pain has been increasingly stressed in recent years, initially as a backlash to the many failures following surgical intervention (particularly repeated surgeries), and, more recently, as a means of controlling health care costs and instituting patient-centered systems of care. It is difficult to define and determine just what "appropriate conservative care" is and should be. Perhaps even more important in this current era of health care reform is the question of who makes this determination.

Bach, A. (1998). "[Costs of sevoflurane in the perioperative setting]." Anaesthesist 47(Suppl 1): S87-96.
The total costs for a department of anaesthesia amount to a fraction of the total hospital budget that is proportional to the overall number of hospital departments; this means anaesthetic departments are in general not cost drivers. In the analysis of perioperative costs, anaesthesia accounts for about 10-15% of the total costs for the complete hospital stay, the exact proportion depending on the type of surgery. In the analysis of costs for the intraoperative period alone anaesthesia personnel contributes about 20%, and material costs about 10% of the total costs, while inhalational agents account for less than 1%. Aggregating the cost for inhalational agents, about 5% of the total budget of an anaesthesia department are accounted for by volatile agents, which take a 20% share of all drug costs in an anaesthesia department. When the costs of one MAC-hour of anaesthesia are compared, halothane, enflurane and isoflurane remain the cheapest agents. Sevoflurane is less expensive than desflurane at current market prices. However, at low fresh gas flows the price difference for one MAC-hour is marginal for these volatile anaesthetics. Total intravenous anaesthesia using propofol is even more expensive, more than 2- to 6-fold the costs of inhalational anaesthesia, depending on the dosage of the intravenous agent, the type of inhalational agent, the fresh gas flow, etc. In our hospital, overall costs for inhalational agents could be reduced over a three year period by increasing use of the low-flow technique, despite sevoflurane becoming the agent of choice for pediatric and ambulatory patients and for operations of short duration. An overall cost-effectiveness analysis must balance the costs of the various agents and the pharmacodynamic advantages of the new agents, e.g. rapid recovery from anaesthesia. Furthermore, indirect costs for side effects have to be taken into account, e.g., nausea and vomiting. The question of whether these effects and side effects translate into cost differences between agents depends largely on local factors, e.g., patient case mix, staffing, policy of discharge from the postanaesthetic care unit, and many others. We conclude that volatile anaesthetics account for only a minor portion of the budgets in the anaesthesia department and the hospital overall. The higher market price for the new agents that result in higher costs per MAC-hour may be compensated for by the economic impact of the fewer side effects and the shorter postanaesthesia stay in the hospital.

Imai, Y., T. Mammoto, et al. (1998). "The effects of preanesthetic oral clonidine on total requirement of propofol for general anesthesia." J Clin Anesth 10(8): 660-5.
STUDY OBJECTIVE: To investigate the effects of preanesthetic oral clonidine on total propofol requirement for uniform minor surgery (breast conservative surgery: breast cancer removal with axillary lymph node dissection), and to compare the action of clonidine with that of preanesthetic oral diazepam, a commonly used benzodiazepine. DESIGN: Randomized double-blinded study. SETTING: Operating room ASA physical status I and II room and recovery room of the cancer center. PATIENTS: 80 breast cancer patients scheduled for surgery. INTERVENTIONS: Patients were randomized to one of four treatment groups (placebo, clonidine 75 micrograms, or 150 micrograms of clonidine, or 10 mg of diazepam were orally administered 60 min before induction of anesthesia); n = 20 per group. After evaluating the sedation and anxiety levels of patients using a visual analog scale, anesthesia was induced with propofol (1.5 mg/kg), and maintained with oxygen (O2): nitrous oxide (N2O) (30:70) with a continuous infusion of propofol. The propofol infusion was started at 10 mg/kg/h for 10 minutes, then decreased to 8 mg/kg/h, and 6 mg/kg/h thereafter, and the rate of infusion was adjusted to obtain adequate anesthesia (maintaining hemodynamic parameters within 20% of that prior to premedication). Fentanyl 0.2 mg (each 0.1 mg was given for intubation and axillary lymph node dissection, respectively) was administered. MEASUREMENTS AND MAIN RESULTS: Preanesthetic oral clonidine (150 micrograms) and diazepam (10 mg) induced anxiolysis without sedation. The total requirement (the mean infusion rates) of propofol in placebo, clonidine 75 micrograms, clonidine 150 micrograms, and 10 mg of diazepam groups were 841 +/- 70 (9.0 +/- 0.3), 720 +/- 63 (7.1 +/- 0.4), 491 +/- 39 (5.6 +/- 0.2), and 829 +/- 77 mg (7.9 +/- 0.4 mg/kg/h), respectively. The cost of propofol in these groups was $51.0 +/- 3.8, $45.5 +/- 3.2, $33.5 +/- 2.3, and $50.5 +/- 4.4, respectively. CONCLUSIONS: Preanesthetic oral clonidine (150 micrograms) but not diazepam (10 mg) reduced the total requirement of propofol while stabilizing hemodynamic parameters. In addition, 150 micrograms of oral clonidine attenuates the hemodynamic responses associated with tracheal intubation.

Lazarov, S. J. (1998). "Office-based surgery and anesthesia: where are we now?" World J Urol 16(6): 384-5.
At the time of publication of this journal, the Center for Urinary Control in Memphis, Tennessee, has performed eight office-based surgical procedures using anesthesia. Patients were aged between 56 and 80 years, and all were ASA I-III class. The procedures involved either cystoscopy with collagen injection into the bladder neck or cystoscopy with indigo laser treatment of the prostate. All patients were prepared by the anesthesiologist prior to the day of surgery, and appropriate laboratory tests were ordered and evaluated. All patients did very well, the surgical field was quiet, and each procedure went very smoothly. Each patient tolerated anesthesia without any adverse effect, was recovered in an adjacent examination room, and was extremely satisfied upon discharge from the office. Anesthesia was induced with Propofol (Diprivan) and sublimaze, maintained with a Propofol infusion and oxygen. The surgeon performed a periprostatic block on the patient having the Indigo laser treatment.

Bollmann, A., N. K. Kanuru, et al. (1997). "Comparison of three different automatic defibrillator implantation approaches: pectoral implantation using conscious sedation reduces procedure times and cost." J Interv Card Electrophysiol 1(3): 221-5.
Recent technological advances in implantable defibrillator systems (ICD) have changed implantation approaches. The aim of this study was to investigate the influence of these improvements on procedure times, implant-related charges, patient recovery, and morbidity. Ninety-six consecutive patients undergoing implantation of a nonthoracotomy ICD were studied. Implantation was performed under general anesthesia with the generator placed abdominally in 22 patients (group I) and pectorally in 40 patients (group II). Thirty-four patients underwent pectoral implantation using conscious sedation (group III). Groups were comparable with respect to clinical variables. Implantation duration and total procedure duration were shorter in group III (67 +/- 21 minutes and 117 +/- 30 minutes) when compared with group I (100 +/- 25 minutes and 157 +/- 39 minutes) and group II (86 +/- 24 minutes and 153 +/- 34 minutes, P < 0.05). Patients in group III did not require admission to the Post-Anesthesia Care Unit. In contrast, patients in groups I and II spent 92 +/- 28 minutes and 91 +/- 31 minutes in the Post-Anesthesia Care Unit. Implantation-related charges were reduced in patients having pectoral implantation using conscious sedation ($1451 +/- 217 vs. $2354 +/- 550 and $2796 +/- 384, P < 0.05). Patients in group III had a lower frequency of postoperative oral analgesic use (3.2 +/- 2.7 doses, P < 0.05) and a shortened post-operative length of stay (1.9 +/- 1.6 days, P < 0.05) when compared with groups I (5.7 +/- 4.0 doses and 3.3 +/- 1.4 days) and II (5.2 +/- 3.5 doses and 2.6 +/- 1.1 days). The overall complication rate was low (6.3%), with no differences between groups. Advances in ICD technology have simplified implantation, leading to shorter, less painful, and less expensive procedures.

Cohen, S. E., C. L. Hamilton, et al. (1998). "Obstetric postanesthesia care unit stays: reevaluation of discharge criteria after regional anesthesia." Anesthesiology 89(6): 1559-65.
BACKGROUND: Obstetric patients may have long postanesthesia care unit (OB-PACU) stays after surgery because of residual regional block or other conditions. This study evaluated whether modified discharge criteria might allow for earlier discharge without compromising patient safety. METHODS: Data were prospectively collected for 6 months for all patients (N=358) who underwent cesarean section or tubal ligation and recovered in the OB-PACU. Regional anesthesia was used in 94% of patients. The duration of anesthesia and PACU stays, the presence and treatment of events in the PACU, and the regression of neural blockade were recorded. Discharge from the OB-PACU required a 60-min minimum stay, stable vital signs, adequate analgesia, and ability to flex the knees. After completion of prospective data collection, events that kept patients in the PACU after 60 min were reevaluated as to whether patients needed to stay in the PACU for medical reasons. "Needed to stay" events included bleeding, cardiorespiratory problems, sedation, dizziness, and pain. "Safe to leave" conditions included pruritus, nausea, and residual neural blockade. The cumulative duration of OB-PACU stays not clearly justifiable for medical reasons was calculated. RESULTS: Residual block and spinal opioid side effects accounted for the majority of "unnecessary" stays. Annually, 429 h of PACU time could have been saved using the revised criteria. Complications did not develop subsequently in any patient deemed "safe to leave." CONCLUSIONS: In many obstetric patients, the duration of PACU stays could safely be shortened by continuing observation in a lower-acuity setting. This may result in greater flexibility and more efficient use of nursing personnel.

Mangano, C. M. (1998). "Show me the money (but first show me the data!)." J Cardiothorac Vasc Anesth 12(6): 615-6.

Luber, M. J. and J. A. Nunley (1998). "How to reduce the cost of hindfoot fusion." Foot Ankle Int 19(11): 735-7.
The purpose of this study was to determine whether modification of a surgical practice by using regional anesthesia and local bone grafting would yield the same surgical results as traditional anesthesia and iliac crest bone graft, with a cost reduction. All patients were matched by preoperative disease and were assessed to determine satisfaction and complications. The length of stay for the seven matched pairs of patients undergoing subtalar arthrodesis decreased significantly, as did blood loss, total operating room time, and tourniquet time. The average cost saving was $7844. Similar data were found for the nine matched pairs of patients who underwent triple arthrodesis, blood loss, and tourniquet time. Total cost was again found to be significantly lower by an average of $9302 in the study group. The most dramatic changes between the two groups were demonstrated in the patients who underwent ankle fusions. The 10 matched pairs showed a marked reduction in length of stay, with a decrease in estimated blood loss from 260 mL to 92 mL (P < 0.05). The total operating room time and tourniquet time in these two groups were similar. There was a cost savings in the study group of $9888, with no increase in complications. The use of longacting regional anesthesia and local bone grafting enabled surgeons to perform hindfoot arthrodeses on an outpatient basis, with a significant reduction in cost to the patient and no increase in complications.

Lam, H. T., S. Cretin, et al. (1998). "Building better team charters: an example from reengineering the preoperative system." Qual Manag Health Care 6(2): 62-73.
This article illustrates a six-step chartering method using a successful project at the West Los Angeles VA Medical Center. The annual savings generated from this project were estimated at $13 million.

Meyer-McCright, A., R. E. Hofer, et al. (1998). "Study of direct variable anesthesia costs in the dilatation and curettage patient." Aana J 66(4): 385-9.
This retrospective study was designed to compare the cost of anesthesia in three different groups of patients who received general anesthesia for a diagnostic dilatation and curettage procedure. The analysis included 194 patients, ASA physical status I, II, or III. All patients were outpatients with similar body mass index and age. The three groups were thiopental/isoflurane (n = 13), propofol/isoflurane (n = 126), and propofol/desflurane (n = 55). Anesthesia drugs, volatile agents, personnel costs, and type of providers were included in the cost comparison. The cost of supplies, inhalation agents, and drugs for the thiopental/isoflurane group were significantly different (P < .001) than the other two groups. The mean +/- SD thiopental/isoflurane combination was $7.00 +/- $2.74, whereas, the mean +/- SD cost of the propofol/isoflurane and propofol/desflurane groups was $12.73 +/- $3.57 and $14.40 +/- $5.05, respectively. The mean +/- SD cost of all three anesthetic drugs/volatile agents/endotracheal tube groups was $12.85 +/- $4.35. No statistically significant differences between the three groups were found in postanesthesia care unit (PACU) drug costs, anesthesia personnel cost, total direct anesthesia costs, or length of stay. The incidence of antiemetic administration intraoperatively and in PACU was significantly different (P < .001) between the thiopental/isoflurane group and the other groups. The thiopental/isoflurane group did not receive any antiemetics in either area, whereas the propofol groups received antiemetics 12.7% of the time. The three anesthesia providers, Certified Registered Nurse Anesthetists, student registered nurse anesthetists (SRNA), and anesthesia residents were reviewed looking at anesthesia supply cost, personnel cost, and total direct anesthesia costs. No statistically significant differences were found between the groups. We conclude that an anesthetic using thiopental/isoflurane is more cost-effective than propofol/desflurane or propofol/isoflurane anesthetics and the postoperative length of stay is no different for the three anesthetic approaches.

Williams, B. A., B. M. DeRiso, et al. (1998). "Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery." J Clin Anesth 10(7): 570-8.
STUDY OBJECTIVES: (1) To incorporate regional anesthesia options for common outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as management tools to measure postoperative same-day surgery processes and discharge outcomes; and (3) to determine the effects of general, regional, and combined general-regional anesthesia on these processes and outcomes. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathway existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients selected general anesthesia (+/- femoral nerve block) or epidural anesthesia, after which the remainder of the perioperative anesthesia process was standardized with respect to the drugs and equipment used. 1995-1996 patients did not necessarily have a choice in anesthesia technique and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by anesthesia technique used, were measured. Combined general-regional anesthesia care for ACLR in 1996-1997, when compared with general anesthesia alone, led to increased pharmacy and materials costs and increased turnover time. However, patients with the combined technique showed improved recovery profiles and lower unexpected admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving epidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients, when compared with the clinical pathway general anesthesia used. CONCLUSIONS: Clinical pathway regional anesthesia care for outpatient orthopedics may have a significant role in simultaneously containing costs and improving both process efficiency and patient outcomes.

Williams, B. A., B. M. DeRiso, et al. (1998). "Benchmarking the perioperative process: II. Introducing anesthesia clinical pathways to improve processes and outcomes and to reduce nursing labor intensity in ambulatory orthopedic surgery." J Clin Anesth 10(7): 561-9.
STUDY OBJECTIVES: (1) To introduce anesthesia clinical pathways as a management tool to improve the quality of care; (2) to use the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as a template for data collection and analysis; and (3) to determine the effects of anesthesia clinical pathways on surgical processes, outcomes, and costs in common ambulatory orthopedic surgery. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathways existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. Regional anesthesia options were routinely offered to patients in the clinical pathway. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients underwent clinical pathway anesthesia care in which the intraoperative and postoperative anesthesia process was standardized with respect to symptom management, drugs, and equipment used. 1995-1996 patients did not have a standardized intraoperative and postoperative anesthetic course with respect to the management of common symptoms or to specific drugs and supplies used. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by the use of the anesthesia clinical pathway, were measured. Clinical pathway anesthesia care of ACLR in 1996-1997, which actively incorporated regional anesthesia options, reduced pharmacy and materials cost variability; slightly increased turnover time; improved intraoperative anesthesia and surgical efficiency, recovery times, and unexpected admission rates; and decreased the number of required nursing interventions for common postoperative symptoms. CONCLUSIONS: Clinical pathway patient management systems in anesthesia care are likely to produce useful outcome data of current practice patterns when compared with historical controls. This management tool may be useful in simultaneously containing costs and improving process efficiency and patient outcomes.

Kanter, G. and N. R. Connelly (1998). "Re: Pharmacy savings generated by preoperative administration of clonidine." J Clin Anesth 10(7): 613-4.

Rowe, W. L. (1998). "Economics and anaesthesia." Anaesthesia 53(8): 782-8.

Lobe, T. E. (1998). "Laparoscopic surgery in children." Curr Probl Surg 35(10): 859-948.
The surgeon should be aware of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide surgical care in association with either outpatient or short-stay hospitalizations appear to be cost-effective and appropriate state-of-the-art medical care. Because the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will continue to become increasingly available.

Ruiz, K. and S. A. Coldwell (1998). "Death in the dental chair--an avoidable catastrophe?" Br J Anaesth 80(6): 877.

McNitt, J. D., E. T. Bode, et al. (1998). "Long-term pharmaceutical cost reduction using a data management system." Anesth Analg 87(4): 837-42.
Cost containment is an important issue in medicine today, and the ability to control costs and maintain quality patient care presents a challenge to practitioners. Educating practitioners about drug costs has been identified as an effective method, but the benefits of education are usually short-lived. To evaluate the role of education in cost control, pharmaceutical use and performance improvement data were analyzed at a tertiary care institution during two time periods. A total of 4,530 anesthesia records and associated performance improvement data from March to June 1993 were analyzed as a baseline. These data were shared with the clinicians of an anesthesia department and used to educate practitioners regarding the costs and use of injectable pharmaceuticals and to identify areas in which cost savings could be achieved. The same information from 10,600 cases during January to October 1996 were compared with the early group. The expenditures for injectable pharmaceuticals to provide anesthesia were decreased by more than $30,000 per month, or $32 per case, without changing the performance indicators that were monitored, and has been maintained for >3 yr. IMPLICATIONS: By using a data management system, the cost for medications to provide anesthesia has been reduced without changing the quality of patient care.

Revol, M., P. Levan, et al. (1998). "[What is the cost of excision-suture of a skin lesion under local anesthesia? 2-month prospective evaluation in a public sector hospital]." Ann Chir Plast Esthet 43(1): 82-6.
The purpose of this study was to assess the cost of a minimal surgical operation: skin surgery under local anesthesia in the outpatients department. A two-month prospective study was carried out on 149 operations, with a mean duration of 33 minutes. The mean cost of the operation was 434 FF. Although this study is very specific and its results cannot be generalized, it gives a method and an order of magnitude. It shows that it is difficult to save money without decreasing the quality of the operation. The price list of the French national health care system, and the price of the surgeon himself are discussed.

(1998). "Alliances benchmarking anesthesia-related costs." OR Manager 14(11): 23.

Welch, J. P., J. L. Cohen, et al. (1998). "Pain control following elective gastrointestinal surgery: is epidural anesthesia warranted?" Conn Med 62(8): 461-4.
Fifty-nine patients undergoing elective major gastrointestinal surgery were entered into a prospective, randomized trial between January 1993 and July 1994 comparing the effectiveness, side effects, and hospital costs of postoperative epidural anesthesia (Group 1, n = 29) and intramuscular narcotic injections (Group 2, n = 30). Epidural catheters were inserted by a team that supervised catheter care and infusion rates in the postoperative period. The nonepidural group received intramuscular injections on a regular basis. Patients filled out visual analog scales to measure levels of pain ( 1 = minimal, 10 = maximal) every eight hours. Patient activity, bowel, and urinary function were recorded by the nursing staff. Control of pain (as measured by the daily average visual analog score) was more effective in Group 1 (P < .001) on postoperative days 1-3 (1.3 vs 3.6 on day 1, 0.7 vs 2.6 on day 2, 0.9 vs 3 on day 3). There was no significant difference in mean values between groups 1 and 2 with respect to first ambulation on the hospital ward, onset of liquid diet, intake of solid food, first spontaneous voiding, first bowel movement, length of hospitalization, or charge of hospitalization ($13,439 +/- 7,452 vs $11,821 +/- 6,630). We conclude that epidural anesthesia significantly lessens incisional pain following major elective lower gastrointestinal surgery when compared to analgesic injections alone. However, while not statistically significant, the overall charge was increased by 14% in the epidural group. This finding should be examined in light of the relatively low pain level in patients receiving narcotic injections alone.

McKenzie, A. J. (1998). "Reinforcing a "low flow" anaesthesia policy with feedback can produce a sustained reduction in isoflurane consumption." Anaesth Intensive Care 26(4): 371-6.
A three-month audit of isoflurane consumption at Palmerston North Hospital in 1994 showed an averaged vapour flow rate of approx 85 ml per minute of anaesthesia, equivalent to 1.4% isoflurane at six litres per minute. After purchasing volatile agent analysers, a program encouraging low flow anaesthesia and providing a report of the previous month's consumption rate was started in July 1996. The isoflurane averaged vapour flow rate was tracked over the following twenty-month period and fell by a sustained 65% to range around 30 +/- 5 ml/min, producing savings of approximately NZ$104,000 over this period.

Ricotta, J. J., T. Hargadon, et al. (1998). "Cost management strategies for carotid endarterectomy." Am J Surg 176(2): 188-92.
BACKGROUND: We developed a model for capitation and global pricing for carotid endarterectomy. METHODS: A care algorithm for diagnosis, perioperative management, and postoperative care using cost data was developed. Perioperative care charges were extrapolated from a 1-year experience and applied to models to determine pricing for a 1-year global fee and a 5-year capitated contract. RESULTS: Global pricing was estimated at $12,071 per patient while a capitated price for 5-year care was $17,175. Based on the age mix of the population, a per member, per month cost could be calculated assuming a frequency of 414 procedures per 100,000 patients over age 65 and 31 procedures per 100,000 patients under 65. Sources of costs were extensive preoperative diagnostic testing, particularly angiography, brain imaging, and cardiac evaluation. CONCLUSIONS: Global pricing and capitation are both feasible for carotid endarterectomy. Each approach has unique risks and benefits.

Maxwell, J. G., B. A. Tyler, et al. (1998). "Laparoscopic cholecystectomy in octogenarians." Am Surg 64(9): 826-31; discussion 831-2.
Performance of laparoscopic cholecystectomy (LC) is increasing, and patients age 80 and over comprise an increasingly larger proportion of the LC population. This study documents that the increase is accompanied by safe outcome in this patient population. However, the evidence also suggests that cholelithiasis appears to have been a neglected condition in this age group. The prevalence of nonelective procedures, the conversion rate to an open operation, more intraoperative complications, and the percentage having evidence of common bile duct stone passage all support this assertion. With the technology of LC, we are now appropriately addressing the problem with a treatment that allows less surgical trauma to the patient and shorter recovery time. Same-day LC surgery for the octogenarian appears to be very safe and would justify a decision to perform earlier LC in these patients. Surgery done before the appearance of comorbid conditions that increase the surgical and anesthetic risks may result in improved outcomes for the elderly at lower cost. Even when necessary in the already hospitalized patient, LC can be accomplished with morbidity and mortality comparable to those of elective abdominal procedures in younger populations.

Munro, E. (1998). "Carotid surgery." Eur J Vasc Endovasc Surg 16(2): 170-1.

Goydos, J. S., T. S. Ravikumar, et al. (1998). "Minimally invasive staging of patients with melanoma: sentinel lymphadenectomy and detection of the melanoma-specific proteins MART-1 and tyrosinase by reverse transcriptase polymerase chain reaction." J Am Coll Surg 187(2): 182-8; discussion 188-90.
BACKGROUND: A minimally invasive standard has yet to be developed for sentinel lymphadenectomy, and many patients undergo this procedure in the main operating room under general anesthesia. These patients often have microscopic metastases in sentinel nodes that could be missed by histopathologic examination. Techniques of reverse transcriptase polymerase chain reaction (RT-PCR) could detect these metastases if the nodes could be preserved intraoperatively. STUDY DESIGN: Fifty patients with melanoma > or = mm thick underwent sentinel lymphadenectomy under local anesthesia in an outpatient surgical unit. Sentinel nodes were identified using blue dye and technetium-99 sulfur colloid and a hand-held gamma probe. Each node was sectioned, with half sent for routine histopathologic study and half preserved in liquid nitrogen. We used RT-PCR to detect mRNA for tyrosinase and Melanoma Antigen Recognized by T cells-1 (MART-1). RESULTS: All patients were able to tolerate sentinel lymph node biopsy under local anesthesia. Sentinel lymph nodes were obtained in 100% of our patients, and usable mRNA was harvested from all but five. Ten patients had positive sentinel node(s) by standard histopathologic examination, and all of these nodes were also positive for MART-1 and tyrosinase. Three patients with negative results by histopathology had positive results by RT-PCR analysis. The average cost of these outpatient operations was 38% less than the same operations performed in the main operating room under general anesthesia. CONCLUSIONS: Sentinel lymphadenectomy under local anesthesia in an outpatient setting and intraoperative lymph node preservation in liquid nitrogen are both feasible. Both tyrosinase and MART-1 are promising markers in the detection of occult melanoma in lymph nodes.

Du Bois, M., P. Donceel, et al. (1998). "Social insurance cost of standard discectomy and percutaneous nucleotomy. A retrospective study of 87 social insurance claim files of male blue collar workers." Acta Orthop Belg 64(2): 144-9.
A retrospective review of social insurance claim files of male blue collar workers was conducted to compare the social insurance costs of percutaneous lumbar nucleotomy with standard lumbar discectomy ; 29 percutaneous nucleotomy procedures were matched with 58 standard discectomies all carried out between January 1992 and December 1994. It was concluded that a standard discectomy procedure results in significantly higher costs during hospitalisation with respect to surgery, anaesthesia and hospital stay. A percutaneous nucleotomy leads to a significantly higher outpatient expenditure especially in radiology and medical devices. The relative proportion of outpatient practitioner's visits and hospital stay costs was significantly higher for the standard discectomy whereas medical devices had a relatively higher share in outpatient expenditure for the percutaneous nucleotomy. In this population of 87 compensation claimants, the average social insurance costs did not significantly differ between the percutaneous nucleotomy and the standard discectomy.

Blain, K. M. and F. J. Hill (1998). "The use of inhalation sedation and local anaesthesia as an alternative to general anaesthesia for dental extractions in children." Br Dent J 184(12): 608-11.
OBJECTIVE: To determine the extent to which inhalation sedation might replace general anaesthesia for extractions in children and assess the success rate, cost and parental reaction in comparison to general anaesthesia. DESIGN: A matched pair design. SETTING: Unit of paediatric Dentistry at the University Dental Hospital of Manchester, UK between December 1992 and June 1994. SUBJECTS AND METHODS: Subjects aged 3 to 16 years who had been referred for extractions under general anaesthesia were used. Data were recorded for each visit and parents were asked to complete a simple post-operative questionnaire. OUTCOME: Treatment success was defined as completion of all treatment planned for the patient. Relative costs were derived from the time taken and staff costs. RESULTS: 265 subjects, mean age 7.63 (+/- 2.45) years had treatment attempted with sedation of whom 221 (83.4%) completed successfully. Young age, multiple extractions and irregular dental attendance predisposed to treatment failure, whereas orthodontic extractions had a similar success rate (97.6%) to general anaesthesia. The cost of sedation was less; parental reaction to sedation was also significantly better. CONCLUSION: Inhalation sedation can be used for many children referred for general anaesthesia. Greater use of this technique in the primary sector is needed to reduce the number of child referrals for general anaesthesia.

Fisher, D. M. and S. D. Kelley (1998). "Pharmaceutical practice guidelines: do they actually cost money?" Anesthesiology 89(1): 269-70; discussion 270-1.

Wellwood, J., M. J. Sculpher, et al. (1998). "Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost." Bmj 317(7151): 103-10.
OBJECTIVE: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN: A randomised controlled trial of 403 patients with inguinal hernias. SETTING: Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.

Cheng, D. C. (1998). "Fast track cardiac surgery pathways: early extubation, process of care, and cost containment." Anesthesiology 88(6): 1429-33.

Ackerstaff, R. G. and C. J. van de Vlasakker (1998). "Monitoring of brain function during carotid endarterectomy: an analysis of contemporary methods." J Cardiothorac Vasc Anesth 12(3): 341-7.

Ho, Y. H., J. Lee, et al. (1998). "Randomized controlled trial comparing same-day discharge with hospital stay following haemorrhoidectomy." Aust N Z J Surg 68(5): 334-6.
BACKGROUND: A randomized controlled trial was conducted to compare traditional hospital stay haemorrhoidectomy (STAY) with same-day discharge haemorrhoidectomy (DAY) with regard to costs, clinical outcome and patient satisfaction. METHODS: A total of 54 consecutive patients were randomized to either STAY or DAY groups. A standardized excision of three piles was performed and the wounds were left open. The DAY patients went home on the same day but the STAY patients remained in hospital until their bowels had opened. A linear analogue pain score and patient satisfaction questionnaire were administered. During a mean follow-up of 60.5 (standard error of mean = 1.2) weeks, the complications and the total medical costs were recorded RESULTS: There were no differences in the age and sex distributions in both groups (STAY: 11 men, 16 women; mean age 40.6 (+/- 1.8) years; DAY: 10 men, 17 women; mean age 40.6 (+/- 1.9) years). Despite accounting for any readmissions, the DAY patients accumulated shorter total hospitalization stays (P < 0.001) and incurred less total medical costs (P = 0.04). The pain scores, analgesia requirements, postoperative complications, patient satisfaction and time taken off work were not different between the two groups. However, more patients in both groups preferred to stay after surgery if they should need another haemorrhoidectomy. CONCLUSIONS: Haemorrhoidectomy (with excision of three piles) can be safely performed as a day procedure, with reduced hospitalization and medical costs.

Bach, A., H. Schmidt, et al. (1998). "[Economic aspects of anesthesia. II. Cost control in clinical anesthesia]." Anasthesiol Intensivmed Notfallmed Schmerzther 33(4): 210-31.
The primary scope of economic analyses is the quantification of the costs (input) in relation to the results (outcome, output). According to whether a similar or different dimension of outcome parameters is chosen, it is possible to differentiate between cost minimisation, cost effectiveness, cost benefit and cost utility analyses. Decision trees and sensitivity analyses serve to develop or examine cost outcome studies. The principal perspective of economic analysis is of crucial significance. In the present overview of cost control programmes in clinical anaesthesia, the perspective chosen throughout is that of budget responsibility in a department of anaesthesiology. With regard to economic factors in clinical anaesthesiology, the cost of medical and nursing staff represents the largest cost block. It is, therefore, essential that personnel is efficiently employed, i.e. how the perioperative procedure is organised. In the area of material costs, blood products--including coagulation factors and plasma substitutes--are particularly cost intensive, followed by medical products and drugs, especially muscle relaxants and inhalational anaesthetics. In the perioperative context, the costs of anaesthesia personnel account for 5-15% of the total costs of patient care, while material costs account for 2-10%. In view of this small portion of the total costs, cost control programmes in anaesthesia can only make a relatively small contribution to reducing overall cost. However, it must be realised that anaesthesia care is vitally important for the perioperative process which means that in this context cost-effectiveness interventions have consequences that also affect other fields, e.g. postoperative pain service besides anaesthesia. In conducting economic analyses, cost considerations or reductions cannot be targeted alone, but must always also integrate outcome aspects so that costs and quality are regarded in relation to one another.

