Cheapest Possible Anesthesia (with stipulations)

[coprolalia]

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Okay, let's say you have to do some general four-hour open abdominal case. What's the way you can possibly do this the cheapest, yet keep the patient asleep, comfortable, safe, and not otherwise compromised in the care you give them.

I ask this because one of the partners was discussing this the other day. He will actually use a multi-dose vial of Brevital, Pavulon, morphine, nitrous, and isoflurane for a lot of these cases. No epidural (doesn't believe in them), and very, very low flows. Everyone gets Phenergan only at the end.

He claims that he can do what he considers to be a superior anesthetic at a fraction of the cost of his colleagues, and offered this to me to think about as the era of "cost containment" begins to prevail in what we do.

He also said that his anesthestic is more "green friendly" because he's using less equipment and releasing less fluorocarbons into the atmosphere. To him, it's win-win.

So, do you think you can more cheaply do such a case given the "standard of good anesthetic practices" we must adhere to? He claims to have just as good outcomes as everyone else doing the same or similar cases.

-copro

 

[ssmallz]

nitrous narcotic sufentanil drip + N2O

 

[periopdoc]

Spinal or CSE +/- Ketamine/ Midaz sedation +/- oxygen. Can you get any cheaper or more environmentally friendly?

I once did a big ventral hernia with an epidural only and talked to the guy for the whole case. Surgeon said that relaxation was the best he had seen in a long time.

- pod

 

[omegaman]

I

 

[Fastrach]

I ask this because one of the partners was discussing this the other day. He will actually use a multi-dose vial of Brevital, Pavulon, morphine, nitrous, and isoflurane for a lot of these cases. No epidural (doesn't believe in them), and very, very low flows. Everyone gets Phenergan only at the end.

What is his rationale for "not believing" in epidurals? Doing an over-under approach with an epidural has a high chance of playing a key role in an overall cheaper hospital stay for the patient. Less postop ileus, less IV narcotics, less postop pain, and the chance of a speedier discharge all add up to a lower cost per patient. Strictly looking only at OR charges is too short-sighted.

 

[bigeyedfish]

Continuous spinal. You could do that whole 4 hour case with a few cc of bupi and some iv fluid. Dirt cheap. Of course, just because you can do something, doesn't necessarily mean you should.

 

[coprolalia]

nitrous narcotic sufentanil drip + N2O

That's called the "Liverpool technique" and has a high incidence of intraop awareness.

-copro

 

[coprolalia]

Halothane is dirt cheap, plus you can mask induce patients saving the cost of an induction agent, and you could try to run then deep enough not to need muscle relaxant.

Halothane is no longer available in the U.S.

-copro

 

[coprolalia]

Spinal or CSE +/- Ketamine/ Midaz sedation +/- oxygen. Can you get any cheaper or more environmentally friendly?

I once did a big ventral hernia with an epidural only and talked to the guy for the whole case. Surgeon said that relaxation was the best he had seen in a long time.

- pod

I suppose this would work if the patient didn't mind the possibility of being aware, even with the midazolam, and you had an unsecured airway with an open abdomen.

-copro

 

[coprolalia]

What is his rationale for "not believing" in epidurals? Doing an over-under approach with an epidural has a high chance of playing a key role in an overall cheaper hospital stay for the patient. Less postop ileus, less IV narcotics, less postop pain, and the chance of a speedier discharge all add up to a lower cost per patient. Strictly looking only at OR charges is too short-sighted.

Good point. I generally agree with you. They guy just hates epidurals for anything but OB/gyn stuff. We didn't talk specifically about this, though, but I think he'd probably say there are too many bad experiences with having to manage on the floors, cost (to the service) associated with maintaining them versus reimbursement you get back, malfunctioning, etc. to make them routinely worthwhile. I suppose you could make an argument about intra-op use with preservative free morphine then pull at the end of the case, but I'm not sure that this does anything more than add cost.

-copro

 

[BLADEMDA]

Okay, let's say you have to do some general four-hour open abdominal case. What's the way you can possibly do this the cheapest, yet keep the patient asleep, comfortable, safe, and not otherwise compromised in the care you give them.

I ask this because one of the partners was discussing this the other day. He will actually use a multi-dose vial of Brevital, Pavulon, morphine, nitrous, and isoflurane for a lot of these cases. No epidural (doesn't believe in them), and very, very low flows. Everyone gets Phenergan only at the end.

He claims that he can do what he considers to be a superior anesthetic at a fraction of the cost of his colleagues, and offered this to me to think about as the era of "cost containment" begins to prevail in what we do.

He also said that his anesthestic is more "green friendly" because he's using less equipment and releasing less fluorocarbons into the atmosphere. To him, it's win-win.