Brown, J. A., D. S. Elliott, et al. (1998). "Postprostatectomy urinary incontinence: a comparison of the cost of conservative versus surgical management." Urology 51(5): 715-20.
OBJECTIVES: Post-radical prostatectomy stress incontinence occurs in up to 20% of patients. Postprostatectomy incontinence is initially treated with undergarments, pads, or drip collectors. Patients with persistent leakage are often treated with a transurethral bulking agent (Contigen) or placement of an artificial genitourinary sphincter (AGUS). We have compared the direct costs of each treatment at our institution over 10 years. METHODS: The Mayo Clinic estimating office provided the Medicare and non-Medicare charges for patients receiving both collagen injection (outpatient) and AGUS placement (2-day hospitalization) during August 1995. The Mayo Store provided the current price of all undergarments, pads, and drip collectors carried. Two local grocery stores provided the cost of Depends undergarments. RESULTS: The following items were the least expensive carried at the Mayo Clinic Store: Entrust undergarments, Active Style pads, and Conveen drip collectors at $0.99, $0.52, $1.05 each, respectively. The average cost of Depends undergarments was $0.52 each. The cost of wearing 5 of the least expensive undergarments or pads per day for 10 years is $9497. The average estimated Medicare and non-Medicare cost for outpatient (general anesthesia) collagen injection is $4300 and $5625, respectively. The average Medicare and non-Medicare cost for AGUS placement is $15,400 and $20,300, respectively. Factoring in our current 22.4% reoperation rate, the average per patient Medicare and non-Medicare cost for AGUS placement is $18,850 and $24,847, respectively. CONCLUSIONS: The cost of the AGUS placement compares favorably with the cost of transurethral collagen injection (under general anesthesia) in patients requiring several (more than three) collagen injection treatments or requiring the continued use of undergarments after collagen injection. Whereas the cost of transurethral collagen injection, when effective, compares favorably with conservative treatment, AGUS placement is significantly more expensive than conservative management for almost all patients except the exceedingly rare patient wearing more than 9 undergarments or pads per day. When the psychosocial benefit of urinary continence is considered, however, transurethral injection of collagen or AGUS placement often becomes the preferred treatment.

Fleisher, L. A., S. E. Metzger, et al. (1998). "Perioperative cost-finding analysis of the routine use of intraoperative forced-air warming during general anesthesia." Anesthesiology 88(5): 1357-64.
BACKGROUND: Despite the well-documented ability of forced-air warming (FAW) to maintain normothermia, it is unclear whether this technique results in a net increase or decrease in costs. The authors did a prospective cost-finding study comparing FAW with routine thermal care in patients at low risk for perioperative complications who were undergoing general anesthesia. METHODS: After institutional review board approval was received, 100 patients were studied who were having elective surgery scheduled for more than 2 h during general endotracheal anesthesia. Patients were randomly assigned to one of two groups: FAW or routine thermal care. All patients received a standardized anesthetic. Anesthesia providers were blinded to core temperatures and the use of FAW. Primary outcomes were those associated with perioperative costs. RESULTS: The time from completion of surgical dressing until tracheal extubation was significantly reduced in the FAW group (10 +/- 1 min compared with 14 +/- 1 min; mean +/- SEM; P < 0.01). There was no demonstrable difference in attainment of postanesthesia care unit discharge criteria between the two groups, although the FAW group used one less cotton blanket there. The net savings related to the use of the FAW depends on the percentage of the intraoperative costs that are fixed rather than variable ($15 additional for FAW if all costs are fixed compared with $29 savings if all costs were variable). CONCLUSIONS: Routine intraoperative FAW significantly reduced time until extubation and use of cotton blankets in the postanesthesia care unit. These results suggest that the influence of FAW on net total perioperative costs depends on patient and surgical characteristics and institutional factors related to cost accounting.

Dexter, F., D. A. Lubarsky, et al. (1998). "A method to compare costs of drugs and supplies among anesthesia providers: a simple statistical method to reduce variations in cost due to variations in casemix." Anesthesiology 88(5): 1350-6.
BACKGROUND: Comparison of costs among anesthesia providers using "cost per case" does not adjust for variations in casemix (such as the type of procedure and patient condition). The authors propose an alternative method for comparing costs using the American Society of Anesthesiologists' Relative Value Scale (ASARVS) system, which incorporates basic units (for the procedure), modifier units (for the patient's physical condition), "other" units (such as for the placement of invasive monitors), and time units (proportional to the case duration). METHODS: Data were obtained from a series of 3,340 anesthetics performed at a tertiary hospital. Administered and discarded drug, supply, and fluid costs were used. RESULTS: Costs expressed as dollars per ASARVS unit had 54% less variability than costs expressed as dollars per case (P < 0.0001). Pearson correlations between demographic variables and cost per ASARVS unit ranged from -0.10 to 0.13. Total (e.g., quarterly) costs for simulated sets of cases were predicted within 0.0 +/- 2.3% by multiplying (1) their sum of units and (2) a like set of case's sum of costs divided by sum of units. CONCLUSIONS: Costs of anesthetic supplies and drugs of a case were more accurately reported as "cost per unit" than as "cost per case." This method of calculating the cost of anesthetic drugs and supplies has several applications, including (1) comparison of costs among anesthesia providers and (2) benchmarking costs among hospitals and anesthesia groups. By design, anesthesia providers' time is quantified by their ASARVS units. Together anesthesia costs (personnel, supplies, and drugs) are better reported as "cost per unit" than as "cost per case."

Apfelbaum, J. L. (1998). "Bypassing PACU: a cost effective measure." Can J Anaesth 45(5 Pt 2): R91-4.

Holland, T. J., S. Lucey, et al. (1997). "Costs in providing facilities for treatment of handicapped patients under general anaesthesia." J Ir Dent Assoc 43(3): 72-5.
The cost of providing dental treatment for severely mentally/physically handicapped patients under general anaesthesia in a specially designed unit are investigated in this study. The costs involved in the provision of such treatment were found to be high at 613 IR Pounds per patient. It is recommended that the full potential of primary care services for handicapped patients be developed in order to reduce the use of these necessary, but expensive secondary care facilities. It is also recommended that such facilities should be shared with other services in order to reduce overall costs.

Engoren, M. C., C. Kraras, et al. (1998). "Propofol-based versus fentanyl-isoflurane-based anesthesia for cardiac surgery." J Cardiothorac Vasc Anesth 12(2): 177-81.
OBJECTIVE: To evaluate drug costs, time of mechanical ventilation, complications, and hospital length of stay comparing propofol-based with fentanyl-isoflurane-based anesthesia. DESIGN: A prospective, randomized study. SETTING: A university-affiliated, tertiary care community hospital. PARTICIPANTS: Seventy patients undergoing primary coronary artery bypass surgery. Interventions: Patients were randomized to either a low-dose fentanyl-isoflurane or a lower-dose fentanyl-isoflurane anesthetic supplemented with a continuous infusion of propofol. MEASUREMENTS AND MAIN RESULTS: Fentanyl-isoflurane anesthesia was significantly less expensive ($50.03+/-$27.26 v $121.69+/-$31.40) for anesthesia drugs and ($58.08+/-$27.39 v $129.91+/-$31.52) for total drug costs. There was also a trend for patients in the fentanyl-isoflurane group to be extubated slightly sooner (388+/-202 v 449+/-252 min) and go home sooner (5.1+/-1.8 v 6.0+/-3.0 days). CONCLUSION: Fentanyl-isoflurane provides an inexpensive anesthetic that permits as prompt an extubation as propofol, thus conserving resources for other patients.

Schmitz, R., S. Shah, et al. (1997). "[Extraperitoneal, "tension free" inguinal hernia repair with local anesthesia--a contribution to effectiveness and economy]." Langenbecks Arch Chir Suppl Kongressbd 114: 1135-8.
In this present randomized controlled study, two groups, each consisting of 45 patients, underwent tension-free inguinal hernia repair under general versus local anesthesia. Patients in the local anesthesia group described their pain during mobilisation by using the VAS and were found to have a significant pain level decrease from the first to the fifth postoperative day. In conclusion, it could be shown that tension-free hernia repair under local anesthesia is superior to tension-free hernia repair during general anesthesia concerning perception of pain and pain management.

Patterson, P. (1998). ""Fast tracking" of patients through PACU: is it safe?" OR Manager 14(6): 1, 8-9.

Overdyk, F. J., S. C. Harvey, et al. (1998). "Successful strategies for improving operating room efficiency at academic institutions." Anesth Analg 86(4): 896-906.
In this prospective study, we evaluated the etiology of operating room (OR) delays in an academic institution, examined the impact of multidisciplinary strategies to improve OR efficiency, and established OR timing benchmarks for use in future OR efficiency studies. OR times and delay etiologies were collected for 94 cases during the initial phase of the study. Timing data and delay etiologies were analyzed, and 2 wk of multidisciplinary OR efficiency awareness education was conducted for the nursing, surgical, and anesthesia staff. After the education period, timing data were collected from 1787 cases, and monthly reports listing individual case delays and timing data were sent to the Chiefs of Service. For the first case of the day, patient in room, anesthesia ready, surgical preparation start, and procedure start time were significantly earlier (P < 0.01) in the posteducation period compared with the preeducation period, and the procedure start time for the first case of the day occurred, on average, 22 min earlier than all other procedures. For all cases combined, turnover time decreased, on average, by 16 min. Unavailability of surgeons, anesthesiologists, and residents decreased significantly (P < 0.05) as causes of OR delays. Anesthesia induction times were consistently longer for the vascular and cardiothoracic services, whereas surgical preparation time was increased for the neurosurgical and orthopedic services (P < 0.05). Identification of the etiology of OR inefficiency, combined with multidisciplinary awareness training and personal accountability, can improve OR efficiency. The time savings realized are probably most cost-effective when combined with more flexible OR staffing and improved OR scheduling. Implications: We achieved significant improvements in operating room efficiency by analyzing operating room data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary team work, and accurate data collection were all important contributors to improved efficiency.

Campos, J. H. and F. C. Massa (1998). "Is there a better right-sided tube for one-lung ventilation? A comparison of the right-sided double-lumen tube with the single-lumen tube with right-sided enclosed bronchial blocker." Anesth Analg 86(4): 696-700.
Anatomic variation between tracheal carina and the take-off of the right upper bronchus often makes the use of a right-sided double-lumen tube (R-DLT) or a single-lumen tube with right-sided enclosed bronchial blocker tube (R-UBB) (Univent) undesirable. This study compared the R-DLT with the R-UBB to determine whether there was any advantage of one over the other during anesthesia with one-lung ventilation (OLV) for right-sided thoracic surgeries. Forty patients requiring right lung deflation were randomly assigned to one of two groups. Twenty patients received a right-sided BronchoCath double-lumen tube, and 20 received a Univent tube with a bronchial blocker placed in the right mainstem bronchus. The following were studied: 1) time required to position each tube until satisfactory placement was achieved; 2) number of times that fiberoptic bronchoscopy was required (including one with the patient supine and one in lateral decubitus position); 3) number of malpositions after initial confirmation of tube placement; 4) time required until lung collapse; 5) surgical exposure; and 6) cost of tubes per case. No differences were found with any of these variables except that the cost of acquisition overall was greater for the R-UBB than for the R-DLT. No right upper lobe collapse was observed in the postoperative period in the chest radiograph in any of the patients studied. We conclude that either tube can be used safely and effectively for right-sided thoracic surgeries that require anesthesia for OLV. Implications: In this study, right-sided double-lumen tubes were compared with the Univent with right-sided bronchial blockers. The results indicate that either tube can be used for right-sided thoracic surgery.

Kuhn, I. (1998). "[Cost management in anesthesia]." Anasthesiol Intensivmed Notfallmed Schmerzther 33(Suppl 1): S36-40.

Mizuno, K. and R. Sumiyoshi (1998). "Air contamination of a closed anesthesia circuit." Acta Anaesthesiol Scand 42(1): 128-30.
Closed-circuit anesthesia (CCA) has certain advantages such as decreased cost, decreased anesthetic gas pollution, improved inhalational gas humidity and temperature in comparison to conventional inhalational anesthesia using a high fresh gas flow, i.e. more than 2 L x min(-1), with a semi-closed breathing circuit. The main disadvantage of CCA is the possibility of hypoxic anesthetic gas delivery. This potentially lethal situation is caused by an insufficient oxygen flow rate for the body metabolism or by the accumulation of inactive gas, usually nitrogen, within the breathing circuit in spite of a sufficient oxygen concentration in the fresh gas supply to the breathing circuit. In the latter case, the accumulation of inactive gas may also lead an increased risk of awareness because of its dilution effect on the concentrations of inhalational anesthetics. We herein present a case of air contamination of the breathing circuit through a sampling line of an anesthetic gas monitor. The air caused a decrease in the oxygen concentration during closed circuit anesthesia.

Koscielniak-Nielsen, Z. J., H. L. Stens-Pedersen, et al. (1998). "Midazolam-flumazenil versus propofol anaesthesia for scoliosis surgery with wake-up tests." Acta Anaesthesiol Scand 42(1): 111-6.
BACKGROUND: Wake-up tests may be necessary during scoliosis surgery to ensure that spinal function remains intact. METHODS: Intra- and postoperative wake-up tests were performed together with somatosensory cortical evoked potentials (SCEPs) monitoring in 40 patients randomized to either midazolam (M) or propofol (P) infusions for scoliosis surgery. Other anaesthetic medication was similar in both groups. At the surgeon's request, N2O was turned off and midazolam or propofol infusions were discontinued. In the M group, flumazenil was given in refracted doses. Patients were asked to move hands and feet. The test was repeated immediately after the end of surgery. RESULTS: The median intraoperative wake-up times were 2.9 min in the M group and 16.0 min in the P group. The respective postoperative wake-up times were 1.8 and 13.9 min. The quality of both intra- and postoperative arousals was significantly better in the M group. Twelve patients in the P group could not be awakened intraoperatively within 15 min and were given naloxone. One of these patients woke up violently and dislodged the endotracheal tube. Another patient in the P group had explicit recall of the test, but no pain. Five patients in the M group became resedated in the recovery room. Cost of anaesthetic drugs was similar in both groups. Satisfactory intraoperative SCEPs were recorded from 17 patients in each group. There were no neurological sequelae. CONCLUSIONS: Wake-up tests can be conducted faster and better with midazolam-flumazenil sequence compared with propofol.

La Fianza, A., G. Coven, et al. (1997). "[Rationalization of the use of preoperative thoracic radiography in obstetrics and gynecology]." Radiol Med (Torino) 94(6): 618-21.
INTRODUCTION: Rationalizing preoperative chest radiography remains a problem in our Country. Therefore, we tried to use preoperative chest films rationally in obstetrics and gynecology to assess their impact on anesthesia planning and patient management and their use in early postoperative complications. MATERIAL AND METHODS: We examined two groups of patients: group A consisted of 570 women (mean age: 31 years) scheduled to be submitted to cesarean section but with no preoperative chest radiography; group B consisted of 471 patients (homogeneous in age to group A patients) submitted to nononcologic gynecologic surgery and with a single-projection preoperative chest radiograph. Anesthesiologic assessment, preoperative biochemical tests and EKG were performed in all patients. All patients underwent abdominal surgery under general anesthesia. The first 24 postoperative hours were monitored for possible anesthesia-related complications. The anesthesiologist need of chest radiography based on clinical findings was investigated in group A patients, as well as the importance of chest film findings in possible anesthesia-related complications. RESULTS: Group A and group B were homogeneous by mean patient age and anesthesia duration; clinical findings never suggested the need of chest radiography in group A patients. Three cardiorespiratory complications occurred (two respiratory arrests in group A and a gas embolism in group B), but the (un)availability of chest film findings made no difference in treatment. DISCUSSION: The availability of the preoperative chest radiographs of a group of healthy women of 31 years mean age does not make any difference in anesthesia planning and type. In our series, the most severe cardiorespiratory complications were homogeneous in the two groups, which confirms their random character, and the (un)availability of preoperative chest film findings made no real difference, even though the lack of radiographic evidence made patient management more demanding for anesthesiologists.

Pourriat, J. L. (1998). "Cost implications of the practice of anaesthesiology." Eur J Anaesthesiol 15(1): 124.

Lang, F. J., P. Grosjean, et al. (1997). "[The current status of broncho-esophagoscopy in otorhinolaryngology]." Laryngorhinootologie 76(11): 704-8.
Most bronchoscopies and esophagoscopies are currently performed with flexible instruments by the respective specialist. Thus the field of bronchoesophagology is in danger of being fragmented; neither the pneumologist nor the gastroenterologist have the complete overview of the upper respiratory and digestive tract. This review shows that number of pathologic conditions in the ENT area and the mediastinum involve the upper respiratory as well as the digestive tract, and thus underscore the need for combined tracheobronchial and esophageal endoscopy. Mastering of rigid and flexible endoscopy is mandatory to be efficient in diagnostic and therapeutic broncho-esophagoscopy. The ENT specialist is in the best position to maintain an overview of this whole field. New developments in broncho-esophagoscopy are presented and discussed in terms of cost effectiveness.

Ishaq, M., R. S. Kamal, et al. (1997). "Value of routine pre-operative chest X-ray in patients over the age of 40 years." J Pak Med Assoc 47(11): 279-81.
The overall usefulness of routine chest X-ray, its cost benefit ratio and effect on anaesthetic management in patients over the age of 40 years was assessed. Four hundred and seventy-seven consecutive patients undergoing elective non-cardiopulmonary surgery with no cardiopulmonary diseases, having a routine preoperative chest x-ray were selected at the Aga Khan University Hospital, Karachi. Twenty five (5.2%) were excluded from the study as their chest x-ray were not available at the time of surgery. Twenty eight (8.3%) below and 33 (28.7%) above 60 years of age had abnormalities in chest x-ray but the difference in cardiac abnormalities in two age groups was insignificant. The frequency of lung field abnormalities increased with age from 3.2% in less than 60 to 15.6% in patients above 60 years of age. The difference in frequency of occurrence of lung field abnormalities was statistically significant in case of lung abnormalities. Only one case required change in anaesthetic management based on routine preoperative chest x-ray. Our study showed that the incidence of significant lung field abnormalities increased in patients aged 60 years and above with no history of chronic obstructive airway disease. We recommend routine preoperative chest x-ray be carried out only in patients over the age of 60 years.

Memon, M. A. and R. J. Fitzgibbons, Jr. (1998). "Assessing risks, costs, and benefits of laparoscopic hernia repair." Annu Rev Med 49: 95-109.
Laparoscopic inguinal herniorrhaphy (LIHR) was introduced with the following potential advantages: less postoperative discomfort and pain, reduced recovery time that allows earlier return to full activity, easier repair of a recurrent hernia, the ability to treat bilateral hernias concurrently, the performance of a simultaneous diagnostic laparoscopy, ligation of the hernia sac at the highest possible site, improved cosmesis, and decreased incidence of recurrence. Potential disadvantages include complications, such as bowel, bladder, and vascular injuries; potential adhesive complications at sites where the peritoneum has been breached or prosthetic material has been placed; the apparent need, at least at the present, for a general anesthetic; and the increased cost because of expensive equipment needs. Most surgeons agree that LIHR has a role in the management of patients with a recurrent hernia after a conventional inguinal herniorrhaphy (CIHR), bilateral inguinal hernia, or a need for laparoscopy for another procedure, such as laparoscopic cholecystectomy. The routine use of LIHR for the unilateral, uncomplicated hernia is a more contentious issue.

Cheng, D. C. (1998). "Fast-track cardiac surgery: economic implications in postoperative care." J Cardiothorac Vasc Anesth 12(1): 72-9.
Economics is the main driving force in changing health care delivery in the 90s. The motto is to "do more with less." Cost containment and efficient resource utilization swing the pendulum back to the debate of early tracheal extubation in cardiac surgical patients. Recently, it has been confirmed that fast-track cardiac anesthesia is both safe and cost-effective. This article describes the economic implications in postoperative care of fast-track cardiac surgery. First, the developments of early extubation postcardiac surgery and the factors that influence costs of cardiac surgery are reviewed. Second, the morbidity outcome, utilization, and cost implications of early extubation in cardiac surgery are summarized. The perioperative cost analysis in fast-track cardiac surgery, including the cost of complications and resource utilization, is outlined. Lastly, it is important to realize that early extubation does not necessarily mean earlier intensive care unit or hospital discharge. To achieve a maximum cost benefit from early extubation, team organization of a fast-track cardiac surgery program for the perioperative management of these patients is detailed.

Doyle, R. L. and J. B. Mark (1998). "Lung volume reduction surgery for the treatment of chronic obstructive pulmonary disease." Adv Intern Med 43: 233-52.

Callesen, T., K. Bech, et al. (1998). "The feasibility, safety and cost of infiltration anaesthesia for hernia repair. Hvidovre Hospital Hernia Group." Anaesthesia 53(1): 31-5.
Data from 400 consecutive elective ambulatory operations for inguinal hernia under unmonitored local anaesthesia with limited pre-operative testing were prospectively obtained by the use of standardised files and questionnaires to assess the feasibility, patient satisfaction and potential cost reductions for such a technique. The median age of the patients was 59 years, and 29 operations were performed in ASA group III patients. The median postoperative hospital stay was 85 min. Conversion to general anaesthesia was necessary only in two cases, and nine patients needed overnight admission. One week postoperative morbidity was low with one case of transient cerebral ischaemia and one case of pneumonia, but no case of urinary retention. On follow-up, 88% were satisfied with the procedure, including unmonitored local anaesthesia. The cost reduction was at least 160 Pounds per patient compared with general/regional anaesthesia. We conclude that elective inguinal herniorrhaphy may be performed routinely under unmonitored local anaesthesia with a low postoperative morbidity, a high satisfaction rate and significant cost reductions.

Lacerda-Filho, A. and J. R. Cunha-Melo (1997). "Outpatient haemorrhoidectomy under local anaesthesia." Eur J Surg 163(12): 935-40.
OBJECTIVE: To compare early and late results and costs of outpatient haemorrhoidectomy under local anaesthesia with those of inpatient haemorrhoidectomy. DESIGN: Prospective study with historical controls. SETTING: University hospital, Brazil. SUBJECTS: 51 patients who required haemorrhoidectomy. INTERVENTIONS: Outpatient haemorrhoidectomy under local anaesthesia. MAIN OUTCOME MEASURES: Early and late results and comparative costs. RESULTS: One patient was withdrawn from the study because of hypertension and subsequently lost to follow-up. The remaining 50 patients were discharged a mean of 68 (23) minutes after operation. Twelve patients complained of severe pain, one had faecal impaction and 2 developed bleeding. One patient developed urinary retention, compared with 18 in the historical group (p < 0.001). Forty-two patients (84%) were thoroughly satisfied with their treatment. Late complications did not differ significantly from those observed in the historical group. The estimated hospital costs were US$ 313.6 for outpatient, and US$ 716 for inpatient treatment. CONCLUSION: Outpatient haemorrhoidectomy under local anaesthesia was safe and comfortable for most patients, with complication rates comparable to or better than those observed after inpatient treatment and at less than half the cost.

Mallow, P. K., M. Klaipo, et al. (1997). "Dental nurse training in Cambodia--a new approach." Int Dent J 47(3): 148-56.
In 1993 a 4-5 month programme to train rural dental nurses in Cambodia was introduced. Courses have now been conducted in 12 of Cambodia's 22 provinces. The dental nurses are trained to provide simple treatment, including local anaesthetic, extractions, ART restorations, and scaling, for all age groups, and also learn how to introduce prevention and oral health promotion activities within their communities. On completion of training nurses are supplied with a set of basic instruments and some materials. Evaluation has shown the programme to be meeting the oral health needs of the rural people where there are no dentists and a number of unique strengths were identified. A recent planning workshop on oral health care in Cambodia to 2005 decided to set up a dental nurses training school in two provincial capitals, and to increase the number of nurses in training. At the same time the annual number of new dentists being trained will be limited to ten. The expansion of the dental nurses training programme will ensure that increasingly more of the population have access to basic preventive and curative dental care, and at a cost which the country can afford.

Raber, M. and M. Tryba (1997). "[Nausea and vomiting in the postoperative phase: drug prevention and therapy with established agents in adults]." Anasthesiol Intensivmed Notfallmed Schmerzther 32(10): 623-6.

Kaynaroglu, V. and F. Agalar (1997). "Efficacy of ketorolac tromethamine and extrapleural intercostal nerve block on post-thoracotomy pain." Int Surg 82(3): 322.

Nakamura, S. J., A. Conte-Hernandez, et al. (1997). "The efficacy of regional anesthesia for outpatient anterior cruciate ligament reconstruction." Arthroscopy 13(6): 699-703.
Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Until recently, the majority of these procedures have been performed on an impatient basis. This retrospective study evaluated 67 consecutive patients who underwent an arthroscopically assisted, autogenous bone-patellar ligament-bone ACL reconstruction that was supervised by the same surgeon. General endotracheal anesthesia was used for 36 patients and a femoral sciatic nerve block was used in 31 patients. Only patients who underwent either isolated ACL reconstructions, or those combined with either medial or lateral meniscectomies, were included. No statistically significant differences in either the mean anesthesia time or operative time existed between the general anesthesia and regional anesthesia groups. Patients receiving regional anesthesia did require a significantly longer recovery room stay than those who received general anesthesia. Most of the patients who received general anesthesia had inpatient procedures. In the general anesthesia group, 31 of 36 patients spent at least one night in the hospital. Three of 30 patients who received regional anesthesia required hospital admission. There were no differences between anesthesia-related complication between groups. The cost saving of performing ACL reconstructions under regional anesthesia compared with general anesthesia was calculated to be $2,907 per case and predominantly reflected the outpatient approach used in these cases. This study supports the use of femoral sciatic nerve block anesthesia as a safe and reliable alternative to general anesthesia for patients undergoing outpatient ACL reconstruction. The use of this technique was not found to compromise operating room efficiency. Patients receiving regional anesthesia did require a slightly longer recovery room stay. ACL reconstruction performed under regional anesthesia with same-day discharge was well tolerated by our patients and it provides a cost-efficient alternative to ACL reconstructions performed as inpatient procedures.

Baum, J. A. (1997). "Low-flow anaesthesia: the sensible and judicious use of inhalation anaesthetics." Acta Anaesthesiol Scand Suppl 111: 264-7.

Rawal, N. (1997). "Organization of acute pain services--a low-cost model." Acta Anaesthesiol Scand Suppl 111: 188-90.

Andel, H., C. Sitzwohl, et al. (1997). "Process analysis in the operating room." Acta Anaesthesiol Scand Suppl 111: 115-7.

Sabate, A., M. J. Pena, et al. (1997). "[Analysis of cost minimization of epidural anesthesia compared with general anesthesia in oncologic coloproctologic surgery]." An Med Interna 14(6): 291-6.
BACKGROUND: Combined general and epidural anaesthesia in abdominal surgery has shown, both, protective and no effect on final outcome. The aim of this study was to evaluate combined epidural and general anesthesia. METHODS: One hundred and eighty four patients, diagnosed of neoplastic process, in whom an elective procedure of coloproctologic resection and reconstruction was scheduled during the period between January-1993 and December 1994, were studied. In thirty consecutive patients a combined general-epidural anaesthesia (EA) was performed. These patients were compared to thirty general anaesthesia patients (GA), selected randomly from the same period. RESULTS: Both groups were comparable for demographic characteristics and for the type and duration of the surgical procedure. Red Blood Cells units transfused were 1.7 +/- 3 in the EA group and 1.4 +/- 1.9 in the GA group. After the operation, most of patients went to SICU. The length of the hospital stay was 13 +/- 6 days for GA group, while for EA group was .13 +/- 5. The hospital mortality for all operated patients (N = 184) was 1.1%, which were directly related to failure of surgical anastomosis. The need for mechanical ventilation and pulmonary complications were similar in both groups. When analyzing costs, EA group represented a value (pesetas) of 433,501 +/- 183,337 for GA group and 437,735 +/- 149,572 for EA group. CONCLUSIONS: As shown, in the actual context, we conclude that the anaesthetic technique did not have any influence on outcome or on cost.

Chilvers, C. R., A. Kinahan, et al. (1997). "Pharmacoeconomics of intravenous regional anaesthesia vs general anaesthesia for outpatient hand surgery." Can J Anaesth 44(11): 1152-6.
PURPOSE: To compare the cost and effectiveness of intravenous regional anaesthesia (IVRA) with general anaesthesia (GA) for outpatient hand surgery. METHOD: A retrospective record analysis of 121 patients who received IVRA were compared with 64 patients who received GA in our Daycare centre. The costs of anaesthesia and recovery were calculated from an institutional perspective using 1995 Canadian Dollar values. Effectiveness was measured in terms of time for anaesthesia, recovery and discharge, % with unsatisfactory anaesthesia and complications. RESULTS: Both groups were well matched in terms of weight, sex and ASA class. Patients in the IVRA group were older (45 +/- 16 vs 38 +/- 13 yr) and had a lower frequency of two types of operation. The median total cost for the IVRA group of $24.60 (15.76-55.29) was less than that for the GA group of +f448.66 (35.59-73.11), (P < 0.00001). Anaesthesia was unsatisfactory in 11% of the IVRA group, but in none having GA,(P < 0.01). Recovery was faster in the IVRA group with a median time to discharge of 70 (35-180) min compared with 118 (45-320) min in the GA group, (P < 0.00001). Vomiting requiring treatment occurred in 5% of the GA group, but in none having IVRA, (P < 0.05). Dizziness which delayed discharged also occurred in 5% of the GA group, but in none having IVRA, (P < 0.05). CONCLUSION: The cost of anaesthesia and recovery using IVRA for outpatient hand surgery was half that of GA. intravenous regional anaesthesia was less effective than GA in achieving satisfactory anaesthesia, equally effective in time to administer anaesthesia, and more effective in speeding recovery and minimising postoperative complications.

Claoue, C. and C. Lanigan (1997). "Topical anaesthesia for cataract surgery." Aust N Z J Ophthalmol 25(4): 265-8.
First, do no harm. We believe that the analgesia provided by topical anaesthetic is adequate for small-incision cataract surgery and does not compromise the safety of the surgery. In addition, the lack of amaurosis is ideal for day-case surgery, which itself is increasingly popular. If preventable, why not prevented? The greatest attraction of topical anaesthesia is its complete absence of the complications described for injectional local anaesthetic techniques. We therefore recommend that our colleagues consider topical anaesthetic for patients undergoing small-incision cataract surgery under local anaesthesia. Our policy for the past 3 years has been to use only topical or general anaesthetics for cataract surgery.

Macnicol, M. F. (1997). "Fracture of the femur in children." J Bone Joint Surg Br 79(6): 891-2.

Weber, D. O. (1998). "Alta Bates takes on "one of the last sacred places"--the OR and its traditions." Strateg Healthc Excell 11(1): 7-9.

Philip, B. K. (1997). "New approaches to anesthesia for day case surgery." Acta Anaesthesiol Belg 48(3): 167-74.
Anesthesia for day case or ambulatory surgery must be specifically tailored to meet its specialized goals, and the use of sevoflurane helps to meet these goals. Maintenance of sevoflurane anesthesia is associated with good titratability and short early recovery times. The rapidity and quality of recovery after sevoflurane anesthesia are as good or better than other available agents. Clinically more important are the new inhalation induction options possible with sevoflurane. These include vital capacity induction of general anesthesia in adult patients, intubation without neuromuscular blocking drugs, and management of selected patients with difficult airways. Anesthesia by facemask or LMA is easily performed without agent-related irritative side effects. The cost of induction with sevoflurane is significantly less than the standard agent propofol, and is even less when sevoflurane is used for both induction and intubation. The costs of maintenance with sevoflurane are more than isoflurane but less than propofol, and can be reduced to low money amounts by the use of N2O and low fresh gas flows, as well as elimination of the anesthetic adjuvant drugs. These new, cost effective anesthetic techniques are useful additions to the spectrum of anesthetic choices for ambulatory surgery.

Camu, F. and A. Van de Velde (1997). "Cost containment in inhalation anesthesia: the best way." Acta Anaesthesiol Belg 48(3): 155-60.

Merritt, W. T. (1997). "Practice patterns and anesthesia-related costs for liver transplantation." Liver Transpl Surg 3(4): 449-50.

Melissano, G., R. Castellano, et al. (1997). "Safe and cost-effective approach to carotid surgery." Eur J Vasc Endovasc Surg 14(3): 164-9.
OBJECTIVE: To evaluate the safety and cost effectiveness of carotid surgery performed altering the perioperative protocol in an attempt to decrease resource utilisation. SETTING: Department of vascular surgery in a large metropolitan teaching hospital in northern Italy. DESIGN: Prospective, non-selective study. MATERIALS AND METHODS: Three hundred and eighty carotid procedures were performed in 1995 on 343 patients (274 males, 69 females, mean age 68.2 years, range 47-86 years). The most important cost containment measures, were: (i) limiting the use of contrast arteriography to cases of dubious ultrasonographic diagnosis; (ii) routine use of loco-regional anaesthesia; (iii) postoperative admission to an intensive care unit (ICU) only in selected cases; (iv) early postoperative discharge where possible. RESULTS: Mortality was 0.26% and neurological morbidity 1.58%. General anaesthesia was required in eight patients (2.1%), and only seven patients (1.8%) were admitted postoperatively to the ICU. Arteriography was performed in 56 cases (14.7%). The average hospital stay was 5 days with a global cost of 43,036 ECU, as compared with a cost of 6764 ECU for patients treated traditionally with routine arteriography, general anaesthesia and routine ICU admission. CONCLUSIONS: Selective use of arteriography and ICU, routine use of loco-regional anaesthesia and reduced hospital stay make it possible to lower the cost of carotid surgery without sacrificing quality.

Norregaard, J. C., O. D. Schein, et al. (1997). "International variation in anesthesia care during cataract surgery: results from the International Cataract Surgery Outcomes Study." Arch Ophthalmol 115(10): 1304-8.
OBJECTIVES: To describe international variation in anesthesia care and monitoring during cataract surgery and to discuss its implications for cost and safety. METHODS: A standardized questionnaire was sent to random samples of ophthalmologists in the United States, Canada, and Barcelona, Spain, and to all ophthalmologists in Denmark. The survey was conducted in 1993 and 1994. Certified ophthalmologists who had performed 1 or more cataract extractions in the previous year were eligible for enrollment. RESULTS: The response rates were 62% in the United States (n=148), 67% in Canada (n=276), 70% in Barcelona (n=89), and 80% in Denmark (n=82). The anesthetic technique for cataract surgery varied significantly between sites (P<.001). Surgeons reported that retrobulbar blocks were used for 46% of the cataract extractions in the United States, 70% in Canada, 66% in Denmark, and 31% in Barcelona. In Barcelona, general anesthesia was used for 23% of the cataract extractions; it was used for less than 3% of the extractions at the other 3 sites. Peribulbar blocks or topical anesthesia was used for the remaining extractions. In the United States, Canada, and Barcelona, surgeons reported that vital functions were monitored during more than 97% of the extractions and anesthesia surveillance was used during more than 78% of the extractions. In Denmark, ophthalmologists reported that vital functions were monitored and anesthesia surveillance was used for 1% of the cataract extractions (P<.001). CONCLUSIONS: Substantial international variation in anesthesia care and monitoring during cataract surgery was observed. The findings suggest a need for further research to determine whether less intensive monitoring is cost-effective.

Ohta, J., I. Kodama, et al. (1997). "Abdominal wall lifting with spinal anesthesia vs pneumoperitoneum with general anesthesia for laparoscopic herniorrhaphy." Int Surg 82(2): 146-9.
BACKGROUND: Laparoscopic herniorrhaphy has generally been very successful since any postoperative inguinal pain or tension is considerably less troublesome than after other open methods. The conventional laparoscopic approach in the treatment of inguinal hernia involves the use of pneumoperitoneum and general anesthesia. Nevertheless, some complications can be encountered and the procedure is costly. We, therefore, examined the possibility of using a more practical and cost efficient method. MATERIALS AND METHODS: Based on our findings, we propose the use of a Kirschner lifting wire as a means of separating the abdominal wall during laparoscopic herniorrhaphy. Two Kirschner wires are introduced through the subcutaneous tissue, between the umbilicus and inguinal ligament, and parallel to the inguinal ligament. Furthermore, we recommend the use of spinal anesthesia as a means by which the problems associated with general anesthesia and the potential cardiopulmonary complications of carbon dioxide insufflation, are circumvented. Fifteen cases of inguinal hernia have been treated with this new method and compared to the more conventional procedure of pneumoperitoneum under general anesthesia. RESULTS: Visibility of the operative field when used in the inguinal region was not limited at all, and Kirschner wire is considerably less expensive. The postoperative course for the patients who were operated by the new method was uneventful. CONCLUSIONS: Our results indicate that this new method can be useful for the treatment of inguinal hernia.

Edsall, D. W., P. D. Deshane, et al. (1997). "Elusive artifact and cost issues with computerized patient records for anesthesia (CPRA)." Anesthesiology 87(3): 721-2.

Quigley, R. L. and F. L. Reitknecht (1997). "A coronary artery bypass "fast-track" protocol is practical and realistic in a rural environment." Ann Thorac Surg 64(3): 706-9.
BACKGROUND: In this study we determine retrospectively whether assignment of all patients undergoing coronary artery bypass grafting to a "fast-track" protocol (FT) is practical and realistic in our rural institution. METHODS: We compared the outcome of 266 consecutive patients undergoing coronary artery bypass grafting who were fast-tracked in 1996 with that of 266 consecutive patients who were managed conventionally (NFT) in 1994. The surgical techniques were comparable in both groups; however, FT anesthesia used inhalational agents and short-acting narcotics. All comparisons were performed using the Student's t test or the chi 2 test. RESULTS: Postoperatively 95% of the FT group were extubated by 24 hours compared with 0% in the NFT group (p < 0.0001). The mean intensive care unit length of stay in the FT group was 1.7 +/- 0.8 days, whereas it was 2.6 +/- 0.6 days in the NFT group (p < 0.001). The mean postoperative length of stay was 6.4 +/- 1.2 days in the FT group compared with 7.5 +/- 0.9 days in the NFT group (p < 0.001). There were no significant differences in 30-day morbidity/mortality. There was a substantial cost savings in the FT group. CONCLUSIONS: The fast-track protocol can be successful without any compromise of patient care. Early discharge from the hospital, however, is not always feasible.

Onwuanyi, O. N., K. A. Omotosho, et al. (1997). "Extraction of Kuntscher (femoral) implant under local anaesthesia: an appraisal of patients tolerance and merits." J Pak Med Assoc 47(6): 153-5.
A preliminary study of 15 patients undergoing extraction of Kuntscher nails after fracture surgery under local anaesthesia indicated varying behavioural responses and tolerance of the procedure. In the main study cohort, of 59 (fifty-nine) patients within the age range of 16-65 years, made up of 41 males and 18 females, 38 patients (64.4%) tolerated the procedure without discomfort, 14 patients (23.7%) experienced mild to moderate pain, while the remaining 7 patients (11.9%), pain and discomfort was severe enough to require the additional use of intravenous anaesthesia (Ketamine Hydrochloride). There were no significant complications post-operatively. Financial considerations are assuming a greater importance, since planned procedures for osteosynthetic metal implants removal contribute considerably to the waiting lists for elective surgery. We conclude that there are clear advantages in removal of Kuntscher nails under local anaesthesia and it is also noteworthy that the compliance rate amongst our patients has been on the increase, as this method offers shorter waiting period, immediate ambulation, is a day procedure, early return to work and lower monetary costs. We are unaware of existing prospective work on the extraction of Kuntscher nails under local anaesthesia.

Ballantyne, J. C. and Y. Chang (1997). "The impact of choice of muscle relaxant on postoperative recovery time: a retrospective study." Anesth Analg 85(3): 476-82.
To test the hypothesis that the use of long-acting muscle relaxants is associated with prolonged postoperative recovery when compared with the use of shorter-acting relaxants, we undertook a retrospective study of 270 patients with induced paralysis recovering from general anesthesia. We calculated the mean recovery time associated with each muscle relaxant used. Regression analyses were performed to control for potential confounding of the results by length and type of surgery, as well as age and sex. Taking these into account, the adjusted difference in mean recovery time between patients receiving short- and intermediate-acting relaxants (mivacurium, atracurium, and vecuronium) versus those receiving long-acting relaxants (d-tubocurarine, pancuronium, and pancuronium and d-tubocurarine combination) was 30 min (95% confidence interval [CI] 8-53). The adjusted difference in mean recovery time between patients receiving vecuronium and those receiving pancuronium (i.e., the single most frequently used drug in each category) was 33 min (95% CI 1-66). Shortened recovery time accounted for an estimated average $37.95 decrease in recovery room charge per patient when vecuronium was used instead of pancuronium, versus a $22.84 increase in drug cost. Our data and analyses support the hypothesis that the use of long-acting muscle relaxants is associated with prolonged recovery after surgery and provide preliminary evidence that restricting the use of the more expensive, shorter-acting muscle relaxants may represent a false economy. IMPLICATIONS: In this retrospective study, the use of old-fashioned, inexpensive, long-acting paralyzing drugs was found to be associated with prolonged postoperative recovery. This has implications when deciding whether, as an economic measure, to restrict the use of the more expensive, shorter-acting paralyzing drugs, because prolonged recovery also has a price.

Pecka, S. L. and F. Dexter (1997). "Anesthesia providers' interventions during cataract extraction under monitored anesthesia care." Aana J 65(4): 357-60.
In 1993 Medicare paid more money to anesthesia providers for cataract surgery than for any other surgical procedure. Patients undergoing cataract surgery often receive monitored anesthesia care (MAC). Thus, cuts in anesthesia payments from Medicare for cataract surgery may be forthcoming. If few interventions were being done after a retrobulbar block was placed, then a registered nurse might be a safe alternative to an anesthesia provider to monitor the patient. The goal of this study was to describe interventions of anesthesia providers during cataract extraction after the placement of a retrobulbar block. Anesthetic records were reviewed for 560 consecutive cases of cataract extraction using MAC at a large tertiary medical center. Anesthesia providers performed interventions (e.g., administration of drugs) on 33% of patients after the retrobulbar block was in place (95% confidence bound, < 36%). In conclusion, insufficient evidence exists for managed care organizations or other groups to justify a change in practice toward a registered nurse monitoring patients undergoing cataract extraction with a retrobulbar block. Furthermore, until a prospective randomized study has been done, such organizations lack justification for decreasing the amount of time that anesthesia providers spend caring for such patients undergoing cataract extraction.

Farah, R. A., Z. R. Rogers, et al. (1997). "Comparison of laparoscopic and open splenectomy in children with hematologic disorders." J Pediatr 131(1 Pt 1): 41-6.
OBJECTIVE: To compare laparoscopic and traditional open splenectomy in children with nonmalignant hematologic disorders. STUDY DESIGN: Retrospective review of 36 consecutive nonrandomized splenectomies (16 laparoscopic and 20 open) performed for hematologic disorders at a single pediatric institution during the past 3 years. The two-sided Mann-Whitney U test for non-parametric variables was used for statistical analysis. RESULTS: An open procedure was performed on 20 patients (mean age, 9.7 years), five of whom had a concomitant cholecystectomy. A laparoscopic splenectomy was performed on 16 children (mean age, 10.3 years), seven of whom had a concomitant cholecystectomy. The mean anesthesia and operative times were longer in the laparoscopic than in the open group (p < 0.001). However, the mean number of hours of postoperative analgesia was less in the laparoscopic group (p < 0.005). Patients who had laparoscopic splenectomy were also discharged home earlier (p < 0.01) and resumed a regular diet sooner. Mean operating room charges were higher in the laparoscopic group (p < 0.001), but total hospitalization costs were not significantly different. Postoperative complication rates were similar. The hematologic response was comparable. CONCLUSIONS: laparoscopic splenectomy is feasible and safe in children with hematologic disorders. Although it currently requires more operative time than the open approach, it is superior with regard to duration of postoperative analgesia, duration of hospital stay, and recovery of bowel function.

Geiger, M. J., A. Wase, et al. (1997). "Evaluation of the safety and efficacy of deep sedation for electrophysiology procedures administered in the absence of an anesthetist." Pacing Clin Electrophysiol 20(7): 1808-14.
Several procedures performed in the electrophysiology laboratory (EP lab) require surgical manipulation and are lengthy. Patients undergoing such procedures usually receive general anesthesia or deep sedation administered by an anesthesiologist. In 536 consecutive procedures performed in the EP lab, we assessed the safety and efficacy of deep sedation administered under the direction of an electrophysiologist and in the absence of an anesthetist. Patients were monitored with pulse oximetry, noninvasive blood pressure recordings, and continuous ECGs. The level of consciousness and vital signs were evaluated at 5-minute intervals. Deep sedation was induced in 260 patients using midazolam, phenergan, and meperidine, then maintained with intermittent dosing of meperidine at the following mean doses: midazolam 0.031 +/- 0.024 mg/kg; phenergan 0.314 +/- 0.179 mg/kg; and meperidine 0.391 +/- 0.167 mg/kg per hour. In the remaining 276 patients, deep sedation was induced with midazolam and fentanyl and maintained with a continuous infusion of fentanyl at a mean dose of 2.054 +/- 1.43 micrograms/kg per hour. Fourteen patients experienced a transient reduction in oxygen saturation that was readily reversed following administration of naloxone. An additional 11 patients desaturated secondary to partial airway obstruction, which resolved after repositioning the head and neck. Fourteen patients experienced hypotension with fentanyl. All but one returned to baseline blood pressures following an infusion of normal saline. No patient required intubation and no death occurred. Only three patients had recollection of periprocedure events. No patient remembered experiencing pain with the procedure. Hospital stays were not prolonged as a result of the sedation used. In conclusion: (1) deep sedation during EP procedures can be administered safely under the guidance of the electrophysiologist without an anesthetist present; (2) the drugs used should be readily reversible in case of respiratory depression; and (3) this approach may reduce the overall cost of the procedures in the EP lab, maintaining adequate patient comfort.

Siebert, S. (1997). "Day ophthalmic surgery: aspects of perioperative care." Med J Aust 166(9): 511-2.

Wasserfallen, J. B., J. Absi, et al. (1997). "[Evaluation of fifteen months' activity in an ambulatory surgery center in a university hospital]." Rev Med Suisse Romande 117(5): 393-8.

Valente, M. and J. A. Aldrete (1997). "Comparison of accuracy and cost of disposable, nonmechanical pumps used for epidural infusions." Reg Anesth 22(3): 260-6.
BACKGROUND AND OBJECTIVES: Temporary epidural catheter pumps are used to infuse analgesics in patients with chronic intractable pain. Three brands of disposable, nonmechanical pumps adapted for epidural infusion were tested to determine their flow rate efficacy and their cost effectiveness. METHODS: Three pump models were tested: the Baxter (2C1075), Homepump (H100020), and SurgiPEACE (SP500-24). Manufacturers of each unit claim to provide a constant 2-mL/h flow rate. A standard setup was used to simulate both the insertion of the catheter into the epidural space and the environmental conditions consistent with patient ambulation. Reservoirs were filled with water and allowed to infuse into a collection receptacle, and flow rates were measured hourly. Four trials were performed with four separate units and flow rate measurements were averaged to determine a flow rate pattern over the entire infusion period. Data were graphed as the percentage of expected flow rate (% of 2 mL/h) versus infusion time (hours), the 90-110% range being defined as acceptable. RESULTS: All pumps initially infused at a rate above 110% for the first 3-6 hours, after which a steady decline in flow rate was observed. The Homepump produced a flow rate in the acceptable range for the greatest part of its infusion period (41%), followed by the SurgiPEACE (34%), and the Baxter unit (10.4%). The Baxter unit was also cumbersome to handle and therefore difficult to fill. The Homepump unit was easily handled but offered considerable resistance to filling, with partial loss of fluid. The SurgiPEACE unit was easy to handle and fill; however, in two of the units tested, an initial blockage was encountered, and manual patency of the connector and/or catheter had to be established. CONCLUSIONS: All three units deviated considerably from the claimed flow rate of 2-mL/h, both at the beginning and at the end of the infusion. Presumably, the decreasing flow rates are responsible for the diminishing pain relief often experienced by patients over the course of the infusion. The Homepump unit appeared to be the most cost-effective and the easiest to handle and maintained an acceptable infusion rate for the greatest percentage of the infusion period. The considerable cost benefit of using a nonmechanical disposable pump as opposed to a costly but more reliable computerized pump appears to warrant further product improvement and development.

Giner, J., P. Casan, et al. (1997). "Sampling arterial blood with a fine needle." Chest 111(5): 1474.

Cisse, C. T., K. Kerby, et al. (1997). "[Tubal ligation using minilaparotomy under local anesthesia. Apropos of 800 cases at the University Hospital Center in Dakar]." Contracept Fertil Sex 25(4): X-XV.

Gantke, S. and U. Matis (1997). "[Minimal-flow anesthesia in the dog]." Tierarztl Prax 25(2): 156-63.
Many veterinary practices possess an anesthetic machine with a rebreathing system, and therefore the facility to induce anesthesia under more cost-effective reduced fresh gas flow conditions in a semi-closed system. However, as the fresh gas flow is frequently far too high, the rebreathing element is used rarely or not at all, making the anesthesia unnecessarily expensive. The relationships between the fresh gas setting and the final concentrations of expired air are discussed, and experience in 53 dogs with minimal flow anesthesia (500 ml/min), an extreme variant of anesthesia induction using a semi-closed system with minimal excess gas volume and a high proportion of rebreathed gas, is described.

Reintgen, D., J. Albertini, et al. (1997). "Investment in new technology research can save future health care dollars." J Fla Med Assoc 84(3): 175-81.
OBJECTIVE: To perform a cost analysis of the emerging technology of lymphatic mapping for patients with malignant melanoma. DESIGN: A retrospective, computer-aided chart and financial cost and charge review of consecutive patients with the diagnosis of melanoma registered at a cancer center from December, 1995 to March, 1996. PARTICIPANTS: 73 consecutive patients with the diagnosis of Stage 1 and 2 melanoma (cutaneous disease only) had nodal staging of their disease with either a sentinel node (SLN) biopsy or an elective complete node dissection (ELND). This was determined largely by patient choice and the protocol in operation at the time of the presentation of the patient to the clinic. OUTCOMES MEASURED: There were no deaths in the series. Patient morbidity endpoints included rates of infection, incidence of extremity lymphedema, development of a seroma in the regional nodal basin wound and wound healing. Clinical outcome was measured by the ability to obtain complete nodal staging information with the new lymphatic mapping technology, and recurrence rates in the nodal basin after a negative SLN biopsy. Total charges, direct costs and total costs were calculated from all hospital, OR, pathology and lab charges. Professional fees were included in the analysis. RESULTS: Group 1 patients (50) had melanomas greater than 0.76 mm in thickness treated with a wide local excision (WLE), lymphatic mapping and SLN biopsy under general anesthesia. Five patients (Group 2) had their procedure performed under a straight local anesthesia. Group 3 patients (18) had nodal staging performed with an elective node dissection. In Groups 1 and 2, if the SLN was positive for micrometastases, the patients were taken back to the OR for a complete node dissection. The total charges per patient were $13,835, $6,853 and $19,285, respectively. Significant dollar savings were achieved if the nodal staging could be accomplished with the lymphatic mapping technology (p = 0.001). Morbidity was significantly less in Groups 1 and 2 compared to Group 3. After a mean follow-up of three years, only one patient has recurred in a SLN negative basin. CONCLUSIONS: With 38,300 new cases of melanoma diagnosed each year in the United States, a projected savings of $172 million per year (general anesthesia) and $350 million per year (local anesthesia) could be realized if this new mapping technology could be incorporated into the care of the melanoma patient. Patient morbidity is minimized, nodal staging is complete and patients return to work sooner. Recently approved adjuvant therapy can be applied in a selective fashion, treating only those patients in which a documented benefit has been obtained, saving the health care system more dollars. Initial investment in defining the technology was minimal.

(1997). "The use of the bladder-tumour associated analyte test to determine the type of cystoscopy in the follow-up of patients with bladder cancer. The United Kingdom and Eire Bladder Tumour Antigen Study Group." Br J Urol 79(3): 362-6.
OBJECTIVE: To assess the use of the bladder-tumour associated analyte test (BTA, Bard UK) to determine whether patients with bladder cancer scheduled for cystoscopy under general anaesthesia can have local anaesthesia instead. PATIENTS AND METHODS: A total of 272 patients who were scheduled for general anaesthesia cystoscopy were entered into a prospective multicentre study. The BTA test was performed on a specimen of freshly voided urine and the type of cystoscopy was determined according to whether the result was positive or negative. Patients with a negative BTA result were examined with the flexible instrument, under local anaesthesia, instead of the planned general anaesthetic cystoscopy. RESULTS: In 59 patients, the BTA test was positive and tumour was found (true positive), in 145 patients the test was negative and cystoscopy was negative (true negative), in 25 patients the test was positive and cystoscopy was negative (false positive) and in 43 patients, the test was negative but tumour was found on flexible cystoscopy; the patient underwent subsequent cystoscopy under general anaesthesia (false negative). The sensitivity and specificity were 58% and 86% respectively. The use of the BTA test resulted in fewer patients needing cystoscopy under general anaesthesia and saved about 25,500 POUNDS ($31,000) OR 76 POUNDS ($114) PER PATIENT. CONCLUSION: THE integration of the BTA test into the follow-up of patients with bladder cancer may help to select those suitable for cystoscopy, under a local anaesthetic and this will result in cost savings as well as sparing patients the more invasive procedure. The test is not sufficiently sensitive to replace cystoscopy and there were false-negative results despite high-grade recurrence. Thus, when the test is used as part of a follow-up programme, a timely back-up of cystoscopy under general anaesthesia should be arranged for patients with false-negative results.

Ditkoff, E. C., J. Plumb, et al. (1997). "Anesthesia practices in the United States common to in vitro fertilization (IVF) centers." J Assist Reprod Genet 14(3): 145-7.
PURPOSE: Our purpose was to characterize and describe anesthesia practice in programs performing IVF in the United States. METHODS: We used a telephone survey requiring respondents to be either the program director, a physician, or a nurse familiar with the practice. Two hundred seven (78%) Society of Assisted Reproductive Technology (SART) registered programs agreed to participate. Programs were divided by geographic region and type of practice (academic versus private). RESULTS: Ninety-one private (68%) and 41 academic (56%) programs used personnel provided by the Department of Anesthesiology. Conscious sedation was performed most commonly (95%). The remaining 5% used primarily either general, regional, or local anesthesia. Typical recovery times were 90 to 120 min. Average costs of anesthetic administration were $300- $400 and were similar among groups except for the Eastern academic programs, with a higher mean cost of $543. Programs using personnel from anesthesiology reported higher costs compared to programs utilizing their own staff ($391 +/- 15 vs $157 +/- 11; P < 0.05). Complications were infrequent (< 10%); no hospitalizations or serious life-threatening incidents were reported. CONCLUSIONS: A large number of programs safely used their own trained personnel to deliver anesthesia, and realized a significant reduction in cost.

Jones, R. L. (1997). "The bigger picture." J Clin Anesth 9(2): 91-2.

Tobin, M. G., S. L. Pinski, et al. (1997). "Cost effectiveness of administration of intravenous anesthetics for direct-current cardioversion by nonanesthesiologists." Am J Cardiol 79(5): 686-8.
Well-trained nonanesthesiologists can safely and effectively administer IV anesthetics for cardioversion. This practice results in considerable cost savings without compromising patient care.

LaRosa-Nash, P. and M. O'Malley (1997). "Streamlining the perioperative process." Nurs Clin North Am 32(1): 141-51.
Health-care reform and capitated reimbursements have and will continue to influence decreased lengths of hospital stay and continued efficiency in perioperative nursing practice. Collaborative efforts by perioperative nurses, anesthesia care providers, and surgical staff should continue to emphasize concise documentation processes as well as comprehensive assessment and evaluation phases to prepare patients and families for earlier discharge and recovery at home. The objective of new documentation practices and streamlining perioperative preparation processes is to eliminate the duplication of information, meet standards set by professional organizations, and provide quality, efficient care along with patient and family satisfaction.

Shah, C., M. Griffiths, et al. (1997). "Direct listing for adult tonsillectomy." J R Coll Surg Edinb 42(1): 45-6.
Health care economic efficiency is important. Adult tonsillectomy is a common operation. The decision to operate is made at an out-patient consultation and is based on information in the general practitioner's (GP) referral letter. This study aims to define what proportion of adult tonsillectomies are suitable for listing with an out-patient consultation (direct listing). GPs were informed of the indications (six episodes of tonsillitis in the last year) and contraindications (tonsillectomy for another reason and general ill health) for direct listing. All referrals for 1 year were screened by an otolaryngologist and suitable patients were listed directly. Patients were then reviewed in the anaesthetic pre-admission clinic and inappropriate listings were cancelled and reasons noted. Of all patients, 50% were suitable for direct listing. Of these 3% were later deemed inappropriate. None of the cancellations were due to a flaw in the direct listing process. This would result in savings to the NHS of 2 million pounds per annum.

Alhashemi, J. A., D. R. Miller, et al. (1997). "Cost-effectiveness of inhalational, balanced and total intravenous anaesthesia for ambulatory knee surgery." Can J Anaesth 44(2): 118-25.
PURPOSE: A randomized, blinded clinical trial was undertaken to compare recovery characteristics and cost-benefits associated with three general anaesthetic techniques for arthroscopic knee surgery in an ambulatory care setting. METHODS: Ninety three, ASA Physical Status I-II patients were randomly allocated to receive one of three types of general anaesthesia: isoflurane/fentanyl/N2O (Group INH); alfentanil/N2O (Group BAL); or propofol/alfentanil/O2 (Group TIVA). Postoperative recovery profiles were evaluated at 30, 60, 90 and 120 min after emergence from anaesthesia, and direct and indirect costs of each anaesthetic were compared. RESULTS: The most rapid emergence was observed in Group BAL (2.2 +/- 1.5 min, P < 0.0001 compared with groups INH and TIVA), although the incidence of post-operative nausea and vomiting was also highest in this group (P = 0.02 compared with groups INH and TIVA). However, overall patient satisfaction, and mean times to discharge from the Post Anesthesia Recovery Unit and hospital, were rapid and similar in all three groups. During anaesthesia which lasted 40-45 min, nearly a four-fold difference was observed in the direct costs of anaesthetic drugs: $16.4 +/- 4.4 (Group INH), $45.3 +/- 11.4 (Group BAL) and $63.4 +/- 17.9 (Group TIVA, P < 0.001 between groups); while indirect costs were similar. CONCLUSIONS: For arthroscopic knee surgery, INH anaesthesia with isoflurane/fentanyl/N2O is associated with similar hospital discharge times, and comparable levels of patient satisfaction as either BAL or TIVA. While indirect costs were similar, lower direct costs suggest that there may be a pharmacoeconomic benefit associated with the use of a "standard" isoflurane/fentanyl/N2O anaesthetic in certain day care surgery procedures.

Chanavaz, M., J. Ferri, et al. (1997). "[Intravenous sedation in implantology]." Rev Stomatol Chir Maxillofac 98(1): 57-61.
Local or block anesthesia can be used satisfactorily in many implant procedures. However, when advanced implant techniques or pre-prosthetic reconstruction surgery of the maxillofacial bones are required, local or regional anesthesia is insufficient. The "day-hospital" concept is a rational approach which meets the requirements for anesthesia and deep sedation with criteria for patient safety and comfort while guaranteeing optimal operating conditions. Intravenous sedation, both "conscious" and "deep" sedation, is a very well adapted form of anesthesia for implant recipients. Local or block anesthesia is enhanced or reinforced prior to surgery by the intravenous administration of a sedative and anxiolytic agent (single-drug concept), such as a benzodiazepine, associated or not with a morphinomimetic agent and an antihistaminic substance (multiple-drug concept). The main goal is to maintain spontaneous respiration while obtaining postoperative amnesia of the entire procedure. Mandatory use of a pulse oximeter has greatly contributed to improved safety of intravenous sedation, essentially indicated for operations not lasting more than 2 and a half hours in patients in good general health (scoring 1 or 2 in the American Society of Anesthesiology (ASA) classification) and with a low risk of postoperative complications. This concept requires an adapted technical facility. The operating theatre should have all the equipment necessary for cardiovascular, neurological and respiratory emergency care. The postoperative recovery room should also be equipped with cardiovascular monitoring devices and be able to accommodate an intensive care unit. Under these strict rules, short duration surgical procedures (< 150') can be performed : 1) with the best conditions of medical safety, 2) with improved operating conditions for the implant surgeon (the patient responds immediately to vocal orders when necessary) while asepsis is maintained as easily as with general anesthesia, 3) with better conditions for postoperative care and patient comfort (the anesthetist is continuously present). 4) better psychological conditions for the patient who will be discharged the same day, 5) with total amnesia of the entire surgical procedure, 6) elimination of a usually disproportionately long hospitalization. Day hospitalization also helps contain health care costs by cutting out the need for overnight care and accommodation. We underline the safety of current intravenous sedation techniques and present two series of data related to the use of this technique by an anesthetist and an operating surgeon in a day hospital from 1986 to 1995.

Rajewski, F. and H. Grudniewicz (1997). "[The author's own method of local anesthesia for skin incision around implants during limb lengthening]." Chir Narzadow Ruchu Ortop Pol 62(2): 155-8.
Infection around implants is the most frequently described problem during limb lengthening. Fast elimination of the inflammatory response is crucial for intensive mobilization and weight bearing of the extremity being elongated. Prior to the unloading incision of the skin stretched around the implant EMLA ointment was used repeatedly in 12 children. EMLA was applied 1-2 hours prior to the procedure and covered with an occlusive dressing. All skin incisions, also within inflamed areas were painless. The management described eliminates the need for general anesthesia and thus for hospitalization, lowers treatment costs and limits child's anxiety.

Raeder, J. (1997). "General or regional anaesthesia--pro regional." Acta Anaesthesiol Scand Suppl 110: 56-8.

Baum, J. (1997). "[Low flow anesthesia with xenon]." Anasthesiol Intensivmed Notfallmed Schmerzther 32(1): 51-5.

Bach, A., H. Bohrer, et al. (1997). "[Economic aspects of modern inhalation anesthetics with sevoflurane as an example]." Anaesthesist 46(1): 21-8.
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.

Gibby, G. L., D. A. Paulus, et al. (1997). "Computerized pre-anesthetic evaluation results in additional abstracted comorbidity diagnoses." J Clin Monit 13(1): 35-41.
OBJECTIVE: To study the impact of information from a physician-entry computerized preanesthetic evaluation system on the coding of International Classification of Diseases (ICD-9-CM) diagnoses and on hospital reimbursement due to alterations in diagnosis-related group (DRG) codes. METHODS: Nonrandomized, unblinded trial conducted at a 570-bed university tertiary care hospital. First without and then with reference to information contained on computer-based preanesthetic evaluation reports, medical charts were coded by the study institution's usual professional codes for ICD-9-CM discharge diagnoses and DRG assignment. RESULTS: For 22 of 180 charts studied (12%, 95% confidence limits 7.4% to 16.7%), at least one ICD-9-CM diagnosis was added. Three of 84 DRG-based reimbursements were altered, increasing hospital reimbursement by 1.5%. CONCLUSIONS: Supplemental information from a physician-entered, problem-oriented, computerized preanesthetic evaluation system improved discovery of diagnoses in the population studied.

Gyermek, L. (1997). "Simple and cost effective clinical methods for measuring neuromuscular fade responses with emphasis on "train of four" fade." J Clin Monit 13(1): 11-7.
OBJECTIVE: To evaluate different pressure transducers, available in the operating room for pressure measurements, interfaced with common monitoring equipment, for quantitation of the train of four (TOF) fade during clinical neuromuscular block (NMB). METHOD: We determined evoked pressure changes produced by the thumb in response to TOF stimuli. We studied the responses of: a) a membrane disc device, and b) modified pressure transducers which were placed directly under the distal phalanx of the thumb of the clenched hand. The responses were displayed/recorded on OR monitors. The optimal positioning of these thumb pressure sensing (TPS) devices and their sensitivity and accuracy during onset, spontaneous (partial) recovery and pharmacologic reversal of NMB, were determined in anesthetized patients during muscle relaxation (Vecuronium) and reversal (Neostigmine). Simultaneous comparisons were made on twenty eight patients between the TOF fade responses obtained by the TPS devices and by conventional electromyographic and/or mechanomyographic methods. Comparisons were made either between pairs of data (e.g. "t" test, correlation coefficients, measuring agreement) or between several "treatment" groups (ANOVA of repeated measures). RESULTS: Correlations between the results of the TPS devices and the other methods were the closest (r- > 0.8) at higher TOF (T4/T1) ratios (e.g. during reversal. Measuring agreement was satisfactory and no significant differences were detected between the regression data (e.g. slope, residuals, x-axis of the regression lines) of the T4/T1 ratios vs. time when comparing EMG and TPS data during reversal of NMB. CONCLUSION: Measuring quantitatively the TOF fade by TPS devices is an economically feasible method for determining the adequacy of recovery from clinical non-depolarizing NMB.

Patel, M. R. and V. J. Moradia (1997). "Percutaneous release of trigger digit with and without cortisone injection." J Hand Surg [Am] 22(1): 150-5.
Percutaneous release was done using the tip of an 18-gauge, 2.5-cm-long needle, mounted on a 3-mL3 syringe in 225 trigger digits. It was successful in 92 (89%) of the digits without cortisone injection (n = 105) and in 115 (96%) of the digits with cortisone injection (n = 120). Negligible or intermittent pain persisted for 8 weeks in the noncortisone group and 6 weeks in the cortisone group after percutaneous release. Of the first 10 digits, 2 needed repeat percutaneous release. With modification of technique, the incidence of repeat percutaneous release was zero in both groups. Open release was needed in 8% in the noncortisone group and 3% in the cortisone group. The procedure was done under local infiltration anesthesia in the office. This reduced patient anxiety, inconvenience and hospital cost.

Saito, H., M. Saito, et al. (1997). "Priming of anesthesia circuit with xenon for closed circuit anesthesia." Artif Organs 21(1): 70-2.
Xenon is an inert gas with a practical anesthetic potency (1 MAC = 71%). Because it is very expensive, the use of closed circuit anesthesia technique is ideal for the conduction of xenon anesthesia. Here we describe our methods of starting closed circuit anesthesia without excessive waste of xenon gas. We induce anesthesia with intravenous agents, and after endotracheal intubation, denitrogenate the patient for approximately 30 min with a high flow of oxygen. This is done to minimize accumulation of nitrogen in the anesthesia circuit during the subsequent closed-circuit anesthesia with xenon. Anesthesia is maintained with an inhalational anesthetic during this period. Then, we discontinue the inhalation agent and start xenon. For this transition, we feel it is unacceptable to simply administer xenon at a high flow until the desired end-tidal concentration is reached because it is too costly. Instead we set up another machine with its circuit filled in advance (i.e., primed) with at least 60% xenon in oxygen and switch the patient to this machine. To prime the circuit, we push xenon using a large syringe into a circuit, which was prefilled with oxygen. Oxygen inside the circuit is pushed out before it is mixed with xenon, and xenon waste will thus be minimized. In this way, we can achieve close to 1 MAC from the beginning of xenon anesthesia, and thereby minimize the risk of light anesthesia and awareness during transition from denitrogenation to closed-circuit xenon anesthesia.

Macario, A., T. S. Vitez, et al. (1997). "Hospital costs and severity of illness in three types of elective surgery." Anesthesiology 86(1): 92-100.
BACKGROUND: If patients who are more severely ill have greater hospital costs for surgery, then health-care reimbursements need to be adjusted appropriately so that providers caring for more seriously ill patients are not penalized for incurring higher costs. The authors' goal for this study was to determine if severity of illness, as measured by either the American Society of Anesthesiologists Physical Status (ASA PS) or the comorbidity index developed by Charlson, can predict anesthesia costs, operating room costs, total hospital costs, or length of stay for elective surgery. METHODS: The authors randomly selected 224 inpatients (60% sampling fraction) having either colectomy (n = 30), total knee replacement (n = 100), or laparoscopic cholecystectomy (n = 94) from September 1993 to September 1994. For each surgical procedure, backward-elimination multiple regression was used to build models to predict (1) total hospital costs, (2) operating room costs, (3) anesthesia costs, and (4) length of stay. Explanatory candidate variables included patient age (years), sex, ASA PS, Charlson comorbidity index (which weighs the number and seriousness of coexisting diseases), and type of insurance (Medicare/Medicaid, managed care, or indemnity). These analyses were repeated for the pooled data of all 224 patients. Costs (not patient charges) were obtained from the hospital cost accounting software. RESULTS: Mean total hospital costs were $3,778 (95% confidence interval +/- 299) for laparoscopic cholecystectomy, $13,614 (95% CI +/- 3,019) for colectomy, and $18,788 (95% CI +/- 573) for knee replacement. The correlation (r) between ASA PS and Charlson comorbidity scores equaled 0.34 (P < .001). No consistent relation was found between hospital costs and either of the two severity-of-illness indices. The Charlson comorbidity index (but not the ASA PS) predicted hospital costs only for knee replacement (P = .003). The ASA PS, but not the Charlson index, predicted operating room and anesthesia costs only for colectomy (P < .03). CONCLUSIONS: Severity of illness, as categorized by ASA PS categories 1-3 or by the Charlson comorbidity index, was not a consistent predictor of hospital costs and lengths of stay for three types of elective surgery. Hospital resources for these lower-risk elective procedures may be expended primarily to manage the consequences of the surgical disease, rather than to manage the patient's coexisting diseases.

Wambani, J. O. (1996). "Halothane consumption under varying breathing circuit designs." East Afr Med J 73(12): 827-9.
Thirty one patients at the Eldoret District Hospital, currently being used as a referral and teaching hospital, were anaesthetised and allowed to breathe through any of the three standard Maplesons circuits. The quantity of halothane required to maintain a satisfactory level of anaesthesia was measured and expressed in millilitres per kilogramme body weight, per minute. This value was used to compare the cost-effectiveness of the three circuits under different modes of ventilation.

Cheng, D. C., J. Karski, et al. (1996). "Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial." Anesthesiology 85(6): 1300-10.
BACKGROUND: Economics has caused the trend of early tracheal extubation after cardiac surgery, yet no prospective randomized study has directly validated that early tracheal extubation anesthetic management decreases costs when compared with late extubation after cardiac surgery. METHODS: This prospective, randomized, controlled clinical trial was designed to evaluate the cost savings of early (1-6 h) versus late tracheal extubation (12-22 h) in patients after coronary artery bypass graft (CABG) surgery. The total cost for the services provided for each patient was determined for both the early and late groups from hospital admission to discharge home. All costs applicable to each of the services were classified into direct variables, direct fixed costs, and overhead (an indirect cost). Physician fees and heart catheterization costs were included. The total service cost was the sum of unit workload and overhead costs. RESULTS: One hundred patients having elective CABG who were younger than 75 yr were studied. Including all complications, early extubation (n = 50) significantly reduced cardiovascular intensive care unit (CVICU) costs by 53% (P < 0.026) and the total CABG surgery cost by 25% (P < 0.019) when compared with late extubation (n = 50). Forty-one patients (82%) in each group were tracheally extubated within the defined period. In the early extubation group, the actual departmental cost savings in CVICU nursing and supplies was 23% (P < 0.005), in ward nursing and supplies was 11% (P < 0.05), and in respiratory therapy was 12% (P < 0.05). The total cost savings per patient having CABG was 9% (P < 0.001). Further cost savings using discharge criteria were 51% for CVICU nursing and supplies (P < 0.001), 9% for ward nursing and supplies (P < 0.05), and 29% for respiratory therapy (P < 0.001), for a total cost savings per patient of 13% (P < 0.001). Early extubation also reduced elective case cancellations (P < 0.002) without any increase in the number of postoperative complications and readmissions. CONCLUSIONS: Early tracheal extubation anesthetic management reduces total costs per CABG surgery by 25%, predominantly in nursing and in CVICU costs. Early extubation reduces CVICU and hospital length of stay but does not increase the rate or costs of complications when compared with patients in the late extubation group. It shifts the high CVICU costs to the lower ward costs. Early extubation also improves resource use after cardiac surgery when compared with late extubation.

Kremer, M. (1996). "Anesthesia providers, patient outcomes, and costs." Anesth Analg 83(6): 1348-9; discussion 1349-50.

Hanna, K. (1996). "Anesthesia providers, patient outcomes, and costs." Anesth Analg 83(6): 1348; discussion 1349-50.

Gaba, D. M. (1996). "Anesthesia providers, patient outcomes, and costs." Anesth Analg 83(6): 1347-8; discussion 1349-50.

Stoelting, R. K. (1996). "Anesthesia providers, patient outcomes, and costs." Anesth Analg 83(6): 1347; discussion 1349-50.

Campos, J. H., D. K. Reasoner, et al. (1996). "Comparison of a modified double-lumen endotracheal tube with a single-lumen tube with enclosed bronchial blocker." Anesth Analg 83(6): 1268-72.
This study compared the modified BronchoCath double-lumen endotracheal tube with the Univent bronchial blocker to determine whether there were objective advantages of one over the other during anesthesia with one-lung ventilation (OLV). Forty patients having either thoracic or esophageal procedures were randomly assigned to one of two groups. Twenty patients received a left-side modified BronchoCath double-lumen tube (DLT), and 20 received a Univent tube with a bronchial blocker. The following were studied: 1) time required to position each tube until satisfactory placement was achieved; 2) number of times that the fiberoptic bronchoscope was required; 3) frequency of malpositions after initial placement with fiberoptic bronchoscopy; 4) time required until lung collapse; 5) surgical exposure ranked by surgeons blinded to type of tube used; and 6) cost of tubes per case. No differences were found in: 1) time required to position each tube (DLT 6.2 +/- 3.1 versus Univent 5.4 +/- 4.5 min [mean +/- SD]); 2) number of bronchoscopies per patient (DLT median 2, range 1-3 versus Univent median 3, range 2-5); or 3) time to lung collapse (DLT 7.1 +/- 5.4 versus Univent 12.3 +/- 10.5 min). The frequency of malposition was significantly lower for the DLT (5) compared to the Univent (15) (P < 0.003). Blinded evaluations by surgeons indicated that 18/20 DLT provided excellent exposure compared to 15/20 for the Univent group (P = not significant). We conclude that in spite of the greater frequency of malposition seen with the Univent, once position was corrected adequate surgical exposure was provided. In the Univent group the incidence of malposition and cost involved were both sufficiently greater that we cannot find cost/ efficacy justification for routine use of this device.

de Villiers, V. P. (1996). "Per capita remuneration of private practitioners performing state hospital services." S Afr Med J 86(10): 1296.

Hussaini, S. H. (1996). "Clinical economics review: the management of gallstone disease." Aliment Pharmacol Ther 10(5): 699-705.
Surgical techniques have an inherent advantage over oral bile therapy and extracorporeal shock-wave lithotripsy because they remove both gallstones and the gallbladder, thus preventing stone recurrence. Moreover, surgical techniques are more effective for patients with symptomatic gallstones compared with non-surgical techniques. Laparoscopic surgery is the best therapy from the clinical economic viewpoint being cost-minimal, effective and beneficial compared with other surgical and medical techniques. However, non-surgical techniques may be preferable in selected patients at high risk from general anaesthesia such as the elderly and those with significant cardiopulmonary disease.

Cresswell, P. A., E. D. Allen, et al. (1996). "Cost effectiveness of a single-function treatment center for cataract surgery." J Cataract Refract Surg 22(7): 940-6.
PURPOSE: To compare the clinical and cost effectiveness of two models for cataract treatment: a single-function Cataract Treatment Centre (CTC) and a general ophthalmology service. SETTING: Cataract Treatment Centre and the general ophthalmology service at Sunderland Eye Infirmary, Sunderland, United Kingdom. METHODS: Two hundred patients were studied using two models of care: 100 in the CTC and 100 in the general ophthalmology service. Outcome measures were best corrected visual at 3 months postoperatively or at discharge and occurrence of surgery-related complications. All direct costs to the National Health Service were identified, measure, and assessed. RESULTS: Clinical outcomes in the two groups were similar. The average cost per patient was 496.90 pounds ($760.25) at the CTC and 566.34 pounds ($866.50) at the general ophthalmology service. The cost per patient treated as a day case in the general service group was 495.84 pounds ($758.63). Thus, treatment at the CTC was more cost effective than in the mixed service group and as cost effective as in the day case subgroup. CONCLUSIONS: Depending on local circumstances, day care must be delivered more cost effectively in a single-function center than in a general ophthalmology service. We recommend day care using local anesthesia and protocols for assessment, surgery, and follow-up.

Boldt, J., M. Muller, et al. (1996). "[Cost aspects in anesthesia. Propofol versus isoflurane anesthesia]." Anaesthesist 45(8): 731-6.
Cost control is no longer an option, but a necessity. Propofol anaesthesia is expensive, however, the true differences in comparison to volatile anaesthetics (isoflurane) are not known. METHODS: Sixty patients undergoing either thyroidectomy (n = 30) or laparoscopic cholecystectomy (n = 30) were randomly divided into 3 groups of 20 patients. In group I propofol and fentanyl were used for anaesthesia, in group II isoflurane ('standard' isoflurane anaesthesia), and in group III isoflurane using a low-flow system (fresh gas flow 2 l/min) was given. All patients were ventilated using 70% N2O in oxygen. Vecuronium was used in all cases for muscle relaxation. Isoflurane consumption was measured by weighing the isoflurane vaporizer. RESULTS: Biometric data and time of administration of the anaesthetic were similar in the three groups. Propofol patients stayed significantly shorter than isoflurane patients in the postanaesthesia care unit (PACU). Costs of additional drugs (antiemetics, analgesics) in the PACU were least in the propofol patients. Costs were without differences between the propofol (78.30 DM/patient) and 'standard' isoflurane groups (81.69 DM/patient). Patients in group III showed the lowest overall costs (57.46 DM/patient) (P < 0.05). CONCLUSION: A climate of cost-consciousness and cost-containment prevails at the present time. The costs of propofol and 'standard' isoflurane anaesthesia were without differences; however, isoflurane used in a low-flow system had the lowest cost in this study. Doubts are justified, however, as to whether the choice of anaesthetic agents may considerably lower the costs of an anaesthesia department.

Lintner, S., S. Shawen, et al. (1996). "Local anesthesia in outpatient knee arthroscopy: a comparison of efficacy and cost." Arthroscopy 12(4): 482-8.
This study was performed to compare the efficacy, cost-effectiveness, and safety of general, regional, and local anesthesia when performing outpatient knee arthroscopy. The study consisted of two portions. A retrospective review of 256 outpatient knee arthroscopies was performed. The types of anesthesia used were general endotracheal, regional (epidural or spinal), and local. Comparisons were made between operative procedure, anesthesia procedure time, need for supplemental anesthesia, recovery room time and cost, pharmaceutical cost, and complications. A prospective study consisted of 100 consecutive outpatient knee arthroscopies performed using local anesthesia. Data identical to the retrospective portion were obtained. Visual analog scales were used in a patient questionnaire completed at the first postoperative visit to assess patient satisfaction with local anesthesia. The retrospective data showed similar demographics and operative procedures performed in the three study groups. The difference between operative time and total anesthetic time for the local group was 35 minutes less than for regional, and 23 minutes less than for the general group. These differences were statistically significant (P < or = .05). Total pharmaceutical cost was significantly less for the local group (P < or = .05). Recovery room cost for the local anesthesia group averaged $134 compared with $450 for regional and $527 for general. This difference was significant (P < or = .05). There were 19 complications with general anesthesia, 16 with regional anesthesia, and 2 with local. There were two regional and two local cases that needed subsequent general anesthesia. The prospective data showed nearly identical time and cost data. The patient questionnaire showed nearly universal acceptance and satisfaction with the use of local anesthesia. The use of local anesthesia for outpatient knee arthroscopy is safe, effective, and well accepted. The use of local anesthesia was shown to save a minimum of $400 per case compared with the other anesthetic methods studied.

Krane, E. J. (1996). "Re: Continuous epidural anesthesia after ureteroneocystostomy in children." J Urol 156(2 Pt 1): 481-2; discussion 482-3.

Heath, K. J., P. Sadler, et al. (1996). "Nitrous oxide reduces the cost of intravenous anaesthesia." Eur J Anaesthesiol 13(4): 369-72.
One hundred and one women (ASA grades I and II) were anaesthetized for routine gynaecological surgery using an intravenous (i.v.) anaesthetic technique combining propofol and alfentanil. The patients were allocated randomly into groups. Group one received 33% oxygen in nitrous oxide and group two received 33% oxygen in air (total i.v. anaesthesia). The group receiving nitrous oxide required significantly less (P < 0.05) of the propofol and alfentanil mixture to maintain anaesthesia and this was found to reduce the mean cost of anaesthesia by 1.70 pounds, (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups. We suggest that nitrous oxide may be used to reduce the cost of total i.v. anesthesia with propofol and alfentanil without causing any increase in post-operative morbidity in patients undergoing routine gynaecological surgery.

Fischer, S. P. (1996). "Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital." Anesthesiology 85(1): 196-206.

Metzger, S. E. and L. A. Fleisher (1996). "Cost-effective modeling." Anesth Analg 83(1): 203-4.

Garforth, R., M. R. Keilani, et al. (1996). "Combinations of drugs for induction and maintenance of anesthesia and sedation of the critically ill." Middle East J Anesthesiol 13(5): 545-57.

Lennox, P., J. Hern, et al. (1996). "Local anaesthesia in flexible nasendoscopy. A comparison between cocaine and co-phenylcaine." J Laryngol Otol 110(6): 540-2.
Flexible nasendoscopy is now an integral part of the diagnostic process in Otorhinolaryngology. Topical local anaesthesia is generally recommended and cocaine is usually the drug of choice in view of its concurrent vasoconstrictor action. However, it is expensive, a controlled drug and serious side effects have been reported. Co-phenylcaine forte is a new preparation which also has both local anaesthetic and vasoconstrictor properties. This study compares the efficacy of cocaine and Co-phenylcaine in flexible nasendoscopy and concludes that they provide similar local anaesthesia and vasoconstriction of the nasal mucosa. Co-phenylcaine forte can therefore be used as an alternative to cocaine in flexible nasendoscopy.

Dexter, F. (1996). "Application of cost-utility and quality-adjusted life years analyses to monitored anesthesia care for sedation only." J Clin Anesth 8(4): 286-8.
STUDY OBJECTIVE: To determine how much society should spend to decrease anxiety lasting for the duration of a surgical case. DESIGN: Indications for monitored-anesthesia care (MAC) include: (1) management of an unstable patient, (2) possible induction of general anesthesia, (3) need for the patient to be unconscious for part of the case, and (4) provision of sedation and/or analgesia. The first three indications facilitate quality surgical care. However, MAC solely to decrease anxiety has been criticized on economic grounds. Although MAC for these cases may improve the patient's experience during surgery, it does not facilitate safer surgery. I limited my theoretical analysis to (1) MAC for sedation only and (2) procedures that have an equal outcome with or without an anesthesiologist. Cost-utility analyses compare costs and benefits of technologies by using a common measure of health outcomes. The quality adjusted life year (QALY) gives the expected life years gained from a procedure, with each year weighted to reflect quality of life in that year. Quality of life generally ranges from zero (dead) to one (healthy without distress). Technologies costing more than $75,000 per QALY are usually considered too expensive to justify. I used a deliberately absurd, one unit change in quality of life to calculate the maximum hourly cost of MAC, which lets the cost per QALY be less than $75,000. MEASUREMENTS AND MAIN RESULTS: Hourly cost must be less than $8.56 per hour. Current Medicare reimbursement corresponds to $876,000 per QALY. CONCLUSION: MAC for sedation only is a very expensive technology compared with other medical interventions.

Swanstrom, L. L. (1996). "Laparoscopic herniorrhaphy." Surg Clin North Am 76(3): 483-91.
There is little doubt that laparoscopic herniorrhaphy has assumed a place in the pantheon of hernia repair. There is also little doubt that further work needs to be done to determine the exact role that laparoscopic hernia repair should play in the surgical armamentarium. Hernias have been surgically treated since the early Greeks. In contrast, laparoscopic hernia repair has a history of only 6 years. Even within that short time, laparoscopic hernia repair techniques have not remained unchanged. This is obviously a technique in evolution, as indicated by the abandonment of early repairs ("plug and mesh" and IPOM) and the gradual gain in pre-eminence of the TEP repair. During the same time frame, surgery itself has evolved into a discipline more concerned with cost-effectiveness, outcomes, and "consumer acceptance." Confluence of these two developments has led to a situation in which traditional concerns regarding surgical procedures (i.e., recurrence rates or complication rates) assume less of a role than cost-effectiveness, learnability, marketability, and medical-legal considerations. No surgeon, whether practicing in a academic setting or a private practice, is exempt from these pressures. Laparoscopic hernia repair therefore seems to fit into a very specialized niche. In our community, the majority of general surgeons are only too happy to not do laparoscopic hernia repairs. On the other hand, in our experience, certain indications do seem to cry out for a laparoscopic approach. At our own center we have found that laparoscopic repairs can indeed be effective, and even cost-effective, under specific circumstances. These include completing a minimal learning curve, utilizing the properitoneal approach, minimizing the use of reusable instruments, using dissecting balloons as a time-saving device, and very specific patient selection criteria. At present these include patients with bilateral inguinal hernias on clinical examination, patients with recurrent unilateral or bilateral hernias, and patients who, because of economic pressures, must return to work within 10 days of surgery. Within these limitations we feel that the laparoscopic approach definitely has a place in repair of inguinal hernias. In the future new techniques, decreased equipment costs, and the ability to use local anesthesia may increase the applicability of laparoscopic herniorrhaphy.

Palter, S. F. and D. L. Olive (1996). "Office microlaparoscopy under local anesthesia for chronic pelvic pain." J Am Assoc Gynecol Laparosc 3(3): 359-64.
STUDY OBJECTIVE: To investigate the utility, tolerance, and costs associated with a program of office laparoscopy under local anesthesia using fiberoptic microlaparoscopes (<2 mm) and accessory instrumentation (<2 mm) for the evaluation of patients with chronic pelvic pain (CPP). DESIGN: Prospective, nonselected cohort study. SETTING: Office-based free-standing faculty practice at a tertiary care referral center. PATIENTS: All women with a history of CPP from February to June 1995 who required diagnostic laparoscopy were compared with a cohort of patients undergoing in office diagnostic laparoscopy for the evaluation of infertility during the same period. INTERVENTIONS: All patients underwent diagnostic office microlaparoscopy under local anesthesia (OLULA) with supplemental intravenous sedation, as well as conscious pain mapping. MEASUREMENTS AND MAIN RESULTS: A specific questionnaire was developed to follow all aspects of patient acceptance and tolerance of the procedures, and all patients were queried preoperatively, and 30 minutes and 1 week postoperatively. Pain was evaluated with a modification of the McGill pain inventory. A subset of questions evaluated the length of time until usual activities were resumed, anxiety level, and general acceptance of the procedure including set-up, operative time, and recovery time until discharge. Overall, there was a high degree of patient acceptance and satisfaction with OLULA; however, women with CPP experienced greater intraoperative and postoperative pain than those with infertility. Some patients with CPP had a generalized visceral hypersensitivity to pain; all areas of the pelvis and bowel were sensitive, and pain was not completely blocked with local anesthesia. Average procedure length was similar for the two groups. Patients with CPP required greater postoperative analgesia and took longer to return to work. Conscious pain mapping identified a focal source of pain in three patients and generalized visceral hypersensitivity in a majority of patients with CPP. Neither of these were found in patients with infertility. Compared with traditional laparoscopy there was almost an 80% reduction in costs. CONCLUSION: Office laparoscopy under local anesthesia is safe and effective for the evaluation of patients with CPP and is less expensive than traditional laparoscopy. Although the procedure is better tolerated by women undergoing infertility evaluation, it was well tolerated by both groups. Conscious pain mapping helps identify potential areas of pelvic pain and helps further characterize patients with CPP.

Shafer, S. L. and P. L. Gambus (1996). "Inhalation versus intravenous anesthesia: a fictitious debate between E.I. Eger II and P.F. White." J Clin Anesth 8(3 Suppl): 38S-41S.

Smith, M. G., D. J. Elliott, et al. (1996). "Anaesthetic rooms--the debate continues." Anaesthesia 51(5): 509.

Jacoby, J. (1996). "Forget the costs: use what is best." Anesthesiology 84(5): 1258-9.

Chadwick, R. G. and S. M. Lindsay (1996). "Dental injuries during general anaesthesia." Br Dent J 180(7): 255-8.
Although most anaesthetic textbooks cite dental injury as a complication of endotracheal intubation few studies have examined the extent and nature of the problem. Such damage however, formed the basis for one-third of all confirmed or potential anaesthetic claims notified to the Medical Protection Society between 1977 and 1986. This article seeks to explore the extent of the problem, outline predisposing factors, summarise current prophylactic measures and make recommendations to reduce the overall incidence. Increased awareness of the problem, by both anaesthetists and dental surgeons, coupled with appropriate prophylactic measures may result in a reduced incidence of dental injury arising from general anaesthesia. Given the high incidence of dental damage we recommend that all patients undergoing a surgical operation under endotracheal intubation should have a pre-operative dental check wherever possible. Clearly, the first dental examination would be conducted by an anaesthetist familiar with the predisposing factors. Where he/she considers there to be a higher than average risk of dental damage occurring during intubation a more specialised examination should be conducted by a dental surgeon. It may, where appropriate, be possible for remedial dental treatment to be carried out and customised mouth guards to be constructed prior to the operation. Obviously such recommendations have certain financial implications and would have to be subject to controlled cost-benefit analysis before their widespread application.

Enlund, M., P. Kobosko, et al. (1996). "A cost-benefit evaluation of using propofol and alfentanil for a short gynecological procedure." Acta Anaesthesiol Scand 40(4): 416-20.
It is well established that the immediate recovery after propofol or alfentanil anesthesia is short. Although the drugs themselves are more expensive than older drugs, a potential for saving costs arises. Concerning the benefits in terms of late recovery, less information is available. With vaginal termination of pregnancy (VTP), anesthesia is supposed to be the major cause of sick-leave. Does propofol and alfentanil anesthesia for VTP reduce sick-leave compared with thiopental and nitrous oxide anesthesia, and do the increased costs of the drugs outweigh the reduced costs of sick-leave? Data were obtained from 39 of 40 patients in ASA class I accepted for VTP and allocated to either propofol and alfentanil anesthesia (PA) or thiopental and nitrous oxide anesthesia (TN). A questionnaire was filled in by the patients at home after regaining full fitness. The number of patients with a sick-leave of 2 days or less in the groups was compared statistically with the number of patients with 3 days or more off work. The economic impact from the reported sick-leave was calculated for each study group, using data from national statistics. The figures were compared with the calculated costs of the drugs. The median number of days of sick-leave was 1 in the PA-group and 2 in the TN-group (range 0-3 and 0-5, respectively). Nineteen of the 20 patients in the PA-group and 13 of the 19 patients in the TN-group needed a short sick-leave period of 2 days or less (one-sided test of proportions, P < 0.05). At the time of the study each patient was paid 210 SEK/day from the social insurance system and the mean cost of the drugs was 72 and 15 SEK/patient in the PA- and TN-groups, respectively. Using the mean difference in sick-leave between the groups of 0.8 days/patient (rather than the difference in median values of 1), a net gain of 111 SEK/patient was the result of changing from thiopental-nitrous oxide anesthesia to propofol-alfentanil anesthesia. Although the cost of drugs was higher, costs for the social insurance system and for the individuals themselves were reduced by almost 50%, when using the propofol and alfentanil combination, resulting in an overall benefit corresponding to almost twice the increase in the cost of anesthesia.

Zukowski, M. L., K. Ash, et al. (1996). "Breast reduction under intravenous sedation: a review of 50 cases." Plast Reconstr Surg 97(5): 952-6; discussion 957-8.
Breast reduction is a surgical procedure most commonly performed on an inpatient basis under general anesthesia. In the current climate of health care reform, we must evaluate such procedures to determine if there are alternate, less expensive, but equally safe means to perform them. Our purpose is to present our experience with 50 bilateral breast reductions performed under local anesthesia with intravenous sedation between October of 1991 and October of 1994. We have excluded bilateral reductions under 500 gm total, unilateral reductions, mastopexies, and gynecomastia procedures. Patients were sedated with intravenous Versed and fentanyl and a local solution consisting of marcaine, lidocaine, and 1:2000,000 epinephrine. Intercostal blocks were not used routinely. Monitoring and sedation were performed by nonanesthesia personnel in 49 patients. There were no complications relating to the sedation or to the local solution. All reductions were performed by the inferior pedicle technique. The average patient age was 28.0 years (20 to 67 years). The total breast tissue resected was 1372 gm (516 to 2948 gm), with 33 patients having resections greater than 1000 gm. Operative times averaged 3 hours (115 to 275 minutes). Forty-nine of the 50 patients tolerated the procedure with little or no recall. Twenty-eight patients were discharged on the same day as admission. One patient recalled some significant discomfort during parts of the procedure. All stated that they would again have the procedure performed under local anesthesia with intravenous sedation. Our conclusions are as follows: (1) Breast reduction can be performed safely and comfortably under local anesthesia with intravenous sedation. (2) Patients should be chosen on their acceptability as intravenous sedation candidates and not with regard to the amount of breast tissue removed. (3) There will be a subset of patients who can be discharged on the same day.

Lydiatt, D. D., K. M. Murayama, et al. (1996). "Laparoscopic gastrostomy versus open gastrostomy in head and neck cancer patients." Laryngoscope 106(4): 407-10.
Alimentation in the surgically treated head and neck cancer patient frequently requires bypassing the upper aerodigestive tract. The laparoscopic gastrostomy fulfills this criterion. The authors compared 25 laparoscopic gastrostomies (group 1) with 18 open gastrostomies (group 2) performed on head and neck cancer patients. The length of operation, morbidity, mortality, and cost were evaluated. Operative time was significantly shorter in group 1 (40 +/- 2 minutes) than in group 2 (56 +/- 4 minutes), with P=.003. The major complication rate was 9% for group 1 and 11% for group 2. There was no procedure-related mortality in group 1, but 1 patient died in the immediate postoperative period in group 2. The cost was not significantly different. It is concluded that the laparoscopic gastrostomy is a safe and cost-effective alternative to open gastrostomy in this patient group.

Gravenstein, J. S. (1996). "Will "cost containment" decrease safety? Noted observer considers relative safety risks." J Clin Monit 12(2): 199-202.

Musser, D. J., K. D. Calligaro, et al. (1996). "Safety and cost-efficiency of 24-hour hospitalization for carotid endarterectomy." Ann Vasc Surg 10(2): 143-6.
The safety and cost savings of carotid endarterectomy (CEA) were determined with guidelines developed after vascular "critical pathways" were implemented. Using these guidelines, our goal was to admit patients the day of surgery and to discharge them the next morning. Morbidity, mortality, readmission rates, same-day admissions, duration of stay, and hospital costs were compared between patients undergoing CEA who were electively admitted between September 1, 1992 and August 31, 1993 (group 1) and January 1, 1994 and March 31, 1995 (group 2). Between these two time periods, vascular critical pathways were instituted and all preoperative examinations were performed on an outpatient basis. The majority of CEAs were performed with the patient under general anesthesia. We found no significant differences between group 2 (n = 68) vs. group 1 (n = 40) in terms of mortality (1.5% [1 of 68] vs. 2.5% [1 of 40]), cardiac events (2.9% [2 of 68] vs. 2.5% [1 of 40]), neurologic events (2.9% [2 of 68] vs. 2.5% [1 of 40]), or readmission rate (1.5% [1 of 68] vs. 0% [0 of 40]). Same-day admissions were significantly higher (94% [64 of 68] vs. 5% [2 of 40]; p < 0.0001), and average duration of stay was significantly lower (1.3 vs. 5.1 days; p < 0.0001) in group 2 vs. group 1, respectively. Hospital charges were decreased by $5510 per patient in group 2. We conclude that hospital costs can be significantly reduced for most patients undergoing CEA when they are admitted on the day of surgery and discharged the following morning, with no negative impact on morbidity and mortality.

Lipscomb, G. H., J. R. Dell, et al. (1996). "A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting." J Am Assoc Gynecol Laparosc 3(2): 277-81.
OBJECTIVE: To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance. DESIGN: A retrospective review of charges. SETTING: The Regional Medical Center, Memphis, Tennessee. PATIENTS: Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization. MEASUREMENTS AND MAIN RESULTS: Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment. CONCLUSION: Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.

Diefenbach, C. and M. Abel (1996). "[Economic control in anesthesia and intensive care medicine--do we need new muscle relaxants? Pro]." Anasthesiol Intensivmed Notfallmed Schmerzther 31(1): 44-5.

Plotz, J. (1996). "[Economic control in anesthesia and intensive care medicine--do we need new muscle relaxants? Contra]." Anasthesiol Intensivmed Notfallmed Schmerzther 31(1): 42-3.

Trieshmann, H. W., Jr. (1996). "Knee arthroscopy: a cost analysis of general and local anesthesia." Arthroscopy 12(1): 60-3.
A cost analysis of outpatient knee arthroscopy was performed on 53 patients to determine if cost savings were associated with local versus general anesthesia. Local anesthesia was associated with an average reduction in overall charges of $600 compared with general anesthesia because of the reduction of charges related to the recovery room and anesthesia equipment. This study demonstrates a reduction in the hospital charges associated with outpatient knee arthroscopy when local rather than general anesthetic technique is used.

Edge, G. and M. Morgan (1996). "Anaesthesia--value for money." Anaesthesia 51(2): 105-6.

Faisy, C., G. Gueguen, et al. (1996). "[Cost effectiveness of local regional anesthesia in a remote area]." Med Trop (Mars) 56(4): 367-72.
Loco-regional anesthesia techniques are considered as a simple and economic solution to problems posed by anesthesia in developing countries. However the cost benefits of some techniques are reduced by cardiovascular effects that affect the quantity and nature of peroperative vascular filling usually necessary during general anesthesia. The purpose of the present study was to ascertain the relative costs of these methods by comparing the quantity of crystalloid solution and blood administered during loco-regional anesthesias and general anesthesias in a general hospital center in Africa. In a retrospective cohort of 1050 consecutive patients operated on in the Surgery and Gynecology/Obstetrics Departments of the A. Sice Hospital in Pointe Noire (Congo), 495 included in a study comparing perimedullary anesthesia and general anesthesia. The total volume of solution and blood administered to the patients during the procedure was studied in function of the type of anesthesia and surgery performed. Results showed that the amount of crystalloid solution administered during peridural and spinal anesthesia tended to be higher. This difference was significant only for prostate surgery. Use of epidural anesthesia did not increase the quantity of fluid modified gelatin and blood transfused in this series. It was also observed that 55% of patients who underwent peridural anesthesia required further intravenous anesthesia as opposed to 18.8% of patients who underwent spinal anesthesia. These findings indicate that loco-regional anesthesia performed under standardized conditions does not significantly change the quantity and nature of preoperative filling usually necessary during general anesthesia. Thus these techniques can be considered as cost-effective in developing countries even though the long period necessary for practitioners to learn them results in a transient increase in cost. A prospective study by surgical groups with experience using loco-regional anesthesia is needed to confirm this study.

van den Oever, R. and B. Debbaut (1996). "[Cost analysis of inguinal hernia surgery in ambulatory and inpatient management]." Zentralbl Chir 121(10): 836-40.
In Belgium 27,426 hernia repairs were performed in 1994 but only 1,451 (5.29%) were done on ambulatory basis, whereas in the U.S. over 50% of the yearly 600,000 hernia repairs are one day surgery procedures with interstate variation ranging from 6% to 89%. The mean treatment cost of inguinal hernia repair (doctors fees + hotel cost) was 53,704 BEF for inpatients vs. 30,510 BEF (general anesthesia) and 27,501 BEF (local anesthesia) for outpatients. Rates of complication and recurrence were not significantly different. This difference in total costs for hospital admission are determined by the mean length of stay and by the individual forfeitairy day price according to size of the hospital. Also the use of routine diagnostic procedures (clinical chemistry and medical imaging) - not necessarily essential for treatment - is higher at hospitalization. Even with 50% of all hernia repairs carried out in the one day clinic, total cost savings for treatment will hardly exceed 20% if the mean length of stay of the remaining inpatients will not decrease simultaneously. Supplementary and dramatic cost reductions however are possible by an earlier resumption of professional activities. The mean advised sick leave period of 4 weeks (+/- 2) still depends on irrelevant parameters as tradition, patients' preferences, job characteristics and type of insurance. Total costs for work incapacity add up to 2.5 billion BEF (vs. 1.4 billion BEF for total treatment costs) and can be cut by 50.18% via a mean 2 weeks earlier return to work. Since open primary hernia repair under local anesthesia can be easily carried out on outpatients resuming unrestricted daily activities in less than 1 week, the laparoscopic procedure with general anesthesia, higher treatment cost (endoscopic material) and still debated advantages in convalescence time and long-term outcome is not the gold standard for uncomplicated inguinal hernia.

Bach, A. and E. Martin (1996). "[Documentation and therapeutic standards in anesthesia and intensive care medicine--means for quality assurance and cost control]." Zentralbl Chir 121(7): 521-8.
Patient data management in anaesthesia and intensive care should include besides medical data of individual patients economically important parameters, e.g. working time or cost of material. Integration of this data management system in the hospital information network enables case-oriented analyses for costs in relation to outcome. Standards of therapy including cost-benefit estimates may be an approach to improve the quality of care and to control the cost of medical care, in particular in the setting of teaching hospitals, avoiding erratic and costly orders by staff in training.

List, W. F. (1996). "Inhalation vs. i.v. anesthesia and intensive care medicine." Acta Anaesthesiol Scand Suppl 109: 161-3.

Schurz, J. W., M. E. Arregui, et al. (1995). "Open vs laparoscopic hernia repair. Analysis of costs, charges, and outcomes." Surg Endosc 9(12): 1311-7.

Johnstone, R. E. (1995). "Comparison of estimated variable costs is a surrogate for actual cost experience." Anesthesiology 83(6): 1387.

Macario, A., T. S. Vitez, et al. (1995). "Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care." Anesthesiology 83(6): 1138-44.
BACKGROUND: Many health-care institutions are emphasizing cost reduction programs as a primary tool for managing profitability. The goal of this study was to elucidate the proportion of anesthesia costs relative to perioperative costs as determined by charges and actual costs. METHODS: Costs and charges for 715 inpatients undergoing either discectomy (n = 234), prostatectomy (n = 152), appendectomy (n = 122) or laparoscopic cholecystectomy (n = 207) were retrospectively analyzed at Stanford University Medical Center from September 1993 to September 1994. Total hospital costs were separated into 11 hospital departments. Cost-to-charge ratios were calculated for each surgical procedure and hospital department. Hospitalization costs were also divided into variable and fixed costs (costs that do and do not change with patient volume). Costs were further partitioned into direct and indirect costs (costs that can and cannot be linked directly to a patient). RESULTS: Forty-nine (49%) percent of total hospital costs were variable costs. Fifty-seven (57%) percent were direct costs. The largest hospital cost category was the operating room (33%) followed by the patient ward (31%). Intraoperative anesthesia costs were 5.6% of the total hospital cost. The overall cost-to-charge ratio (0.42) was constant between operations. Cost-to-charge ratios varied threefold among hospital departments. Patient charges overestimated resource consumption in some hospital departments (anesthesia) and underestimated resource consumption in others (ward). CONCLUSIONS: Anesthesia comprises 5.6% of perioperative costs. The influence of anesthesia practice patterns on "downstream" events that influence costs of hospitalization requires further study.

Smith, I., M. H. Nathanson, et al. (1995). "The role of sevoflurane in outpatient anesthesia." Anesth Analg 81(6 Suppl): S67-72.
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).

Brown, B., Jr. (1995). "Sevoflurane: introduction and overview." Anesth Analg 81(6 Suppl): S1-3.

Dexter, F., S. Coffin, et al. (1995). "Decreases in anesthesia-controlled time cannot permit one additional surgical operation to be reliably scheduled during the workday." Anesth Analg 81(6): 1263-8.
We tested whether anesthesiologists can decrease operating room (OR) costs by working more quickly. Anesthesia-controlled time (ACT) was defined as the sum of 1) the time starting when the patient enters an OR until preparation or surgical positioning can begin plus 2) the time starting when the dressing is finished and ending when the patient leaves the OR. Case time was defined as the time starting when one patient undergoing an operation leaves an OR and ending when the next patient undergoing the same operation leaves the OR. An actual case series was constructed of 709 consecutive patients who underwent one of 11 elective operations at a tertiary care center. Statistical analysis of measured OR times showed that ACt would have to be decreased by more than 100% to permit one additional scheduled, short (30-min) operation to be performed in an OR during an 8-h workday after a prior series of cases, each lasting more than 45 min. Anesthesiologists alone cannot reasonably decrease case times sufficiently to permit one extra case to be reliably scheduled during a workday. Methods to decrease ACT (e.g., using preoperative intravenous catheter teams, procedure rooms, and/or shorter acting drugs) may simply increase costs.

Wollman, B., H. B. D'Agostino, et al. (1995). "Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature." Radiology 197(3): 699-704.
PURPOSE: To evaluate the effectiveness and safety of radiologic, percutaneous endoscopic (PEG), and surgical gastrostomy. MATERIALS AND METHODS: This project involved 5,752 patients (837 patients underwent radiologic gastrotomy; 4,194, PEG; and 721, surgical gastrostomy). Seventy-two (47 male, 25 female; age range, 12-94 years) underwent gastrostomy within 1 year in this series (radiologic gastrostomy, n = 33; PEG, n = 35; surgical gastrostomy, n = 4). A meta-analysis of 5,680 additional cases from literature published from 1980 to the present was also performed. RESULTS: Rates of successful tube placement were higher for radiologic gastrostomy than for PEG in our series and in the meta-analysis (99.2% vs 95.7%, P < .001). Major complications occurred less frequently after radiologic gastrostomy in our series and in the meta-analysis (5.9% vs 9.4% for PEG and 19.9% for surgery, P < .001). Thirty-day procedure-related mortality rates were highest for surgery (2.5% vs 0.3% for radiologic gastrostomy and 0.53% for PEG, P < .001). CONCLUSION: Radiologic gastrostomy is associated with a higher success rate than is PEG and less morbidity than either PEG or surgery.

Mingus, M. L. (1995). "Recovery advantages of regional anesthesia compared with general anesthesia: adult patients." J Clin Anesth 7(7): 628-33.
The data support but do not conclusively prove, that RA results in a superior recovery compared with GA. However, several questions need to be answered. Even though the patient may leave the hospital or surgicenter sooner after RA, how does the patient treat pain at home once the block has "worn off"? Since short-acting sedatives and opioids are so commonly used with RA, to what extent is recovery due to them and to what extent is recovery due to the RA alone? Many of the studies examining beneficial effects of RA have been poorly conducted, combining RA with GA and producing inconclusive results. Anesthetic techniques need to be carefully compared to determine whether they are equal in quality, efficiency, and cost. Finally, to determine whether RA is cost-effective, future studies involving ambulatory patients with a focus on outcome and well-being need to be conducted.

Greenberg, C. P. (1995). "Practical, cost-effective regional anesthesia for ambulatory surgery." J Clin Anesth 7(7): 614-21.

Philip, B. K. (1995). "Practical cost-effective choices: ambulatory general anesthesia." J Clin Anesth 7(7): 606-13.
To determine cost-effectiveness, we need to determine the value obtained for the price paid. Several points emerge. We need to identify specific recovery goals as our benefits, looking at early, intermediate, and late phases of recovery. Benefits such as effects on nausea may be specific to the procedure, duration, and site of practice. Time savings in the OR or recovery areas do not generate cost savings unless utilization actually increases or staffing actually decreases. Recovery care protocols that mandate a specific duration of stay in the PACU can negate any intraoperative or postoperative benefit differences generated by an anesthetic agent. Most of all, it is difficult to assign a dollar value to a very important benefit: patient satisfaction. Each of us, in our practices, must identify cost-effective choices for ambulatory anesthesia. Determining prices is simple. This we can and should do. Determining value, however, is more complicated and it is in this direction our work must lie.

Kapur, P. A. (1995). "Cost containment: at what expense?" Anesth Analg 81(5): 897-9.

Groudine, S. B. and J. Singh (1995). "Oxygen is cost effective." Anesth Analg 81(4): 891.

Rovira, J. (1995). "Economic analysis and pharmaceutical policy." Anaesthesia 50(Suppl): 49-51.
Economic evaluation, a comparative analysis of alternative actions in terms of costs and consequences, allows rational decisions to be made concerning the deployment of resources (people, time, equipment, facilities and knowledge). Pharmaceutical policy reflects the various objectives of the many social groups, some of which are conflicting. While new methodologies for evaluation of health care programmes still need to gain wider acceptance, resource limitations for both care providers and decision makers make economic analysis an increasingly important tool.

Eger, E. I., 2nd (1995). "Economic analysis and pharmaceutical policy: a consideration of the economics of the use of desflurane." Anaesthesia 50(Suppl): 45-8.
Several factors have to be considered in determining the cost of applying a new inhalational anaesthetic such as desflurane into clinical practice. Factors beyond the immediate control of the anaesthetic practitioner include the price set by the manufacturer (although this may be influenced by economic and political pressures), and the physical-pharmacological properties of the anaesthetic (e.g. vaporization, potency, solubility). The anaesthetic practitioner can minimise cost by applying lower inflow rates. Lower solubility (and hence lower uptake) provides a greater economy at lower inflow rates than does higher solubility. Furthermore, lower solubility permits the use of lower inflow rates with greater precision to the control of anaesthesia, and greater ease of application. At present unit prices, the cost of desflurane approximately equals that of isoflurane when a 1 l.min-1 inflow rate is used. The use of lower inflow rates presupposes that such rates do not allow the production of toxic compounds in recirculating gases. Modern equipment makes low-flow anaesthesia reliable and easy to control, and as desflurane is not degraded by the standard carbon dioxide absorbents, its use in low-flow systems is effective and economical. These cost considerations do not take into account the savings that may result from a more rapid recovery from anaesthesia, nor do they take into account the increased expense of capital equipment needed to apply a new anaesthetic.

Lubarsky, D. A. (1995). "Understanding cost analyses: Part 1. A practitioner's guide to cost behavior." J Clin Anesth 7(6): 519-21.

Yemen, T. A. (1995). "Analysis of cost savings in the recovery room requires complex models." Anesth Analg 81(3): 655.

Friedman, S. G. and A. J. Tortolani (1995). "Reduced length of stay following carotid endarterectomy under general anesthesia." Am J Surg 170(2): 235-6.
BACKGROUND: The widespread use of diagnosis-related groups has led to a significant reduction in the length of hospital stay following many surgical procedures. In light of this, an examination of early discharge following carotid endarterectomy under general anesthesia was undertaken. PATIENTS AND METHODS: A prospective study of 72 patients was conducted, in which the workup was done on an outpatient basis, admission took place on the same day as surgery, and patients were discharged home on the day after carotid endarterectomy. RESULTS: There were no strokes or deaths following carotid endarterectomy, and only two transient ischemic attacks occurred. In 88% of the cases, discharge was possible on the first postoperative day. CONCLUSIONS: Early discharge following carotid endarterectomy under general anesthesia is safe and cost effective.

Lubarsky, D. A. (1995). "Comparing apples to oranges." Anesth Analg 81(2): 428-9.

Viscomi, C. M. and J. P. Rathmell (1995). "Labor epidural catheter reactivation or spinal anesthesia for delayed postpartum tubal ligation: a cost comparison." J Clin Anesth 7(5): 380-3.
STUDY OBJECTIVES: To evaluate the costs and resource consumption associated with utilizing epidural catheters placed during labor versus spinal anesthesia for postpartum tubal ligation. To examine maternal demographics, anesthetic management variables, and time interval from delivery until surgery for association with epidural catheter reactivation success rate. DESIGN: Retrospective study. SETTING: University hospital labor and delivery center. PATIENTS: 120 consecutive postpartum patients with tubal ligations performed between June 1991 and December 1993. INTERVENTIONS: Postpartum women scheduled for tubal ligation with labor epidural catheters in place either had local anesthetic injected via the epidural catheter (n = 45) or had the catheter removed without reinjection and spinal anesthetic administered (n = 20). Patients with inadequate epidural anesthesia went on to receive spinal anesthesia. Women without a labor epidural catheter received spinal anesthesia (n = 55). MEASUREMENTS AND MAIN RESULTS: Adequate anesthesia for tubal ligation was achieved in 78% of women after reinjection of their epidural catheter. Operating room (OR) and anesthesia times were highest when epidural catheter reactivation was unsuccessful, intermediate when epidural catheter reactivation was successful, and lowest with initial spinal anesthesia (p < 0.05). The longer OR and anesthesia provider times associated with epidural catheter reactivation increased patient charges on average of $176 compared with the initial use of spinal anesthesia. CONCLUSIONS: Spinal anesthesia for postpartum tubal ligation was associated with lower anesthesia professional fees and OR charges compared with attempted reactivation of epidural catheters placed during labor. Anesthesiologists should weigh the cost advantages of spinal anesthesia against the small, but increased probability of headache after dural puncture.

Prielipp, R. C., J. S. Kelly, et al. (1995). "Use of esophageal or precordial stethoscopes by anesthesia providers: are we listening to our patients?" J Clin Anesth 7(5): 367-72.
STUDY OBJECTIVE: To ascertain current anesthesia utilization of esophageal and precordial stethoscopes in U.S. anesthesia training programs. DESIGN: Prospective, single-blind, incidence study. SETTING: Operating rooms of three tertiary care hospitals with major academic anesthesiology departments. SUBJECTS: Anesthesia faculty [MD and certified registered nurse-anesthetist (CRNA) staff] and anesthesia trainees (anesthesiology residents and student nurse-anesthetists). INTERVENTIONS: observe and record the placement (stethoscope device appropriately positioned) and utilization (stethoscope in place and connected to the ear piece of the anesthesia provider) of the esophageal or precordial stethoscope during general, regional, and monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS: During 520 anesthetics, an esophageal stethoscope was inserted in 68% of subjects, a precordial stethoscope was positioned in 16%, and an anesthetic stethoscope was absent in 16% of cases. Utilization (stethoscope connected to earpiece) ranged from a low of 11% of cases to a high of 45%, depending on the institution. Overall, providers were listening via an anesthetic stethoscope in only 28% of anesthetics. CONCLUSIONS: Our data suggest infrequent utilization of esophageal and precordial stethoscopes in anesthesia training institutions. Thus, current anesthesia training may be fostering an environment where providers overlook a valuable minimally invasive, and cost-effective continuous monitor of patients' dynamic vital organ function.

Hargasser, S., L. Mielke, et al. (1995). "[Anesthesia with low fresh gas flow in clinical routine use]." Anasthesiol Intensivmed Notfallmed Schmerzther 30(5): 268-75.
Anaesthesia in low-flow techniques gains increasing interest. The possibility of cost reduction, widespread use of highly developed anaesthesia machines and monitors, and introduction of two new fluorinated inhalational anaesthetics with low solubility in human tissues encourage the use of low-flow anaesthesia techniques. Further advantages are improved climatisation of breathing gas and estimation or even measurement of the important parameter "oxygen consumption". The anaesthesia machines and inhalational anaesthetics currently available allow a safe use of low-flow techniques if safety requirements are complied with (tight circle system, monitoring of: inspired oxygen concentration, minute ventilation, airway pressure, transcutaneous oxygen saturation). Low-flow anaesthesia techniques using a fresh gas flow rate of 1 l/min can be performed with almost every anaesthesia machine. However, the use of multigas monitors, analyzing most parts of the breathing gas, facilitates the use of low-flow techniques. Multigas monitors and anaesthesia machines equipped with intermittent fresh gas delivery are recommended for the use of fresh gas flow rates close to the metabolic rate. Because of its physicochemical properties the new inhalational anaesthetic desflurane offers advantages for the use in low-flow anaesthesia techniques.

Yu, D. S., T. H. Yang, et al. (1995). "Snail-headed catheter retriever: a simple way to remove catheters from female patients." J Urol 154(1): 167-8.
A snail-headed catheter retriever was designed to remove the Double-J* catheter from female patients. The catheter can be removed within a few minutes using topical anesthesia at the outpatient department without endoscopic instrumentation and lithotomy position. No infection or bleeding developed following the procedure and all patients tolerated it well. The cost-effective retriever can be used as a convenient alternative for Double-J catheter removal from female patients.

Dembo, J. B. (1995). "Methohexital versus propofol for outpatient anesthesia. Part II: Propofol is superior." J Oral Maxillofac Surg 53(7): 816-20.

Lieblich, S. E. (1995). "Methohexital versus propofol for outpatient anesthesia. Part I: Methohexital is superior." J Oral Maxillofac Surg 53(7): 811-5.

Zorab, J. S. (1995). "A general anaesthesia service for magnetic resonance imaging." Eur J Anaesthesiol 12(4): 387-95.
A general anaesthesia service for magnetic resonance scanning is described and figures for scans under general anaesthesia for the past 5 years are presented together with a description of the anaesthesia service related to the environment, the equipment and the techniques employed. The involvement of a representative from the department of anaesthesia is necessary in the design of scanner suites if general anaesthesia services are to be provided, as they will almost certainly need to be. The revenue costs of such a service are also briefly considered.

Hagan, M. (1995). "Postanesthesia care unit costs." Anesthesiology 82(6): 1534-5.

Liu, S., R. L. Carpenter, et al. (1995). "Epidural anesthesia and analgesia. Their role in postoperative outcome." Anesthesiology 82(6): 1474-506.

Joshi, G. P. (1995). "Cost comparison: a desflurane- versus a propofol-based general anesthetic technique." Anesth Analg 80(6): 1251-2.

Dorenbusch, M. J., D. D. Maglinte, et al. (1995). "Intravenous cholangiography and the management of choledocholithiasis prior to laparoscopic cholecystectomy." Surg Laparosc Endosc 5(3): 188-92.
The preoperative diagnosis of choledocholithiasis simplifies the laparoscopic management of biliary tract disease. Slow infusion intravenous cholangiography (SI-IVC) may be an accurate and cost-effective screening test for choledocholithiasis, and it is safer than traditional intravenous cholangiography. Forty-nine patients underwent SI-IVCs for suspected choledocholithiasis. These patients subsequently had endoscopic retrograde cholangiograms (ERC) or intraoperative cholangiograms (IOC) during laparoscopic cholecystectomies. Sixteen SI-IVCs demonstrated choledocholithiasis; 13 were confirmed by ERCs or by IOCs. The remaining 33 patients with negative SI-IVCs had negative ERCs or IOCs. The sensitivity, specificity, and accuracy of detecting choledocholithiasis by SI-IVC were 100%, 92%, and 94%. Only one patient had a mild reaction to the contrast agent. In our hospital the cost of an SI-IVC is $324, the cost of an IOC is $393 (including operating room and anesthesia costs), and the cost of an ERC is $1,085. SI-IVC is an accurate method of preoperative screening for choledocholithiasis. It is safe and cost-effective.

Penfield, A. J. (1995). "Twenty-two years of office and outpatient laparoscopy: current techniques and why I chose them." J Am Assoc Gynecol Laparosc 2(3): 365-8.
Since 1972 I have introduced the following technical modifications in outpatient laparoscopy under local anesthesia to improve safety, economy, and patient acceptability: avoiding the insufflating needle and sharp trocar in favor of open abdominal entry, using the Hasson cannula; introducing room air for insufflation instead of nitrous oxide or carbon dioxide; using the Hulka clip in place of tubal coagulation; making a single-incision, open surgical entry through the central umbilical fossa in obese patients; and completing fascial penetration with a blunt hemostat or Kelly clamp to minimize the risk of bowel or vessel injury.

Kraiss, L. W., L. Kilberg, et al. (1995). "Short-stay carotid endarterectomy is safe and cost-effective." Am J Surg 169(5): 512-5.
BACKGROUND: Carotid endarterectomy (CEA) is conventionally performed following a contrast arteriogram, under general anesthesia, and with postoperative admission to an intensive care unit (ICU). We investigated whether any of these traditional adjuncts to CEA is necessary. PATIENTS AND METHODS: Eighteen consecutive patients had CEA performed according to a protocol of duplex scanning only, operation under regional anesthesia, and admission to the ICU only in cases of a proven need for services unique to the ICU (group I). Utilization of preoperative arteriography, admission to the ICU, postoperative complications, total hospital length of stay, and hospital charges were calculated for this group and results were compared with a group of 178 patients undergoing conventional CEA (arteriography, general anesthesia, routine ICU admission) during the same period (group II). RESULTS: In group I, 1 patient (6%) underwent preoperative arteriography and 4 patients (22%) were admitted to the ICU after CEA. Most group II patients (114 of 178, or 64%) underwent preoperative arteriography and virtually all (175 of 178, or 98%) were admitted to the ICU. Compared with group II, the average hospital length of stay for group I was significantly shorter (1.3 +/- 0.1 versus 3.1 +/- 0.3 days, P = 0.03) and hospital charges were significantly reduced ($5,861 +/- 229 versus $11,140 +/- 729, P = 0.02). CONCLUSIONS: This pilot study suggests that CEA can be safely performed without routine preoperative carotid arteriography; that routine ICU admission is unnecessary for the majority of cases; and that elimination of routine arteriography and ICU admission can reduce hospital charges for CEA by nearly one half.

Berge, J. A., L. Gramstad, et al. (1995). "A simplified concept for controlling oxygen mixtures in the anaesthetic machine--better, cheaper and more user-friendly?" Acta Anaesthesiol Scand 39(4): 563-7.
Modern anaesthetic machines are equipped with several safety components to prevent delivery of hypoxic mixtures. However, such a technical development has increased the complexity of the equipment. We report a reconstructed anaesthetic machine in which a paramagnetic oxygen analyzer has provided the means to simplify the apparatus. The new machine is devoid of several components conventionally included to prevent hypoxic mixtures: oxygen failure protection device, reservoir O2 alarm, N2O/air selector, and proportioning system for oxygen/nitrous oxide delivery. These devices have been replaced by a simple safety system using a paramagnetic oxygen analyzer at the common gas outlet, which in a feed-back system cuts off the supply of nitrous oxide whenever the oxygen concentration falls below 25%. The simplified construction of the anaesthetic machine has important consequences for safety, cost and user-friendliness. Reducing the complexity of the construction also simplifies the pre-use checkout procedure, and an efficient 5-point check list is presented for the new machine.

Boothe, P. and B. A. Finegan (1995). "Changing the admission process for elective surgery: an economic analysis." Can J Anaesth 42(5 Pt 1): 391-4.
This study compared the costs of an inpatient elective surgical admission process with an outpatient based same day admission programme in patients undergoing laparoscopic cholecystectomy. The effect of this process change on annual surgical volume and case flow (number of procedures performed per surgical bed) in the year before the initiation of same-day method (1989/90) and subsequent to the widespread use of the process (1992/93), was also assessed. Costs incurred by 53 patients who underwent preoperative anaesthetic and surgical assessment as outpatients and were admitted as an outpatient on the day of surgery (SD Group) were compared with those incurred by 11 patients who entered hospital on the day before surgery and underwent anaesthetic and other assessments as inpatients (IP Group). Nursing, radiology, laboratory, operating room, rehabilitation and clinic costs were obtained for each patient. The remaining costs were not amenable to individual attribution and were assigned to each group as a percentage of the allocated costs. The cost per case in the SD Group was $360 less than in the IP Group, reflecting decreased nursing costs incurred by the SD Group. Between the period 1989/90 and 1992/93, the number of surgical beds declined 15.7%; however, surgical volume decreased by only 5.4%. Total case flow improved by 12.2%, that for elective and non-elective surgery increasing by 14.1% and 9.5%, respectively. Elective surgery, where same day admission was used, showed the greatest improvement in case flow. We conclude that a same day admission process reduces cost and serves to enhance hospital productivity.

Suver, J., S. R. Arikian, et al. (1995). "Use of anesthesia selection in controlling surgery costs in an HMO hospital." Clin Ther 17(3): 561-71; discussion 516.
The cost of induction and maintenance of anesthesia is analyzed in this article from the perspective of a health maintenance organization's (HMO) chief financial officer. While earlier economic studies tended to focus on the raw cost of anesthesia drugs, our model also includes the cost of the clinical labor involved in administering the drug as well as the fixed costs associated with the facility. Such a model is consistent with the goal of an HMO, which is to provide high-quality health care services to its membership while containing costs. Our model disaggregated the costs associated with anesthesia into cost centers. The costs associated with two anesthesia regimens, propofol and thiopental/isoflurane, were calculated and analyzed via cost-minimization methods. Our data were acquired from a prospective economic trial conducted in university, community, and HMO hospitals. Because institutional pricing policies differ greatly, only the findings at the HMO hospital are presented in this report. Our results suggest that intra-abdominal surgical procedures with a duration of less than 4 hours that use propofol for induction and maintenance of anesthesia reduce the total cost of surgery by $202.71, compared with the costs of using thiopental/isoflurane. Sensitivity analysis maintains the robustness of the conclusions with regard to all major parameters.

Riley, E. T., S. E. Cohen, et al. (1995). "Spinal versus epidural anesthesia for cesarean section: a comparison of time efficiency, costs, charges, and complications." Anesth Analg 80(4): 709-12.
Spinal anesthesia recently has gained popularity for elective cesarean section. Our anesthesia service changed from epidural to spinal anesthesia for elective cesarean section in 1991. To evaluate the significance of this change in terms of time management, costs, charges, and complication rates, we retrospectively reviewed the charts of patients who had received epidural (n = 47) or spinal (n = 47) anesthesia for nonemergent cesarean section. Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 +/- 20 vs 83 +/- 16 min, [mean +/- SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 +/- 11 vs 29 +/- 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (i.v.) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections.

Schulte-Sasse, U. (1995). "[Anesthesia for surgery in ambulatory patients: organizational aspects of the hospital physician]." Anasthesiol Intensivmed Notfallmed Schmerzther 30(2): 77-85.
At first sight it seems impossible to put into practice the 1992 resolution of the German Federal Council recommending increased frequency of hospital based operative care for ambulatory patients and the duty to do so under full financial coverage. A detailed analysis of the current situation suggests that this may be possible even today--with some reservations regarding the infrastructure of the hospitals. Selection and preparation of the patient is a process in which the anaesthesiologist must play an important role. Delegation of this duty to the surgeon or the general practitioner is not permitted. The anaesthesiologist must have sufficient time, prior to the procedure, to meet the patient; meeting the patient for the first time a few minutes before induction of anaesthesia is unacceptable. Even if one concedes freedom of methods, one drug and one procedure should be avoided while caring for surgical ambulatory patients: this drug is succinylcholine, because of life-threatening hyperkaliaemia in children with occult myopathy and severe and frequent myalgia especially in ambulatory patients. The procedure not suitable in ambulatory patients is subarachnoidal analgesia--due to an unacceptably high percentage of headaches in young ambulatory patients. The postoperative care and observation must be delegated to especially qualified persons only--and these persons should not be distracted by duties outside the recovery area. The anaesthetist must--in addition--be available at all times without delay. Pain, nausea and emesis molest the ambulatory patient during the postoperative course to a particular extent. The anaesthesiologist must take care of these complaints--even if the patient is discharged.(ABSTRACT TRUNCATED AT 250 WORDS)

Martin, E. (1995). "[Anesthesia in ambulatory surgery]." Anasthesiol Intensivmed Notfallmed Schmerzther 30(2): 69-70.

Biro, P., G. Suter, et al. (1995). "[Intravenous anesthesia with propofol versus thiopental-/enflurane anesthesia. A consumption and cost analysis]." Anaesthesist 44(3): 163-70.
It may be possible to reduce costs in anaesthesia when there is a choice of drugs and methods. Two of the most widespread techniques are inhalation anaesthesia with enflurane following induction with thiopentone, and intravenous anaesthesia (IVA) with propofol. The aims of our study were to compare the costs, effectiveness and side effects of the anaesthetics involved in these two techniques, and to measure significant clinical parameters. METHODS. After approval by the hospital ethics committee, 40 adult patients of ASA physical status 1 and 2 who had been scheduled for elective septorhinoplasty and had given informed consent were entered in our prospective, single-blind randomized study. In 20 patients anaesthesia was induced with thiopentone (4-5 mg/kg) and suxamethonium (1-1.5 mg/kg) and maintained with enflurane. The other 20 patients received an initial i.v. bolus of propofol (2-2.5 mg/kg) followed by a propofol infusion adjusted to their individual clinical needs. Ventilation was performed in both groups with 70% nitrous oxide in oxygen, using a nonrebreathing system. Muscle relaxation was maintained with atracurium. The amounts of anaesthetics, oxygen, nitrous oxide, and muscle relaxants used were measured and a record of the costs was kept. In addition, circulatory and respiratory parameters and quantitative and qualitative aspects of recovery from anaesthesia were recorded. RESULTS. The biometric and clinical data did not differ significantly between the two groups. For induction, 382 (+/- 55.9) mg thiopentone costing 1.24 Swiss francs (SFr), or 172 (+/- 25.1) mg propofol costing 11.87 (SFr) was used. For maintenance, 28.3 (+/- 6.4) ml enflurane costing 21.96 SFr/h, or 450.7 (+/- 247) mg propofol costing 29.75 SFr/h was required. The need for muscle relaxants, oxygen, and nitrous oxide was also not significantly different in the two groups. Additional expenses were due to relaxation antagonists (1.91 SFr per patient in both groups) and to the perfusion pump system (8.60 SFr per patient in the IVA group only). Circulatory and respiratory parameters remained normal in both groups. In the propofol group, the heart rate tended to increase more at the beginning of anaesthesia, whereas later on it showed a tendency to lower values than in the thiopentone/enflurane group. Patients receiving IVA generally had a shorter awakening period, a higher degree of wellbeing during recovery, and needed less systemic analgesics (P < 0.05). CONCLUSIONS. Costs of anaesthetic drugs in the IV group totalled 54.50 SFr during the first hour, i.e. 1.65 times the costs in the thiopentone/enflurane group for the same time. However, with continuing duration of anaesthesia this ratio declines to 1.43 in anaesthesia lasting 2 h. In addition, IVA patients had a noticeably faster and far more pleasant recovery. Minute ventilation, oxygen consumption, heart rate and CO2 production indicated a less pronounced stress response and sympathetic activity during and after propofol. Quicker recovery of cognitive and psychomotor abilities, less postoperative pain and less impairment of respiratory function after IVA may lead to an earlier release from the postoperative recovery unit. This might be a cost-reducing factor that should be taken into account when these two anaesthetic regimens are concerned.

Macario, A. (1995). "A health policy perspective on costs of short-term anesthesia services." J Clin Anesth 7(2): 175-6.

Mathias, J. M. (1995). "Study tests RN monitoring for eye surgery." OR Manager 11(3): 16-7.

Rolf, N. and H. Van Aken (1995). "[Inhalation anesthesia and intravenous anesthesia from the medical and economic viewpoint]." Anasthesiol Intensivmed Notfallmed Schmerzther 30(1): 13-9.
The unique pharmacokinetic properties of propofol gave rise to a widespread use of the technique of total intravenous anaesthesia. These properties of propofol are reviewed and compared to those of barbiturates and benzodiazepines. Based on this comparison and with respect to their respective intra- and postoperative effects, a cost-benefit analysis of both inhalational- and intravenous anaesthesia is presented. The choice of an anaesthetic technique must not only be made with regard to medical implications; economical aspects have also to be taken into account without challenge to the quality of care. A consequent use of low-flow techniques and a market oriented purchase of drugs and disposables may allow cost savings in anesthesia.

Candelaria, L. M. and R. K. Smith (1995). "Propofol infusion technique for outpatient general anesthesia." J Oral Maxillofac Surg 53(2): 124-8; discussion 129-30.
PURPOSE: The purpose was to evaluate the suitability of a continuous propofol infusion in combination with alfentanil for outpatient general anesthesia in an oral and maxillofacial surgery practice. MATERIALS AND METHODS: Twenty-seven ASA 1 patients were selected to undergo oral and maxillofacial surgery outpatient procedures of short duration. Induction of anesthesia was accomplished with 1 mg/kg intravenous (i.v.) propofol and 10 micrograms/kg i.v. alfentanil. Local anesthesia was administered. General anesthesia was maintained with a continuous infusion of 150 micrograms/kg/min of propofol. Various physical and psychomotor responses were recorded during induction, maintenance, emergence, and recovery. RESULTS: Anesthesia was successfully induced in all patients with single, slowly titrated, bolus doses of 1 mg/kg of propofol and 10 micrograms/kg of alfentanil. Induction of general anesthesia occurred in less than 1 minute in all cases and no excitatory phenomena, tremor, or hypertonus were observed. Maintenance of anesthesia was adequately accomplished and cardiovascular parameters remained within acceptable limits throughout the procedure. The average length of surgery was 22 minutes. Movement to surgical stimulus was minimal and easily managed with additional local anesthetic and/or a 10-mg bolus of propofol. Time to eye opening was approximately 5 minutes from the discontinuation of the propofol infusion. No emergence phenomena were observed. All patients were ready for discharge with baseline psychomotor activity within 30 minutes following the end of the procedure. The average total dose of propofol was 350 mg and the average dose of alfentanil was 750 micrograms. CONCLUSION: This anesthetic technique has numerous advantages with minimal side effects, and should be considered for routine use for outpatient general anesthesia in oral and maxillofacial surgery.

Kelly, D. and S. J. Brull (1995). "The cost of modern technology." J Clin Anesth 7(1): 80-1.
Continuous infusion of intravenous (i.v.) drugs is increasing in popularity, as technological advances in equipment (such as "smart" pumps) and pharmacologic improvements of drugs (such as ultra-short acting drugs) are introduced into clinical anesthesia practice. Such new technology, however, also introduces potential new complications. We report one such complication associated with the improper manufacturing of a proprietary i.v. tubing and cassette system.

Squires, R. H., Jr., F. Morriss, et al. (1995). "Efficacy, safety, and cost of intravenous sedation versus general anesthesia in children undergoing endoscopic procedures." Gastrointest Endosc 41(2): 99-104.
We prospectively evaluated 226 patients under 18 years of age who underwent 296 procedures, and intravenous sedation and general anesthesia were compared in regard to efficacy, safety, and cost. Children 6 to 9 years of age required the highest doses of midazolam (0.14 +/- 0.04 mg/kg) and meperidine (2.5 +/- 0.8 mg/kg). A Relative Adequacy Scale, constructed to assess each patient's arousal and cooperation during intravenous sedation, revealed a 95% completion rate. Heart rate monitored before, during, and after the procedure was similar in both groups during the procedure, but a lower preprocedure heart rate was noted in older patients having intravenous sedation, suggesting less patient anxiety. Average charges, excluding endoscopist's and pathology fees, were $768.52 in the intravenous sedation group versus $1,965.42 in the general anesthesia group. Endoscopic procedures can be performed safely, effectively, and at a lower cost to the patient under intravenous sedation in a properly equipped and staffed pediatric endoscopy suite.

Eubanks, J. R., Jr. (1995). "Variations in hospital charges for epidural steroid block." Ala Med 64(8): 18-9.

Callesen, T. and H. Kehlet (1995). "[Inguinal herniotomy--which kind of anesthesia? Economical considerations]." Ugeskr Laeger 157(4): 421-4.
Economical aspects of three different types of anaesthesia for inguinal hernia repair are discussed on the basis of relevant papers and economical estimates. Infiltration anaesthesia is found to be less expensive than both spinal and general anaesthesia. The reduction in cost is mainly based on a reduced demand for observation facilities during and after the operation as well as for preoperative evaluation. Early postoperative analgesia is improved after inguinal field block. Urinary retention is seen with a reduced frequency after inguinal field block. The risk of wound complication seems unrelated to the type of anaesthesia. The risk of serious complications related to anaesthesia (i.e. aspiration pneumonitis and significant circulatory events) is probably lower after infiltration anaesthesia. It is recommended that infiltration anaesthesia be employed for hernia repair.

Dragomirescu, C., N. Iordache, et al. (1995). "[A comparative study of the hospital costs for laparoscopic cholecystectomy and classical cholecystectomy]." Chirurgia (Bucur) 44(2): 9-16.

Scheidegger, D. (1995). "[Preoperative assessment from the viewpoint of the anesthetist]." Swiss Surg(3): 128-9.

Nabai, H., B. Haghshanas, et al. (1995). "Cost reduction of skin biopsy and surgical instrumentation." Dermatology 191(3): 240-1.
Saving the physicians time is very desirable in rendering first-rate dermatological service at lower cost. The aim is to reduce surgical instrumentation during skin biopsy procedures and follow-up visits. A combined instrument is used to obtain skin biopsies from 100 patients, and gelatin sponge plugs are used in hemostasis and to assist healing of the biopsy wound site. Skin biopsy samples are obtained simply and with ease, and, as the tissue sample is handled minimally, it appears to be more intact and less distorted in comparison to the usual procedure. Skin biopsy samples can be obtained with the combined instrument in a more cost-effective manner with savings of the physician's time and less instrumentation.

Dexter, F. and J. H. Tinker (1995). "Analysis of strategies to decrease postanesthesia care unit costs." Anesthesiology 82(1): 94-101.
BACKGROUND: The goal of this study was to identify interventions that anesthesiologists can make to decrease total costs of a postanesthesia care unit (PACU). METHODS: Data were collected retrospectively from patients who underwent ambulatory surgery at our tertiary care center. RESULTS: Supplies and medications accounted for only 2% of PACU charges. Personnel costs, which depend on the peak number of patients in the PACU, accounted for almost all PACU costs. If nausea and vomiting could have been eliminated in each patient who suffered this complication, without causing sedation, the total time to discharge for all patients would have been decreased by less than 4.8% (95% confidence interval < 7.3%). Arrival rates to and times to discharge from the PACU followed triangular and log-normal distributions, respectively. Computer simulations, using published times to discharge for drugs with "faster recovery," such as propofol, showed that the use of these drugs would only decrease PACU costs if operating rooms were consistently scheduled to run later each day. Such earlier discharge also might be beneficial if used at night, but only if the PACU could close after a single patient leaves. However, reasonably achievable decreases in the times to discharge for all patients undergoing general anesthesia are unlikely to substantively decrease PACU costs. In contrast, arranging an operating room schedule to optimize admission rates would greatly affect the number of PACU nurses needed. CONCLUSIONS: Anesthesiologists have little control over PACU economics via choice of anesthetic drugs. The major determinant of PACU costs is the distribution of admissions.

Shapiro, M. S., M. R. Safran, et al. (1995). "Local anesthesia for knee arthroscopy. Efficacy and cost benefits." Am J Sports Med 23(1): 50-3.
We performed a retrospective review of a series of knee arthroscopic procedures that were completed using local, general, or regional anesthesia to evaluate the efficacy of these anesthetic techniques. Operative time, complications or failures, procedures successfully performed, recovery room time and postoperative stay, and patient satisfaction were recorded. Local anesthesia with intravenous sedation compared favorably with the other techniques: operative time was not increased, a large variety of operative procedures were successfully completed, recovery time was significantly shortened, and patient satisfaction remained high. This technique offers several advantages over other types of anesthesia for knee arthroscopy, including improved cost effectiveness.

Broadway, P. J. and J. G. Jones (1995). "A method of costing anaesthetic practice." Anaesthesia 50(1): 56-63.
This paper identifies the main factors involved in the cost of elective general anaesthetic practice. The costs of anaesthesia were divided into overheads and running costs, which are sensitive to the duration of anaesthesia, and fixed costs which are incurred by each patient but are not sensitive to the duration of anaesthesia. The overhead costs consisted of salaries, capital equipment and maintenance costs. The overhead cost of a consultant anaesthetist combined with a technical assistant's salary, monitoring equipment and anaesthetic machine was estimated at 45.05.h-1 pounds (using 1993 salary scales and prices). The fixed costs of pre-operative assessment and nursing care in recovery were the same for all patients, 20.60 pounds per patient. For the majority of anaesthetics the combined cost of the anaesthetist, overheads and postoperative care was about 70% of the total cost, the remainder being the running costs which included drugs, anaesthetic gases, vapours, intravenous fluids, sterile equipment and other disposable items. Four sample anaesthetics were costed in two ways: both methods used the same overhead and fixed cost per patient but one added the cost of all the individual drugs and consumables used, whereas the other grouped these together using a charge sheet which can be computerised and used prospectively to cost anaesthesia. There was close agreement between the costs derived with the two methods. The cost of a 30 min delay in the start of an operating session was 27.30 pounds (anaesthetist, assistant and nurse salary (9.50.h-1 pounds)) which is more than the cost of 2 h of propofol infusion anaesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Del Papa, M., M. Mobili, et al. (1995). "[Treatment of inguinal hernia with Marlex patch using the Trabucco method: costs and benefits]." Ann Ital Chir 66(1): 99-100; discussion 101.

Amid, P. K., A. G. Shulman, et al. (1995). "An analytic comparison of laparoscopic hernia repair with open "tension-free" hernioplasty." Int Surg 80(1): 9-17.
Two of the most important etiological factors in the development of primary and recurrent inguinal hernias are collagen deficiency and tension on the suture line respectively. These factors can be eliminated by the use of open "tension-free" hernioplasty, advocated by the Lichtenstein Hernia Institute since 1984. In this procedure, the entire floor of the inguinal canal is reinforced by an 8 cm x 16 cm sheet of Marlex mesh that is sutured in place to protect the floor from all future adverse mechanical and metabolic effects without the risk of displacement or folding. A new ring and shutter mechanism is also created by the procedure, which is performed under local anesthesia and requires only a few hours of in-hospital postoperative observation. Pain control following the operation involves only 2-20 tablets of 5 mg hydrocodone bitartrate, for 2-4 days. The recurrence rate of early procedures was a mere 0.1%, and has been zero for 2,500 patients treated in the past five years. In addition, there has only been one complication (a testicular atrophy) in 4,000 operations over ten years. The postoperative pain and recovery period of the "tension free" procedure compare favorably with those of laparoscopic repair, while the complication and recurrence rate and costs are significantly lower. The Lichtenstein "tension-free" method has been performed on tens of thousands of patients worldwide and these results have been duplicated and published by authors from the United States, England, Belgium, Spain, Italy and Austria.(ABSTRACT TRUNCATED AT 250 WORDS)

Suver, J. D., S. R. Arikian, et al. (1995). "A multifactorial approach to understanding anesthesia selection." Health Care Manage Rev 20(3): 7-15.
A full hospital cost accounting model to track the total costs of surgery and anesthesia for inpatients, from the perspective of a hospital CFO, utilizing time-allocation methodology is presented. This model was tested in a prospective multicenter economic clinical trial in three settings.

Klug, W. (1995). "[Ambulatory surgery in the hospital--analysis of a 1978-1994 patient sample]." Zentralbl Chir 120(8): 598-603.
In the outpatient department of the University hospital of the Technology University Dresden ambulatory surgery has been performed since 1965. The patients of 16 years were analyzed. From 1978 till VI/1994 we have carried out 13948 elective operations. The personal wish of a cooperative patient without risk factors and an orderly social surrounding are the prerequisites for carrying out outpatient operations. Applied anaesthetic techniques were: general anaesthesia 9.2%, spinal anaesthesia 7.1%, sacral anaesthesia 14.8%, nerveblock of the upper extremity 11.1 and infiltration anaesthesia 57.8%. On the day of operation 61 patients had to be admitted to the hospital because of intraoperative events, expansion of the operation and complications of anaesthesia. Between the first to eight postoperative day 23 patients were hospitalised due to bleeding and 1 patient due to a wound infection. After aseptic elective operations 33 patients (0.35%) and after proctology operations with primary wound closure 10% of the patients developed wound infections. The cooperation of the general practitioner must be ensured in the post-operative days. Outpatient operations lower the financial burden of the health insurance companies, medical care services can be reduced.

Berry, F. A. (1995). "The winds of change." Paediatr Anaesth 5(5): 279-80.

Meakin, G. (1995). "Role of propofol in paediatric anaesthetic practice." Paediatr Anaesth 5(3): 147-9.

Wender, R. H. (1995). "Monitoring of low flow anesthesia: the United States perspective." Appl Cardiopulm Pathophysiol 5(Suppl 2): 83-91.

Aldrete, J. A. (1995). "From the theory to the practice of 'near-closed system' anesthesia." Appl Cardiopulm Pathophysiol 5(Suppl 2): 5-11.

Erdmann, W. and H. van der Zee (1995). "Basic principles of quantitative practice." Appl Cardiopulm Pathophysiol 5(Suppl 2): xi-xii.

Maddern, G. J., G. Rudkin, et al. (1994). "A comparison of laparoscopic and open hernia repair as a day surgical procedure." Surg Endosc 8(12): 1404-8.
To evaluate the merits of laparoscopic inguinal hernia repair (LHR) compared to conventional open hernia repair (OHR) a randomized study has been conducted. All patients were day surgical cases, of which 44 were randomized to a standardized OHR under local anesthetic (LA) and 42 to an LHR under general anesthesia (GA). Fifteen LHR patients had bilateral repairs. Operative time for OHR was 30.5 min, for unilateral LHR 35 min, and for bilateral LHR 60 min. OHR patients were discharged after a median of 134.5 min, which was significantly shorter than LHR patients, whose median discharge was 225 min (P < 0.01). Pain scores, activity levels, analgesia requirements, and time taken to return to work were not significantly different following surgery in either group (P < 0.05). There have been two recurrent hernias and one small bowel obstruction in the LHR group. We conclude that both repairs can be successfully performed as day surgical procedures. The added cost of LHR at this stage does not warrant its widespread use in unilateral hernia repairs. Which procedure is adopted should be individualized; however, patients with bilateral hernias on presentation can be successfully managed as day cases, obviating the need for hospitalization or two operations.

Thomson, W. M. (1994). "Day-stay treatment for dental caries at a New Zealand hospital dental unit: a 5-year retrospective audit." N Z Dent J 90(402): 139-42.
A retrospective audit of day-stay dental treatment for children under general anaesthesia at a New Zealand hospital dental unit showed that demand for such treatment has risen. Waiting times increased substantially over the 5-year period of the study--only 3.4 percent of children had to wait more than 3 months for treatment in 1989-1990, compared with 28.4 percent in 1993-1994. The re-treatment rate over the 5-year period was 4.2 percent. Extractions were the most common treatment item provided, followed by Class I and Class II amalgam restorations. A change of operator and an improvement in equipment in the 1993-1994 period contributed to a change in the range of treatment provided, and a concomitant increase in Dental Benefit revenue. Regional Health Authorities need to take a more realistic approach to purchasing such services so that safe practice is encouraged. Purchasing bodies in general need to give high priority to integrated child health promotion initiatives so that the need for day-stay dental treatment under general anaesthesia is ultimately reduced.

Fleischer, M., C. P. Marini, et al. (1994). "Local anesthesia is superior to spinal anesthesia for anorectal surgical procedures." Am Surg 60(11): 812-5.
In this prospective study we compared local with spinal anesthesia for anorectal surgical procedures with regard to pain control, recovery time before unassisted ambulation, incidence of postoperative complications, length of hospital stay, and cost effectiveness in 80 consecutive patients. Patients were allocated in two groups: group 1 (n = 52) received local anesthesia, and group 2 (n = 28) had spinal anesthesia. There were no intraoperative complications related to the anesthetic technique, and there was no difference between groups in the number of doses of narcotics required to control postoperative pain (1.2 +/- 1.5 vs 1.8 +/- 1.7 in group 1 and 2 respectively, P > 0.05). Recovery time before unassisted ambulation was significantly longer in group 2 (139 +/- 96 minutes in group 2 vs 82 +/- 62 minutes in group 1, P < 0.05). There were 21/52 complications in group 1 in contrast to 21/28 in group 2, (P < 0.05). There was no difference between groups in the postoperative incidence of nausea, vomiting, headache, weakness, and constipation; however, the incidence of postoperative urinary retention was significantly higher in group 2 (5/52 in group 1 vs 9/28 in group 2, P < 0.05). As a result of urinary retention, more patients in group 2 required overnight hospitalization (12/52 in group 1 vs 21/28 in group 2, P < 0.05). Patients in group 2 required 36 hospital days in contrast to 21 days for patients in group 1, P < 0.05. The difference in hospital days resulted in $18,000 greater cost for patients in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Rosenberg, M. K., P. Bridge, et al. (1994). "Cost comparison: a desflurane- versus a propofol-based general anesthetic technique." Anesth Analg 79(5): 852-5.
The purpose of this study was to compare the cost of a desflurane-based with a propofol-based general anesthetic technique. Fifty ambulatory orthopedic surgery patients were randomly assigned to one of two groups. Premedication and induction of anesthesia were standardized in both groups. In Group I patients, anesthesia was maintained with a propofol infusion and nitrous oxide-oxygen and in Group II patients, with desflurane-oxygen. The techniques used were identical to those routinely used with these drugs by our practitioners. The actual drug acquisition costs for the maintenance periods were calculated and compared, as was the duration of the postanesthesia care unit (PACU) stay (Phase I + Phase II). The drug acquisition cost for the maintenance period of general anesthesia with our desflurane-based technique was $11.24/h and for our propofol-based technique, $44.08/h. The length of PACU stay was not significantly different in the two groups. In conclusion, maintenance general anesthesia with our desflurane technique was considerably less expensive than with our propofol technique. PACU stay was not increased using desflurane as opposed to propofol in our study. Desflurane offers a cost effective alternative to propofol for ambulatory general anesthesia.

Horrow, J. C. and H. Rosenberg (1994). "Price stickers do not alter drug usage." Can J Anaesth 41(11): 1047-52.
Anaesthetists choose daily among wide varieties of neuromuscular blocking drugs and rapidly acting hypnotic agents. This study sought to determine whether definitive, immediate knowledge of drug cost might influence clinician choices, ultimately reducing the cost of anaesthesia care. Faculty anaesthetists, residents in training, and nurse anaesthetists served as subjects in this prospective, sequential, blinded study of prescribing habits. Weekly inventories of selected neuromuscular blocking and rapidly acting hypnotic agents were performed over 24 wk at a tertiary-care hospital. Supermarket style price stickers plainly indicating the hospital cost of each unit of drug appeared continually for 13 wk following an initial 11 wk control period. Both actual usage data in priced units as well as data normalized by total anaesthesia duration underwent comparison between control and priced periods. The usage of pancuronium, vecuronium, atracurium, mivacurium, succinylcholine, thiopentone, etomidate, and propofol did not differ in the control from the priced periods. Pipecuronium decreased after sticker placement (2 vs 1 vials.wk-1 median, P < 0.05), as did methohexitone (39 +/- 9.0 [SD] vs 29 +/- 11 syringes.wk-1, P < 0.05). Ketamine usage normalized by total anaesthesia duration increased (P < 0.05) following sticker placement. The weekly cost of all drugs inventoried normalized for caseload did not differ during the measurement periods. Immediate cost awareness, implemented simply as price stickers on drug units, had minimal impact on clinicians' drug usage in a tertiary care setting.

Zorab, J. S. (1994). "Pain control during interventional biliary procedures: epidural vs i.v. sedation." AJR Am J Roentgenol 163(4): 998-9.

Freebairn, R., G. M. Joynt, et al. (1994). "A double-blind comparison of vecuronium administered by the Springfusor infusion device to vecuronium by intermittent bolus injection in critically ill adult patients." Anaesth Intensive Care 22(5): 580-5.
To evaluate the Springfusor infusion device for clinical use in an Intensive Care Unit and to compare the technique of intermittent bolus and constant infusion of muscle relaxants, we undertook a prospective double-blind randomized placebo-controlled study. Twenty critically ill ventilated patients requiring muscle paralysis were investigated. Although we could show no clinical advantage in infusing vecuronium, the Springfusor provided a more constant level of paralysis compared with hourly bolus doses. The device is robust, easy to use and reduces nursing workload. This may translate into cost-saving improvement in patient care if the Springfusor is used to provide muscle relaxation, sedation and analgesia.

Thys, D. M. (1994). "Can our patients afford the cost of cost containment?" J Cardiothorac Vasc Anesth 8(5): 487-9.

Becker, K. E., Jr. and J. Carrithers (1994). "Practical methods of cost containment in anesthesia and surgery." J Clin Anesth 6(5): 388-99.
With the increasing focus of national attention on health care and health care costs, anesthesiologists, along with all other medical specialists, must become more cost conscious in their practice behaviors. This review describes the current concerns about health care in the United States, including a discussion of some of the forces causing the increase in health care spending. The role of anesthesiology in the increase in health care costs is discussed. Practical methods for controlling anesthesia costs are outlined, including reducing preoperative testing, decreasing blood product use, and employing more regional and local anesthetic techniques. Several ideas for reducing the costs of anesthetic gases and drugs, including low-flow anesthesia and less expensive alternative drugs, are presented. The final section describes the changes in anesthesia drug use that occurred from 1992 to 1993 at one health care center (St. Francis Regional Medical Center, Wichita, KS, which is associated with the University of Kansas School of Medicine-Wichita). These changes resulted in a 13% reduction in anesthesia drug costs, which amounted to a savings of $127,472. The largest decreases were in anesthetic gases (16%), resulting from an increase in the use of low-flow techniques, and in muscle relaxants (26%), resulting from a switch to older lower-cost drugs.

DeMonaco, H. J. and A. S. Shah (1994). "Economic considerations in the use of neuromuscular blocking drugs." J Clin Anesth 6(5): 383-7.
The acceptance of new and increasingly expensive technologies is a major component of the rising costs of health care. While the practice of anesthesia has been relatively immune from the effects of cost containment, it is inevitable that practitioners will have to justify costly practices. Available pharmacoeconomic methods can be applied to the use of all anesthetic drugs, particularly neuromuscular blocking drugs. Cost-effectiveness analysis allows the practicing anesthesiologist to prioritize the use of neuromuscular blocking drugs to maximize their benefit while reducing unnecessary costs.

Szocik, J. F. and D. W. Learned (1994). "Impact of a cost containment program on the use of volatile anesthetics and neuromuscular blocking drugs." J Clin Anesth 6(5): 378-82.
STUDY OBJECTIVE: To determine the impact of a cost containment program on the use of volatile anesthetics and neuromuscular blocking drugs. DESIGN: Historical, controlled, retrospective analysis. SETTING: Main operating rooms of an adult general hospital at a university medical center. PATIENTS: All patients undergoing anesthesia between July 1991 and November 1993. MEASUREMENTS AND MAIN RESULTS: Cost per case was determined by dividing the monthly expenditure for each class of drug by the caseload for that month. Cost per case of volatile anesthetic drugs decreased from $19.20 +/- 1.16 to $15.16 +/- 0.39 (p = 0.0034 by unpaired t-test). For neuromuscular blocking drugs, cost per case decreased from $19.67 +/- 1.35 to $12.23 +/- 0.66 (p = 0.003). CONCLUSIONS: Concerted educational efforts can decrease the per case expenditures for both volatile anesthetic drugs and neuromuscular blocking drugs.

Vitez, T. S. (1994). "Principles of cost analysis." J Clin Anesth 6(5): 357-63.
In medicine, reimbursement changes that block cost shifting are rendering revenue-based strategies less productive. Under these conditions, cost-benefit and cost-effective analyses are being touted as more effective financial tools. The anesthesia literature reflects misunderstanding and misapplication of the terminology, and principles of cost analysis are reviewed in this essay. Current evidence suggests that anesthesia costs are a minor part of the problem of controlling health care expenditures. However, the ability to perform cost analysis is essential for anesthesia groups to secure their position in health care.

White, P. F. and L. D. White (1994). "Cost containment in the operating room: who is responsible?" J Clin Anesth 6(5): 351-6.

Eagle, C. J., J. M. Davies, et al. (1994). "The cost of an established quality assurance programme: is it worth it?" Can J Anaesth 41(9): 813-7.
Although the literature concerning quality assurance (QA) is voluminous, little information exists about the costs or benefits of departmentally based QA programmes. We measured the direct costs and then investigated the financial and nonfinancial benefits derived from a well-funded QA programme over a period of five years. Data were obtained from departmental budgets, annual reports of the QA programme, and several databases used by the programme. The average annual cost was $79,900, with salaries being the largest component, while $14,300 each year were recovered through the activities of the programme. True costs were higher than those calculated since time volunteered by medical staff and resources shared with other programmes could not be determined. Some of the costs encountered at the outset of this programme were later offset by the use of commercial software and employment of volunteers and casual staff. Fifty-three projects were identified over the five-year period. Most lacked directly measurable financial outcomes (because they were based on education, research, patient or practitioner satisfaction). The benefit of the programme has been greater to the department than suggested from cost analysis alone. Although this programme could not be justified on a simple cost recovery basis, the authors felt it to be worthy of continued support because of the nonfinancial benefits. However, modification is required to minimize costs.

Duncan, P. G. (1994). "The price of quality." Can J Anaesth 41(9): 765-8.

Lieberman, J. R. and W. H. Geerts (1994). "Prevention of venous thromboembolism after total hip and knee arthroplasty." J Bone Joint Surg Am 76(8): 1239-50.

Komesaroff, D. (1994). "Low flow anaesthesia--an Australian devotee's perspective." Anaesth Intensive Care 22(4): 343-4.

Gunther, P. (1994). "The economic advantages of low-flow isoflurane-nitrous oxide anaesthesia." Acta Anaesthesiol Scand 38(6): 617-8.

Healey, T. G. (1994). "The price of anesthesia care." Crna 5(3): 86-8.
The focus on the cost of health care presents a paradox. Although society demands lower cost healthcare, few want to cut health services or the quality of the care received. There continues to be strong consumer pressure to improve the quality of health care and to increase the scope of services, while keeping cost increases to a minimum. Obviously, there is no single answer to the complex issues facing the health care industry. The nurse anesthetist, must however, begin answering these demands with an analysis of our own practice. Our role in the health care system of the future will be determined, not just on our clinical competency, but also on how we respond to the system as a whole. "Cost effectiveness" will need to be redefined as CRNAs provide a "value added" service.

Vleugels, A. M. (1994). "Anesthesiology in the Belgian health care environment." J Clin Anesth 6(4): 324-32.
This article focuses on anesthesiology practice in the context of Belgian health care. The first part describes the organization of Belgian health care, the role of private and public initiatives, the division of responsibilities between the different health authorities, the financing mechanisms, and the central role of the compulsory social health care insurance. Quantitative information on the evolution of expenditures, services, providers, and facilities is presented. The second part of the article deals more specifically with anesthesiology and contains information on current practice. The emphasis, however, concerns recent developments in training and accreditation.

Johnstone, R. E. and K. G. Jozefczyk (1994). "Costs of anesthetic drugs: experiences with a cost education trial." Anesth Analg 78(4): 766-71.

Kapur, P. A. (1994). "Pharmacy acquisition costs: responsible choices versus overutilization of costly pharmaceuticals." Anesth Analg 78(4): 617-8.

(1994). "Desflurane (Suprane). Considerations for introducing the new inhalation anesthetic agent into clinical practice." Health Devices 23(4): 131-42.
Ohmeda PPD is counting on desflurane's decreased solubility, which provides improved control of anesthetic level and allows faster recovery, and its reduced toxicity to the liver and kidney to sufficiently differentiate it from its competitor, isoflurane, to make it the inhalation anesthetic of choice in the future. However, even though initial interest has been high, resistance has arisen for several reasons: Desflurane's high MAC requires reduced fresh-gas flows to keep its rate of consumption down. It may not be suitable for certain applications (e.g., for induction of pediatric patients, for use with patients with tachycardia or hypertension). It is usually necessary to supplement it with an injectable agent for induction. Even though it is superior to other agents with respect to speed of initial recovery, no striking advantage relative to time of discharge from the hospital has been demonstrated. Agent monitors will need to be upgraded or new monitors will need to be purchased if the drug is to be measured. The future prices of the drug and its vaporizer are not certain. All of these factors must be considered before committing to this new technology.

Izuora, K. L., D. J. Ffoulkes-Crabbe, et al. (1994). "Open comparative study of the efficacy, safety and tolerability of midazolam versus thiopental in induction and maintenance of anaesthesia." West Afr J Med 13(2): 73-80.
In a multicentre study, 145 adult Nigerian patients presenting with diverse conditions (falling into ASA1 or ASA2 classification) for short surgical procedures (< 1 hour) were given either midazolam (0.15-0.20 mg/kg) or thiopentone (4-6 mg/kg) intravenously for induction of anaesthesia. Study population consisted of 58 male and 89 female patients with a mean age of 33.5 +/- 10.42 years. The primary efficacy criteria for induction of anaesthesia was induction time measured by the time of spontaneous closing of eyes and disappearance of palpebral reflexes following injection of trial drug. For maintenance of anaesthesia efficacy was assessed by the requirement of an additional dose of the anaesthetic agent either alone or in combination with other agents in addition to N20/O2 mixture. The secondary efficacy criteria was the degree of anterograde amnesia produced by trial drug, this was assessed by memory test. Safety was assessed by the frequency of the incidence of apnoea and cardio-stability measured by changes in the haemodynamic parameters (BP and pulse). Tolerability was evaluated by incidence of phlebitis or pain at the injection site. The standard efficacy population was all the 145 patients while only 100 patients were considered evaluable for maintenance efficacy. The mean induction time was 67.28 +/- 63.36 secs and 31.28 +/- 13.01 secs for the midazolam and thiopentone groups respectively. Anaesthesia was maintained with N20/O2 alone in 47% of patients in the midazolam group compared with 28.6% of patients in the thiopentone group. The degree of anterograde amnesia was significantly more pronounced in the midazolam group than in the thiopentone group (p = 0.000).(ABSTRACT TRUNCATED AT 250 WORDS)

Eagle, C. J. and S. Kryski (1994). "The cost of anaesthesia." Can J Anaesth 41(3): 265-6.

Munk, S. and K. M. Pedersen (1994). "[Knee arthroscopy under local anesthesia with or without anesthesiologic assistance. A cost-benefit analysis]." Ugeskr Laeger 156(3): 313-6.
The benefit of anaesthesiological assistance during arthroscopy of the knee in local anaesthesia was evaluated in a cost-effectiveness analysis. One hundred consecutive patients had arthroscopy of the knee performed in local anaesthesia without anesthesiological assistance. In 15% of the cases the arthroscopy was insufficient because of pain reaction. Sixteen percent of the patients indicated that they would prefer general anaesthesia for a similar procedure in the future. The costs for arthroscopy of the knee in local anaesthesia without anaesthesiological assistance were calculated to Dkr. 2055. The amount includes costs for rearthroscopy in local anaesthesia with anaesthesiological assistance for 15% of the patients. Thirty-three patients had arthroscopy of the knee done in local anaesthesia with anaesthesiological assistance. General anaesthesia was needed for twelve percent of the patients. The cost for this procedure, including the costs of possible general anaesthesia were calculated to Dkr. 2458. Any significant difference in the sensation of pain during the arthroscopy could not be demonstrated between the two groups. Based on this study it is recommended that arthroscopy of the knee in local anaesthesia is planned without anaesthesiological assistance.

Hendrickx, J. and A. M. De Wolf (1994). "Costs of administering desflurane or isoflurane via a closed circuit." Anesthesiology 80(1): 240-2.

Lehot, J. J., P. G. Durand, et al. (1994). "[Anesthesia for carotid endarterectomy]." Ann Fr Anesth Reanim 13(1): 33-48.

Campbell, D. C., M. J. Douglas, et al. (1993). "Comparison of the 25-gauge Whitacre with the 24-gauge Sprotte spinal needle for elective caesarean section: cost implications." Can J Anaesth 40(12): 1131-5.
Spinal anaesthesia provides rapid, safe anaesthesia for Caesarean section. The pencil-point spinal needles (Sprotte and Whitacre) are reported to have a low incidence of post-dural puncture headache (PDPH). As the 25G Whitacre is less expensive than the 24G Sprotte needle, this prospective, randomized, double-blind study was designed to compare the incidence of PDPH and ease of insertion of these needles in 304 ASA 1 and 2 women having elective Caesarean section under spinal anaesthesia. Each patient was assessed daily for five consecutive days following Caesarean section by an investigator blinded to the needle used. The results indicate that the two needles have a similar ease of insertion, number of failed insertions, and failed subarachnoid blockade. An inability to insert the spinal needles occurred in two patients in each group. Therefore, 150 patients in each group completed the study. The incidence of PDPH with the 24G Sprotte needle was 4.0% (6/150) compared with 0.66% (1/150) with the 25G Whitacre (NS). There was no correlation between the occurrence of PDPH and the difficulty of needle insertion, presence of transient hypotension or the effectiveness of anaesthesia delivered. This study indicates that both needles are comparable with respect to ease of insertion and incidence of PDPH. As the Whitacre needle is less expensive it is a reasonable alternative to the more expensive Sprotte needle.

Hudson, R. J. and R. M. Friesen (1993). "Health care "reform" and the costs of anaesthesia." Can J Anaesth 40(12): 1120-5.

Hardy, J. F., S. Belisle, et al. (1993). "Cardiac anaesthesia: a perspective for the 1990's." Can J Anaesth 40(12): 1115-9.

Schow, D. A., T. L. Jackson, et al. (1993). "Use of alfentanil sedation anesthesia with the Dornier HM3 lithotripter." J Endourol 7(6): 445-8.
Our results with the combination anesthetic technique of midazolam-alfentanil during elective outpatient extracorporeal shock wave lithotripsy on the Dornier HM3 (N = 79) were compared with those of epidural anesthesia in the same setting (N = 81). The mean anesthesia time and recovery room time were significantly shorter (72.85 v 113.58 minutes and 115.0 v 159.20 minutes, respectively) with the combination technique. No procedures in the alfentanil group had to be discontinued because of patient discomfort. Side effects with alfentanil were minimal, and oxygen saturation remained above 90% for all patients. Combination midazolam-alfentanil anesthesia is safe and allows the urologist to treat renal and ureteral calculi effectively and efficiently without using general or regional anesthesia.

Weiskopf, R. B. and E. I. Eger, 2nd (1993). "Comparing the costs of inhaled anesthetics." Anesthesiology 79(6): 1413-8.
BACKGROUND: The immediate cost of an inhaled anesthetic results from an interplay between four factors: (1) the cost per milliliter of liquid anesthetic, (2) the volume of vapor that results from each milliliter of liquid, (3) the effective potency of the anesthetic (what concentration must be delivered from a vaporizer to provide a clinically appropriate level of anesthesia), and (4) the background flow of the gases that is chosen. A background flow that supplies only the gases/vapors required (taken up) by the patient (a "closed circuit") produces the least cost but also the least control of anesthetic level, whereas a high flow prevents rebreathing (a non-rebreathing system) but produces the greatest cost and control. We define greater "control" as a smaller ratio of delivered to alveolar concentrations. A lower solubility of an anesthetic accords the same level of control at a lower background flow rate than is achieved at a higher background flow rate with a more soluble anesthetic. Thus, a poorly soluble anesthetic may be used with a lower background flow rate than a more soluble anesthetic and may offer greater control and/or decreased cost. METHODS: This report presents a method of determining the cost of inhaled anesthetic use. As an example, the cost of delivering a desflurane anesthetic is compared with that of delivering an isoflurane anesthetic, assuming both provide an alveolar concentration of 1 MAC. The comparison is based on the pharmacokinetic differences of the two anesthetics: taking into account that for a given therapeutic anesthetic concentration (MAC), for desflurane a lower flow rate of background gas is needed to produce similar control (relationship between delivered and alveolar gases) than is needed for isoflurane. RESULTS: The analysis demonstrates that the relative cost of administering the newer and less soluble anesthetic, desflurane, can be less than, greater than, or the same as the cost of administering isoflurane, depending on the background gas inflow rate selected. CONCLUSION: The manner in which inhaled anesthetics are used and their kinetic differences are important determinants of relative cost.

Kreder, K. J., R. Stack, et al. (1993). "Direct vision internal urethrotomy using topical anesthesia." Urology 42(5): 548-50.
A consecutive series of 18 patients underwent attempted direct vision internal urethrotomy (DVIU) under topical lidocaine anesthesia. The procedure was completed successfully in 15 of 18 (83%) patients. In these patients 12 of 15 (80%) reported either minimal or no discomfort. Direct vision internal urethrotomy using topical lidocaine anesthesia is a safe and cost effective procedure.

Werner, M. E., D. E. Bach, et al. (1993). "A comparison of propofol with methohexital and isoflurane in two general anesthetic techniques." J Oral Maxillofac Surg 51(10): 1076-9; discussion 1079-80.
The purpose of this study was to compare two general anesthetic techniques involving oral intubation for use in outpatient third molar surgery. Fifty American Society of Anesthesiologists I or II patients were randomly allocated to two groups. Group 1 received methohexital, isoflurane, nitrous oxide, and alfentanil, while group 2 received propofol, alfentanil, and nitrous oxide. An analysis of the results showed that although the technique used in group 2 cost more, had a slightly longer induction time, and produced a similar duration of apnea, it did not cause significant hypotension (as previously reported), and had a significantly better overall recovery. It was concluded that the use of propofol in the outpatient surgery setting may be a valuable addition to the oral and maxillofacial surgeon's anesthetic armamentarium.

Bailey, C. R., R. Ruggier, et al. (1993). "Anaesthesia: cheap at twice the price? Staff awareness, cost comparisons and recommendations for economic savings." Anaesthesia 48(10): 906-9.
We questioned 50 anaesthetic staff about the costs of consumables used in routine anaesthetic practice. By means of a questionnaire staff were asked for estimates of the cost of 28 drugs, fluids and disposables. The responses were more accurate than in previous surveys; 47% of all the estimated costs were within 50% of the actual costs and 75% were within 100%. The costs of relatively expensive items such as blood, laryngeal mask airways, enflurane and isoflurane were consistently underestimated whereas cheaper items such as disposable syringes and electrocardiograph electrodes were consistently overestimated. Using 'state of the art' consumables, an hour-long anaesthetic in 1992 cost 14.02 pounds compared with 1.24 pounds in 1959. However, allowing for inflation, the cost today is actually equivalent to the cost in 1959. Since 1980 there has been no consistent pattern in drug prices, with some prices remaining the same, others falling and some increasing; all are, however, cheaper in real terms. It is possible to make substantial savings by using the more expensive drugs judiciously and by encouraging the use of low-flow, closed-circuit anaesthetic systems.

Milnes, A. R., C. W. Rubin, et al. (1993). "A retrospective analysis of the costs associated with the treatment of nursing caries in a remote Canadian aboriginal preschool population." Community Dent Oral Epidemiol 21(5): 253-60.
Nursing caries is a specific form of rampant dental caries affecting the majority of preschool aboriginal children who live in the Province of Manitoba, Canada. Since the majority of these individuals live in remote regions of the province access to dental treatment is difficult, resulting in long delays in the provision of treatment and, most likely, significant morbidity associated with dental pain and oral infection. Travel to distant centres for treatment under general anesthesia by pediatric dentists has become the usual method by which treatment is provided to the majority of affected children. We believed that this was an expensive method of providing these necessary services and our purpose was to document all costs associated with the treatment of nursing caries in this population. We analyzed the records of 884 children who were treated for nursing caries between 1980 and 1988 in Manitoba and collected data for costs in the following categories: travel, lodging, medical, dental, hospital and nursing. Our results show that the remote band groups had significantly higher costs (P < 0.001) than groups which were located closer to treatment centres. The costs which accounted primarily for this significant difference were travel and medical costs associated with hospitalization and the administration of general anesthesia. Our results support the need for the redeployment of resources on the basis of regional need and the development of community-based preventive programs and treatment programs which will significantly reduce the incidence of nursing caries in preschool Canadian aboriginal children.

Young, P. C., S. Q. Tighe, et al. (1993). "Cost of anaesthesia for minor surgery." Anaesthesia 48(9): 820.

Biro, P. (1993). "[Anesthetic gas consumption and costs in a closed system with the PhysioFlex anesthesia equipment]." Anaesthesist 42(9): 638-43.
A marked decrease in both personal and environmental pollution with anaesthetic gases as well as in costs is possible with anaesthesia machines which can be run with a low fresh gas flow (FGF) [9]. Low-flow anaesthesia can be performed with appropriately equipped circle systems, although strongly reduced FGF minimises the control of depth of anaesthesia and gas concentrations. Microprocessor-controlled feedback systems allow the utilisation of closed-circuit systems throughout the whole duration of anaesthesia, maintaining full anaesthetic control [3,5]. The aim of this investigation was to determine the costs resulting from gas consumption and clinical suitability of the recently marketed PhysioFlex anaesthesia machine. METHODS. We used a PhysioFlex (Physio, Hoofdorpp, Netherlands) in a series of 15 routine otorhinolaryngological interventions. After induction with thiopentone and suxamethonium, general anaesthesia was maintained with nitrous oxide in 30% oxygen and isoflurane and supplemented with fentanyl and atracurium. The expenditure of anaesthetic gases was recorded during a total of 61 h and 27 min and differentiated into its components. Anaesthetic gas uptake and costs were compared with different breathing systems (low-flow anaesthesia, semiclosed system and non-rebreathing system) under similar clinical conditions. RESULTS. The average minute volume was 6.84 (+/- 1.17) l and the expiratory isoflurane concentration was 0.91% (+/- 0.14%) (Table 1). These settings resulted in an oxygen expenditure of 27.9 (+/- 8.46) l/h with total costs of SFr. 0.04, nitrous oxide 11.9 (+/- 5.4) l/h and 0.27, isoflurane 3.9 ml/h and SFr. 5.42. In contrast, other breathing systems in analogous settings resulted in greater costs by a factor of 0.77 for low-flow anaesthesia (FGF 1 l/min), 2.47 for a semiclosed system (FGF 3 l/min) and 5.63 for a valve-controlled non-rebreathing system (FGF 6.84 l/min) (Table 2). DISCUSSION. The emission of anaesthetic gases can be lowered by measures that avoid unintended gas fallout, the application of filters, scavenging systems and efficient air circulation in operation and recovery rooms [8]. Above all, the use of the lowest possible FGF is advantageous for the patient insofar as better conditioned breathing gases are available, and economic and environmental effects are more significant (Table 3). With the method of quantitative anaesthesia as performed by the PhysioFlex, it is now possible to reduce gas expenditure according to the requirements of the patient as well as maintaining full control of anaesthesia depth. Simultaneously, multiple secured feedback control systems guarantee adequate monitoring and storage of respiratory and metabolic parameters. The duration of nitrous oxide wash-out can be a problem, in particular, when a changeover to O2/air is required.

Robins, R. H., T. D. Scott, et al. (1993). "Day care surgery for Dupuytren's contracture." J Hand Surg [Br] 18(4): 494-8.
Contrary to standard practice in the United Kingdom, primary surgery for Dupuytren's contracture can be performed safely on a day care basis provided that strict criteria are followed. Although demanding on Consultant surgical time, this policy offers a considerable saving in hospital resources.

Bevan, D. R. (1993). "Anaesthesia pharmacoeconomics." Can J Anaesth 40(8): 693-5.

McKenzie, A. G. (1993). "A plea for "low flow" anaesthesia in Zimbabwe." Cent Afr J Med 39(8): 175-6.

Dimick, P., E. Helvig, et al. (1993). "Anesthesia-assisted procedures in a burn intensive care unit procedure room: benefits and complications." J Burn Care Rehabil 14(4): 446-9.
A retrospective review of 109 procedures was performed to evaluate the safety and efficacy of anesthesiologist-administered anesthesia in the burn intensive care unit treatment room. Intraprocedural and postprocedural complications, impact on patient activity, and nutritional goals were evaluated. The review suggested that these procedures can be performed safely with appropriate supervision and monitoring without detrimental effects on patient activity level or nutritional status.

Pedersen, F. M., J. Nielsen, et al. (1993). "Low-flow isoflurane-nitrous oxide anaesthesia offers substantial economic advantages over high- and medium-flow isoflurane-nitrous oxide anaesthesia." Acta Anaesthesiol Scand 37(5): 509-12.
Isoflurane consumption was studied for three different fresh gas flows in patients scheduled for major elective abdominal, urological or gynaecological surgery under general anaesthesia with an expected duration of 2 h or more. Thirty patients were randomly assigned to either high-flow anaesthesia using a partial rebreathing system without carbon dioxide absorption (Mapleson D) or medium- or low-flow anaesthesia using a circle system with carbon dioxide absorption. Patients were anaesthetised with isoflurane in 40% oxygen and 60% nitrous oxide. The amount of isoflurane consumed was measured with a precision scale. The total consumption of liquid isoflurane (mean +/- s.d.) during the first 2 h was 40.8 +/- 12.2 ml in the high-flow group, 18.5 +/- 5.4 ml in the medium-flow group and 7.9 +/- 2.2 ml in the low-flow group. The corresponding cost of isoflurane for the three groups was 214 Danish kroner (DKK) (19.5 pounds), 97 DKK (8.8 pounds) and 42 DKK (3.8 pounds), respectively. The calculated total cost of anaesthetics was 286 DKK (26 pounds), 155 DKK (14.1 pounds) and 91 DKK (8.3 pounds), respectively. In conclusion, low-flow isoflurane-nitrous oxide anaesthesia offers substantial economic advantages over high- and medium-flow isoflurane-nitrous oxide anaesthesia.

Bastin, K., D. Buchler, et al. (1993). "Resource utilization. High dose rate versus low dose rate brachytherapy for gynecologic cancer." Am J Clin Oncol 16(3): 256-63.
A comparative analysis of anesthesia use, perioperative morbidity and mortality, capital, and treatment cost of high dose rate versus low dose rate intracavitary brachytherapy for gynecologic malignancy is presented. To assess current anesthesia utilization, application location, and high dose rate afterloader availability for gynecologic brachytherapy in private and academic practices, a nine-question survey was sent to 150 radiotherapy centers in the United States, of which 95 (63%) responded. Of these 95 respondents, 95% used low dose rate brachytherapy, and 18% possessed high dose rate capability. General anesthesia was used in 95% of programs for tandem + ovoid and in 31% for ovoids-only placement. Differences among private and academic practice respondents were minimal. In our institution, a cost comparison for low dose rate therapy (two applications with 3 hospital days per application, operating and recovery room use, spinal anesthesia, radiotherapy) versus high dose rate treatment (five outpatient departmental applications, intravenous anesthesia without an anesthesiologist, radiotherapy) revealed a 244% higher overall charge for low dose rate treatment, primarily due to hospital and operating room expenses. In addition to its ability to save thousands of dollars per intracavitary patient, high dose rate therapy generated a "cost-shift," increasing radiotherapy departmental billings by 438%. More importantly, perioperative morbidity and mortality in our experience of 500+ high dose rate applications compared favorably with recently reported data using low dose rate intracavitary treatment. Capital investment, maintenance requirements, and depreciation costs for high dose rate capability are reviewed. Application of the defined "revenue-cost ratio" formula demonstrates the importance of high application numbers and consistent reimbursement for parity in high dose rate operation. Logically, inadequate third-party reimbursement (e.g., Medicare) reduces high dose rate parity and threatens the future availability of high dose rate technology.

Loke, J. and W. A. Shearer (1993). "Cost of anaesthesia." Can J Anaesth 40(5 Pt 1): 472-4.

Gignac, E., P. H. Manninen, et al. (1993). "Comparison of fentanyl, sufentanil and alfentanil during awake craniotomy for epilepsy." Can J Anaesth 40(5 Pt 1): 421-4.
Neurolept anaesthesia is used during awake craniotomy for epilepsy surgery. This study compares analgesia, sedation and the side effects of the newer opioids sufentanil and alfentanil, with those of fentanyl in patients undergoing awake craniotomy. Thirty patients were randomized into three groups, each received droperidol, dimenhydrinate and the chosen opioid as a bolus followed by an infusion. The opioid doses used were fentanyl 0.75 microgram.kg-1 plus 0.01 microgram.kg-1 x min-1; sufentanil 0.075 microgram.kg-1 plus 0.0015 microgram.kg-1 x min-1, and alfentanil 7.5 micrograms.kg-1 plus 0.5 microgram.kg-1 x min-1. There were no differences in the requirements for droperidol, dimenhydrinate or in the incidence of complications among the three groups. The total doses of the opioids required were fentanyl 4.9 +/- 1.3 micrograms.kg-1, sufentanil 0.6 +/- 0.2 microgram.kg-1 and alfentanil 149 +/- 36 micrograms.kg-1. Two patients became uncooperative requiring general anesthesia. The conditions for surgery, electrocorticography and for stimulation testing were satisfactory in all other patients. We conclude that the newer opioids did not offer any benefit over fentanyl.

Johnstone, R. E. and C. L. Martinec (1993). "Costs of anesthesia." Anesth Analg 76(4): 840-8.

Rockefeller, J. D. t. (1993). "Anesthesia and health care reform in 1993." Anesth Analg 76(4): 689.

Strauss, R. P. and S. D. Resnick (1993). "Pulsed dye laser therapy for port-wine stains in children: psychosocial and ethical issues." J Pediatr 122(4): 505-10.
The port-wine stain is a disfiguring vascular birthmark that commonly occurs on the face. Amelioration of this condition in children was difficult or impossible until the introduction of the flashlamp-pumped pulsed dye laser in the late 1980s. This article provides an interdisciplinary social and ethical examination of pulsed dye laser therapy for port-wine stain in childhood. Specific issues raised relate to the management of pain during therapy, rationale for care, expectations of treatment, the high costs of care, equity, marketing pressures, and therapeutic activism. Laser therapy in the dermatologic care of children is an exciting innovation that has transformed clinical practice and raised important social, ethical, and health policy issues.

Werner, C. (1993). "Groups dicker for price breaks as anesthetic gas goes multi-source." Hosp Mater Manage 18(4): 1, 9.

Orkin, F. K. (1993). "Moving toward value-based anesthesia care." J Clin Anesth 5(2): 91-8.

Neal, J. A., T. B. Welch, et al. (1993). "Analysis of the analgesic efficacy and cost-effective use of long-acting local anesthetics in outpatient third molar surgery." Oral Surg Oral Med Oral Pathol 75(3): 283-5.
Bupivacaine hydrochloride, an amide-type of long-acting local anesthetic was compared with lidocaine hydrochloride to determine its analgesic efficacy and its cost-effective use in an oral and maxillofacial surgery private practice. The results show that 0.5% bupivacaine hydrochloride provides greater analgesia than 2% lidocaine, with an insignificant cost increase to the operating surgeon.

Rathmell, J. P., R. F. Brooker, et al. (1993). "Hemodynamic and pharmacodynamic comparison of doxacurium and pipecuronium with pancuronium during induction of cardiac anesthesia: does the benefit justify the cost?" Anesth Analg 76(3): 513-9.
We compared the pharmacodynamic effects and hospital costs of three long-acting neuromuscular blocking drugs in a prospective, randomized, double-blind manner. Each neuromuscular blocking drug was administered with fentanyl (50 micrograms/kg) for intravenous induction of anesthesia for coronary artery bypass surgery. Each patient received twice the 95% effective dose (ED95) of either pancuronium (0.14 mg/kg, n = 10), pipecuronium (0.10 mg/kg, n = 10), or doxacurium (0.05 mg/kg, n = 10). Hemodynamic measurements were recorded at baseline, 5 min after completion of anesthetic induction, immediately after endotracheal intubation, and 5 min after intubation. Only small hemodynamic differences between neuromuscular blocking drugs were observed. Doxacurium (but not pancuronium or pipecuronium) significantly decreased mean arterial blood pressure (from 94 +/- 4 mm Hg before induction to 83 +/- 3 mm Hg 5 min after intubation); nevertheless, there were no significant between-group differences at any time. Pancuronium increased heart rate (from 68 +/- 4 beats/min before induction to 76 +/- 5 beats/min 5 min after intubation); however, pancuronium differed significantly from doxacurium and pipecuronium only 5 min after induction and 5 min after intubation. Central venous pressure, pulmonary artery occlusion pressure, cardiac index, and systemic and pulmonary vascular resistance indices did not change. Electrocardiographic abnormalities were observed in two pipecuronium patients: ST segment depression in one and premature ventricular contractions in another. No other electrocardiographic changes were observed. There were no significant between-group differences in the need for hemodynamic interventions.(ABSTRACT TRUNCATED AT 250 WORDS)

Trabucco, E. E. (1993). "The office hernioplasty and the Trabucco repair." Ann Ital Chir 64(2): 127-49.

Rhodes, S. P. and S. Ridley (1993). "Economic aspects of general anaesthesia." Pharmacoeconomics 3(2): 124-30.
Proper economic evaluation involves comparative analysis of alternative courses of action in terms of both costs and outcome. This is difficult for general anaesthesia as there are few alternatives and measurement of outcome is difficult to define. All that is generally available is a cost description of different anaesthetic techniques. This article outlines the choice of drugs, breathing systems and ventilatory pattern available to the anaesthetist, and compares regional with general anaesthesia. For each technique the cost and advantages/disadvantages are outlined. There is a discussion of some wider issues involved together with their implications: the abandonment of cyclopropane and nitrous oxide; equipment costs and recommendations by the Association of Anaesthetists of Great Britain and Ireland; staffing levels; legal aspects and the increase in day surgery. The limitation of cost-effectiveness analysis of general anaesthesia is outlined.

Nichols, R. J., Jr. (1993). "Current anesthesia breathing systems are just fine." J Clin Monit 9(1): 63-4.

Jindani, A., C. Aps, et al. (1993). "Postoperative cardiac surgical care: an alternative approach." Br Heart J 69(1): 59-63; discussion 63-4.
Combined appropriate anaesthetic and surgical techniques have allowed increasing numbers of patients to be successfully managed in a general surgical recovery ward after cardiac surgery rather than in an intensive care unit. From 1983 to 1989, 933 of 1542 patients undergoing open heart surgery were transferred to the general surgical recovery ward in the immediate postoperative period. Of these, 718 (77%) had undergone coronary artery bypass grafts, sometimes combined with other procedures and 168 (18%) had had cardiac valve replacements with or without other procedures. The remaining 47 (5%) had had miscellaneous cardiac operations. Significant cardiac complications occurred in 29 (3%) patients. The 24 hour chest radiograph was reported as abnormal (mainly atelectasis and effusion) in 63% of patients. Most resolved spontaneously or with physiotherapy. Twenty nine (3%) patients were re-explored to achieve haemostasis. There were no deaths in the general surgical recovery ward. Thirty seven (4%) patients had to be transferred to the intensive care unit for various reasons. The remaining 896 patients were transferred to the general ward after one night (871 patients) or two nights (25 patients) in the general surgical recovery ward. The average duration of stay in hospital for these patients was 9.3 days. Because of the overall success of such management and the low rate of complications over 80% of patients are now managed in the general surgical recovery ward after open heart surgery. The resulting savings in capital expenditure of equipment, medical, nursing, and technical personnel are substantial, and there are major implications for the planning of new cardiothoracic units.

Eisen, L. B. and J. A. Fisher (1993). "Cost of soda lime." Can J Anaesth 40(1): 81-3.

Baum, J., J. Enzenauer, et al. (1993). "[Soda lime--service life, consumption and costs in relation to fresh gas flow]." Anaesthesiol Reanim 18(4): 108-13.
The utilisation time of carbon dioxide absorbers in anaesthesia textbooks is nearly identically specified to last about 5 hours. Therefore in most departments the soda lime of the absorbers is changed routinely on a daily schedule. As rebreathing volume increases considerably with fresh gas flow reduction, the question arises as to whether the soda lime should be changed at even shorter intervals--if low-flow anaesthesia is performed routinely--to to guarantee carbon dioxide absorption safely. In three anaesthesia machines with different technical properties the carbon dioxide absorbers were only changed when the inspiratory carbon dioxide concentration increased to 1 vol. %, indicating definite exhaustion of the soda lime. If a fresh gas flow of 4.4 l/min was used exclusively, utilisation times of 42.7 and 62.3 hours were measured using absorbers filled with 1 l of soda lime pellets, whereas a utilisation time of 98.7 hours was noted with a 1.5 l absorber, all values being surprisingly higher than the above-mentioned figure. If, however, minimal flow anaesthesia is performed routinely in clinical practice, the percentage of time in which the fresh gas flow can really be reduced to 0.5 l/min does not exceed 50 to 80%. Under these conditions the utilisation time of the absorbers decreases to between one half (1/2) and one quarter (1/4) of the utilisation time which can be gained if a flow of 4.4 l/min is used. Thus, the performance of minimal-flow anaesthesia increases the consumption of soda lime two- to fourfold.(ABSTRACT TRUNCATED AT 250 WORDS)

Nathan, N., A. Rezzoug, et al. (1993). "[Infusion of propofol or closed-circuit isoflurane. A study of cost]." Ann Fr Anesth Reanim 12(6): 571-4.
The choice of an anaesthetic agent is influenced by its cost. The use of a circle absorber system decreases the cost of the maintenance of anaesthesia with halogenated agents. Fast recovery and low incidence of postoperative nausea and vomiting are the main advantages of propofol. The cost of propofol can limit its use for the maintenance of anaesthesia except for short procedures. This prospective study compared in 50 ASA 1 and 2 patients the cost of anaesthesia with either propofol (group P, n = 25) or the association thiopentone-isoflurane administered with a rebreathing circuit (group I, n = 25). Patients were premedicated the evening before surgery with 2.5 mg lorazepam. Anaesthesia was induced with either propofol (2-3 mg.kg-1) or thiopentone (4-6 mg.kg-1) and maintained with either propofol (6-10 mg.kg-1.h-1) in group P or isoflurane continuously injected as liquid in the expiratory limb of the circuit in group I. The side effects of anaesthesia and the delay of recovery and discharge from the recovery room were assessed. Peroperative cost of anaesthesia included nitrous oxide, isoflurane and i.v. agents, fluids volumes and disposable devices. The total cost of anaesthesia included also the recovery room stay. The mean duration of anaesthesia was not significantly different between the two groups (109.4 +/- 7.1 min vs 107.3 +/- 7.3 min group P vs group I). The delay lf recovery (eyes opening) was shorter in the propofol group (14.4 +/- 1.3 min vs 19.4 +/- 1.4 min) as well as the delay of discharge from the recovery room (70 +/- 4 min, vs 82.4 +/- 4.6 min).(ABSTRACT TRUNCATED AT 250 WORDS)

Pontone, S., S. Finkel, et al. (1993). "[Is the Relative Complexity Index beta an accurate indicator of the cost of anesthesia?]." Ann Fr Anesth Reanim 12(6): 539-43.
In order to assess the medical activity and the related costs, the French Ministry of Health has designed a relative value scale for medical procedures, the Relative Complexity Index (RCI). The RCI for anaesthesiology, called BETA, is the result of the combination of four subindexes: T for the type of anaesthesia, D for the duration, C for the related surgical procedure, and EG for the patient's status according to the ASA scale. The goal of this study has been to test whether the BETA index was actually an acceptable indicator of the direct cost of an anaesthetic. We have determined the cost of 248 procedures in a teaching hospital and achieved a statistical analysis of the relationship between costs, RCI and the various subindexes. The mean cost of an anaesthetic was 1,205 FF (SD = 1,325), 61.4% of which being for salaries. The cost of a general anaesthetic was 2.5 times higher than the cost of a local/regional anaesthesia procedure. Mean cost was around 700 FF for ENT, urology, gynaecology and obstetrics, 1,200 FF for orthopaedia and visceral surgery, and 5,130 FF for cardiac surgery (not including the equipment for extracorporeal circulation). A strong positive relation was found between the BETA and cost (r = 0.90, p < 10(-4)). The best predictive model of cost was log-linear, using only the duration, the type of anaesthetic and the related surgical procedure. The patient's status was not a significant factor, nevertheless in our sample, ASA 4 patients had a significantly higher cost than others (p = 0.0004, Mann & Whitney test).(ABSTRACT TRUNCATED AT 250 WORDS)

Montejo Rosas, G. and E. Bruera (1993). "Palliative care in Mexico: coeliac plexus block for incidental visceral pain." J Palliat Care 9(4): 35-6.

Hugosson, J., S. Bergdahl, et al. (1993). "Outpatient transurethral incision of the prostate under local anesthesia: operative results, patient security and cost effectiveness." Scand J Urol Nephrol 27(3): 381-5.
Thirty patients with small and medium-sized obstructive prostates were operated by transurethral incision of the prostate (TUIP) under local anesthesia as an outpatient procedure. All patients except one tolerated this manoeuvre without any complications or discomfort. The obstructive symptoms were relieved in all patients; however, 6 patients had lasting irritative symptoms, 2 of whom were cured after TURP. The costs of TUIP was calculated to be one sixth of that of TURP. During one year follow-up 5 patients were found to have prostate cancer despite careful rectal examination and PSA measurement preoperatively. In conclusion, TUIP may be carried out as safely and cost-effectively as an outpatient procedure and is beneficial in patients with predominantly obstructive symptoms. However, careful investigations concerning possible prostate cancer must be undertaken in this group of patients with small but symptomatic prostates.

Collier, P. E. (1992). "Carotid endarterectomy: a safe cost-efficient approach." J Vasc Surg 16(6): 926-9; discussion 930-3.
The diagnosis-related groups have encouraged physicians to become more efficient in the care of their patients; often, however, raising the question of safety. For 3 years all patients undergoing carotid endarterectomy at our institution were monitored in the intensive care unit for 24 hours and the majority were discharged on the second postoperative day. After review of these patient's hospital records and direct patient interviews, it was clear that many patients did not require a stay in the intensive care unit and could be discharged on the first postoperative day. In January 1991 a prospective policy was established to evaluate the safety and efficacy of outpatient arteriography, same-day admission, selective use of the intensive care unit, and early discharge on the first postoperative day when feasible. During a 10-month period all patients undergoing carotid endarterectomy at our institution were evaluated (n = 52). Eleven patients had had a prior stroke (21%), 31 had either amaurosis fugax or transient ischemic attacks (60%), and 10 had no symptoms (19%). The arteriogram for 49 of the patients was obtained on an outpatient basis or during a prior admission, and these patients were admitted to the hospital on the day of operation. Nine patients were placed under general anesthesia and had shunting procedures, and 43 patients had cervical block anesthesia, eight of whom had shunting (19%). Only five patients required an intensive care unit stay for either hypertension, hypotension, or neurologic complication (one transient ischemic attack and one minor stroke). Forty-six patients (88%) were discharged on the first postoperative day; average length of stay was 1.29 days/patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Bonadio, W. A. and V. R. Wagner (1992). "Adrenaline-cocaine gel topical anesthetic for dermal laceration repair in children." Ann Emerg Med 21(12): 1435-8.
STUDY OBJECTIVE: To evaluate the anesthetic efficacy of a gel form of adrenaline-cocaine topical medication for minor dermal laceration repair. DESIGN: Unblinded, prospective. SETTING: An urban pediatric emergency department. TYPE OF PARTICIPANTS: Thirty-five children aged 20 months to 18 years with lacerations of the face, outer lip, and scalp. INTERVENTIONS: All received adrenaline-cocaine gel made by mixing 1.5 mL of conventional adrenaline-cocaine liquid (adrenaline, 1:2,000; cocaine, 11.8%) with 0.15 g of methylcellulose powder (an inert emulsifying agent). MEASUREMENTS AND MAIN RESULTS: Lacerations were located on the face or outer lip in 25 patients and on the scalp in ten patients. Larger lacerations (length of more than 5 cm and/or depth of more than 5 mm) occurred in nine patients. The average dose of adrenaline-cocaine gel applied per laceration was 0.35 mL (containing 40 mg cocaine). One hundred ninety-five sutures were placed (175 cutaneous, 20 subcutaneous); 192 (98.5%) were placed without eliciting any pain. There were no observed adverse reactions with adrenaline-cocaine gel administration or reported complications of wound healing in any patient. CONCLUSION: Adrenaline-cocaine gel preparation provides excellent anesthetic efficacy for minor dermal lacerations in children. Compared with conventional adrenaline-cocaine liquid, adrenaline-cocaine gel may be advantageous in reducing the total cocaine requirement and may diminish the risk for adverse reactions that can result from runoff of liquid medication onto mucosal or ocular surfaces.

(1992). "Ethics of organ transplantation from living donors." Transplant Proc 24(5): 2236-7.

Wetchler, B. V. (1992). "Economic impact of anesthesia decision making: they pay the money, we make the choice." J Clin Anesth 4(5 Suppl 1): 20S-24S.

Eldor, J. (1992). "Reinserting a catheter into a single-use adapter: an unsafe method." Anesth Analg 75(2): 311.

Dion, P. (1992). "The cost of anaesthetic vapours." Can J Anaesth 39(6): 633.

Van Sickels, J. E. and B. D. Tiner (1992). "Cost of a genioplasty under deep intravenous sedation in a private office versus general anesthesia in an outpatient surgical center." J Oral Maxillofac Surg 50(7): 687-90.
The cases of twenty-four patients who underwent genioplasties either under deep intravenous (IV) sedation in a dental office or under general anesthesia in a surgical center were reviewed. A cost comparison of this operation in these two environments showed that it was twice as expensive to have the same procedure done in an outpatient surgical suite under general anesthesia as it was in a private office under IV sedation.

Varesio, V., G. M. Martegni, et al. (1992). "[Determination of drug costs in general anesthesia]." Minerva Anestesiol 58(7-8): 447-52.
Drug costs of various general anaesthesia techniques have been assessed. These costs are used as a basis to point out the economies that could be made in the conduct of general anaesthesia.

Rutten, P., M. Ledecq, et al. (1992). "[Primary inguinal hernia: Lichtenstein's ambulatory hernioplasty: early clinical results and economic implications. Study of the initial 130 surgical cases]." Acta Chir Belg 92(4): 168-71.
The authors report their preliminary experience of 130 ambulatory treatment under local anesthesia of primary inguinal hernia. This method of treatment is very well accepted by the patients. There are few early recurrences. This method of treatment is very cost-effective.

Axelband, A. A. (1992). "High cost of getting older." N Y State Dent J 58(4): 10.

Behnia, R., F. Hashemi, et al. (1992). "A comparison of general versus local anesthesia during inguinal herniorrhaphy." Surg Gynecol Obstet 174(4): 277-80.
The current study was done to compare the hemodynamic changes, recovery events and economic impact of elective inguinal herniorrhaphy performed with general anesthesia (GA) or regional field block (RB) in 20 patients (American Society of Anesthesiology class I). In the GA group, anesthesia was induced with thiopental and the trachea was intubated after intravenous administration of 0.08 milligrams per kilogram of vecuronium. GA was maintained with 1.2 +/- 0.25 per cent enflurane in 50 per cent nitrous oxide and oxygen, and ventilation was controlled to keep PECO2 at 36 +/- 2 millimeters of mercury. Anesthesia in the RB group was accomplished by local injection of 3.5 +/- 0.5 milligrams per kilogram of 0.5 per cent bupivacaine. In each patient, a suprasternal ultrasonic Doppler probe was used to measure cardiac output before induction of anesthesia, during and after operation. Total peripheral resistance was calculated from mean arterial pressure and cardiac output. There were no statistically significant differences between cardiac output, mean arterial pressure, total peripheral resistance and heart rate in the two groups at any time period during the study. Patients in the RB group did not require parenteral medication for relief of postoperative pain, whereas all those in the GA group did. Significant cost benefits were realized by the RB group because of elimination of general anesthetic and reduction of recovery room fees.

Klide, A. M. (1992). "The case for low gas flows." Vet Clin North Am Small Anim Pract 22(2): 384-7.
When nitrous oxide is not used, there are no clinically significant, valid reasons for not using low gas flows. There are many clinically significant, valid reasons for using low flows.

Ludders, J. W. (1992). "Advantages and guidelines for using isoflurane." Vet Clin North Am Small Anim Pract 22(2): 328-31.
Isoflurane offers many advantages over other inhalational anesthetics. Its faster induction and recovery, relative sparing effect on cardiovascular function and cerebral blood flow autoregulation, and negligible metabolism make this drug particularly useful in the anesthetic management of the debilitated, aged, or unusual veterinary patient.

Hartsfield, S. M. (1992). "Precautions when using enflurane." Vet Clin North Am Small Anim Pract 22(2): 327-8.
Enflurane offers few advantages over halothane, and it is more expensive than halothane. It causes greater cardiopulmonary depression and induces seizure activity. When economy and systemic effects are considered, enflurane offers no real benefits for veterinary anesthesia.

Sadler, G. P., H. Richards, et al. (1992). "Day-case paediatric surgery: the only choice." Ann R Coll Surg Engl 74(2): 130-3.
Since January 1989 a policy of day-case surgery has been adopted for suitable paediatric procedures by one firm (MEF) at East Glamorgan Hospital. There have been 184 children treated to date, with an age range of 4 weeks to 13 years. There were 58 circumcisions, 48 hernias, 35 orchidopexies, 18 hydrocoeles and 25 miscellaneous procedures performed with no significant complications. All children were given a general anaesthetic, 42 procedures (22%) were performed using endotracheal intubation, the remainder with a facemask. Postoperative analgesia was provided in most cases by local wound infiltration with bupivacaine 0.25%. The average length of stay before January 1989 was 3 days and 2 nights for similar cases. Cost analysis shows significant potential financial savings of 105 pounds per patient treated. The implications for future planning are discussed.

Ferrari, L. R. and J. V. Donlon (1992). "A comparison of propofol, midazolam, and methohexital for sedation during retrobulbar and peribulbar block." J Clin Anesth 4(2): 93-6.
STUDY OBJECTIVE: To compare the efficacy of propofol, methohexital, and midazalom in providing adequate sedation during administration of retrobulbar block and satisfactory postoperative amnesia. DESIGN: Retrospective chart review over a 4-month period. SETTING: Ambulatory patients in the main operating room of a university-affiliated hospital. PATIENTS: One hundred forty-seven ambulatory patients undergoing ophthalmologic surgery of less than 2 hours' duration under regional anesthesia consisting of retrobulbar or peribulbar block and intravenous (IV) sedation. INTERVENTIONS: One of three drugs--propofol 0.47 +/- 0.06 mg/kg, midazolam 0.02 +/- 0.005 mg/kg, or methohexital 0.45 +/- 0.16 mg/kg--was administered IV. Patients were observed for a minimum of 60 seconds or until adequate sedation was achieved, after which a retrobulbar or peribulbar block was performed. MEASUREMENTS AND MAIN RESULTS: Blood pressure, electrocardiogram, and oxygen saturation were monitored and recorded. Patients were observed for apnea, hiccups, pain on injection, excitement, tremor, grimacing, or verbal response during the block. The requirement for additional sedation intraoperatively was noted. Patients were questioned postoperatively in the ambulatory recovery room for recall of needle insertion or discomfort during the block, as well as about their satisfaction with the overall experience. CONCLUSIONS: Grimacing or verbal response during the retrobulbar or peribulbar block did not predict or correlate with patient recall. Propofol was equal to both midazolam and methohexital in providing adequate sedation and postoperative amnesia but possesses the added advantages of reduced postoperative vomiting, lower intraocular pressure, and earlier return-to-home readiness.

Wilder-Smith, O. H. and A. Borgeat (1992). "Propofol vs methohexitone." Anaesth Intensive Care 20(1): 115-6.

Di Filippo, A., L. Bonetti, et al. (1992). "[Closed circuit inhalation anesthesia. Consumption and cost]." Minerva Anestesiol 58(1-2): 51-5.
Closed circuit anaesthesia (CCA) and minimal flow anaesthesia diminish inhalatory anaesthetic consumption. Consumption of inhalatory anaesthesia was calculated using two different techniques: CCA and "non rebreathing" system. Costs were compared on the basis of the official list price. The CCA allowed for reduced consumption at lower costs. The resulting annual savings are equal to one third of the total price of the whole apparatus with its complementary monitoring and control systems.

Charpak, Y., I. Nicoulet, et al. (1992). "[Current practice and attitude of anesthesiologists for prescribing preoperative investigative tests]." Ann Fr Anesth Reanim 11(5): 576-83.
A telephone enquiry was undertaken to assess current practice among French anaesthetists, and to obtain their opinion, concerning preoperative laboratory screening tests. It included 204 anaesthetists, randomly selected from the membership directory of the French Society of Anaesthetics and Intensive Care. The sample was concordant with the distribution (sex and age) given by the specialists' list of the National Medical Council. It comprised 64.2% male anaesthetists, and the overall mean age was 44.2 years. On average, each anaesthetist carried out 26 elective and 4 emergency anaesthetist a week. An organized preanaesthetic consultation was available in only 73% of public hospitals. However, even when existing, it does not automatically concern all surgical stations of the hospital and only 59% of patients benefit from that consultation. In 55% of patients the screening tests had still been made before the preanaesthetic consultation for scheduled surgery. About 15% of patients were seen for the first time by an anaesthetist on the very day of surgery. A routine prescription of preoperative tests was not systematic. Non prescription ranged from 7 to 34% of patients, depending on the tests. The responders recognized that for the same tests the rate could be comprised between 21 and 66% of patients. Moreover, 38% of anaesthetists admitted that sometimes they did not see results of the prescribed tests before carrying out the anaesthetic. Overprescription of preoperative tests has been recognized. However, legal, organisational, relational or economical reasons are given which may explain difficulties met with to rationalize prescription of these tests.

Picard, C., D. Gomez, et al. (1992). "[A comparative study of the cost of open-circuit as opposed to closed-circuit ventilation]." Cah Anesthesiol 40(5): 321-32.
The authors compared two open randomized groups of patients undergoing surgery through general anaesthesia. Group 1 consisted of 54 patients ventilated by a Siemens 900 B ventilator in open circuit, and group 2, 56 patients ventilated by an ELSA de Gambro ventilator in a closed circuit. Comparative hour cost for nitrous oxide (N2O), oxygen (O2) and halogen gas, Enflurane, Isoflurane, was noted. All patients received the same regimen of anaesthesia and the two groups were identical in age, weight, surgery, respiratory volume and ventilation time. The evaluation of comparative hour cost included specific materials of close circuit ventilator: CO2 filter (Aridus), Lime. Were excluded maintenance and gas consumption expenditures before patient connected to the ventilator. The total hour cost (O2, N2O, specific materials for close circuit, without halogen gas) was 8.23 FF in closed circuit against 13.28 FF in open circuit, an economy of 38.27%. Hence, for oxygen, the hour cost was 0.70 FF in open circuit against 0.27 FF in closed circuit (gain of 65.3%). For nitrous oxide, the hour cost in open circuit was 12.50 FF against 2.44 FF in closed circuit (80.5%). For Isoflurane, the open circuit hour cost was 41.38 FF against 22.44 FF in closed circuit (47%). For Enflurane, the open circuit hour cost was 14.17 FF against 5.94 FF in closed circuit (58.1%). And, lastly for Enflurane, open circuit hour cost was 14.17 FF against 5.94 FF in close circuit, gain of 58.1%. These "modest" economy against those found in previous studies can be explained by the long-time duration of ventilation, saturating time in open circuit more or less long, depending on the physician, specific materials for closed circuit ventilation--lime, CO2 filter--in not taken into account, the hour cost of O2 + NO2 goes from 8.23 FF to 2.71 FF, and the gain against the close circuit becomes 79.6%: reducing hour cost by 5 times. In order to improve the effective cost of close circuit, the authors proposed: the use of closed circuit ventilation for more than 3 hours surgery, gas saturation in closed circuit after denitrogenation--which demands the use of halogen infjectors, and lime in containers cheaper than disposable cartridges. Respecting the above criteria, the total hour cost in close circuit fell to 4.90 FF, gain of 63% against open circuit. For O2 et N2O, the hour cost goes from 1.34 FF in close circuit to 13.28 FF in open circuit, 90% economy.(ABSTRACT TRUNCATED AT 250 WORDS)

Halbrecht, J. L. and D. W. Jackson (1992). "Office arthroscopy: a diagnostic alternative." Arthroscopy 8(3): 320-6.
Twenty patients with enigmatic knee symptoms were selected for evaluation by both magnetic resonance imaging (MRI) and office arthroscopy. Office arthroscopy was performed in a standard examination room using a miniature (1.7 mm) fiberoptic arthroscope under local anesthesia. All MRI scans were performed on a state-of-the-art 1.5-T magnet unit, and included specialized cartilage sequences in 7 patients. In 14 patients, 26 areas showed articular cartilage changes by arthroscopy (grade 2-3). Only nine of these areas were detected by MRI (sensitivity 34.6%). There were five false-positive and four false-negative readings of meniscal tears by MRI as compared with office arthroscopy. These results improved when postoperative menisci were excluded. Only one of three anterior cruciate ligament (ACL) disruptions identified by MRI could be verified by arthroscopy. The one posterior cruciate ligament (PCL) disruption was confirmed by both techniques. MRI was superior to arthroscopy in identifying bone contusions, subchondral sclerosis, and medial cruciate ligament (MCL) sprains. Office arthroscopy is an accurate and cost-efficient alternative to MRI in diagnostic evaluation of knee pathology in patients with enigmatic symptomatology.

Neidhardt, A., K. Bachour, et al. (1992). "[Choice of respirators for anesthesia]." Agressologie 33(Spec No 1): 23-8.
Criteria of quality of gases and vapours supply, ventilator, patient's circle circuit and monitoring devices are recalled to help the anesthetist to choose his anesthesia machine. Advantages of compact or modular apparatus are discussed. Four, now wellknown, anesthesia machines (modulus II+, Siemens 900 D+SAC985, Roche Kontron 4300 and Engstrom Elsa) were analysed in clinical controlled ventilation and in simulated spontaneous ventilation to study the imposed work of breathing. Results are discussed with regard to safety rules and to ergonomics, bearing in mind their respective prices. Comparison is made with an original "bisontin" prototype.

Cotter, S. M., A. J. Petros, et al. (1991). "Low-flow anaesthesia. Practice, cost implications and acceptability." Anaesthesia 46(12): 1009-12.
An 8-week survey was conducted to determine whether the introduction of low-flow anaesthesia (a fresh gas flow of 4 litres/minute or less) into routine use would be acceptable to members of a representative anaesthetic department and if the consequent reduction in use of volatile anaesthetics would result in financial savings. The hourly consumption of the volatile agents was measured during anaesthesia conducted using either conventional or low fresh gas flows. Anaesthetists' acceptance of low-flow anaesthesia was assessed using a questionnaire. Data were gathered on 286 patients undergoing inhalational anaesthesia for routine operative procedures. A 54.7% reduction in the consumption of isoflurane and a 55.9% reduction in that of enflurane was found. Of the 28 anaesthetists at the hospital, 21 would use low-flow anaesthesia routinely. The routine use of low-flow anaesthesia would therefore be acceptable and could result in annual savings of 26,870 pounds at Northwick Park Hospital.

Frosali, D., L. Colpani, et al. (1991). "[The surgical treatment of inguinal hernia by Shouldice's plastic repair under local anesthesia: our path towards day-hospital surgery. The results and prospects]." Minerva Chi