So, do you think you can more cheaply do such a case given the "standard of good anesthetic practices" we must adhere to? He claims to have just as good outcomes as everyone else doing the same or similar cases.

-copro

So, have you compared the cost of your ANESTHETIC to his?

For example, you decide on a "basic" anesthetic for your 2 hour plus cases. Some may want N20 others would avoid due to possible increased morbidity/mortality in select patients. You decide on 1.5 liter flow vs. his 1 liter flow. You decide on generic Vecuronium or generic rocuronium to his generic pancuronium. Fentanyl costs less than 30 cents per 5 cc vial.

In the end you can give your anesthetic with Isoflurane within $5-$8 of his anesthetic without making any significant compromises.

Droperidol- Pennies
Odansetron- $1.00 (generic)
Vecuronium- $1.00 more than Pancuronium
1.5 L flow vs. 1 Liter flow ISo- $1.00
Save Phenergan (12.5 mg) for PACU if needed

My point is that YOUR anesthetic can be within $5.00 of his anesthetic for a 2 hour case. Are things that bad in Medicine that your $15,000 surgery comes down to $5.00?

 

[Consigliere]

I guess my question is......who the eff cares? I had attendings during my residency say the same crap; as if their paycheck was predicated on their judicious use of anesthetic agents.

 

[Jeff05]

Halothane is no longer available in the U.S.

-copro

i think it may be, we still have a halo vaporizer in the peds cardiac room and a stock pile of bottles.

 

[Pilot Doc]

i think it may be, we still have a halo vaporizer in the peds cardiac room and a stock pile of bottles.

The US maker stopped production in 2007. I think the bottles have a 1 year expiration date, arbitrary though that may be. Even though I'm sure somebody's still using it, it won't be for much longer.

 

[deleted50478]

Okay, let's say you have to do some general four-hour open abdominal case. What's the way you can possibly do this the cheapest, yet keep the patient asleep, comfortable, safe, and not otherwise compromised in the care you give them.

I ask this because one of the partners was discussing this the other day. He will actually use a multi-dose vial of Brevital, Pavulon, morphine, nitrous, and isoflurane for a lot of these cases. No epidural (doesn't believe in them), and very, very low flows. Everyone gets Phenergan only at the end.

He claims that he can do what he considers to be a superior anesthetic at a fraction of the cost of his colleagues, and offered this to me to think about as the era of "cost containment" begins to prevail in what we do.

He also said that his anesthestic is more "green friendly" because he's using less equipment and releasing less fluorocarbons into the atmosphere. To him, it's win-win.

So, do you think you can more cheaply do such a case given the "standard of good anesthetic practices" we must adhere to? He claims to have just as good outcomes as everyone else doing the same or similar cases.

-copro

I'd question whether nitrous is really useful for cost containment. You have to run higher flows with nitrous/O2/Iso than with just O2/Iso. The savings from having a lower % Iso when combined with nitrous don't make up for the loss of Iso and nitrous to scavenging. Not to mention the increased PONV treatment costs...

I think the cheapest technique would use scopolamine - preop sedation, decreased secretions, decreased recall, decreased narcotic requirements, decreased nausea/vomiting all in one cheap vial.

Real savings would come from circulators showing up early enough to start on time and cleaning crews finishing the rooms between cases in less than 40 minutes.

 

[coprolalia]

I guess my question is......who the eff cares? I had attendings during my residency say the same crap; as if their paycheck was predicated on their judicious use of anesthetic agents.

Okay, using Blade's analogy... if I could save $5.00 ever two hours...

Let's say that's $20/day (8 hours of GA, at $2.50/hr)... multiply that by the 250 days/year that I'd be giving anesthesia... that's $5,000/yr I've saved... now, if everyone does it (14 ORs in my hospital), that's $70,000 per year...

Is that peanuts? You be the judge. Might be able to hire another anesthesia tech for that... No one the eff cares because no one follows that stuff that closely...

I think the guy has a point, personally.

-copro

 

[OB1🤙]

I think the guy has a point, personally.-copro

Agreed. It doesn't have to be taken to extremes, but we should be cost-conscious in the OR.

One thing I see all the time- apparently it became institutional norm without my knowledge that all volatile anesthetics must be administered at flows of 2L/min. Sevo- 2L. Iso- 2L. Des- 2L. Doesn't matter.

Drives me f^(%!ng crazy when I take over a 8 hour marathon at hour 6 and des has been running at 2L/min the whole time.

 

[BLADEMDA]

Okay, using Blade's analogy... if I could save $5.00 ever two hours...

Let's say that's $20/day (8 hours of GA, at $2.50/hr)... multiply that by the 250 days/year that I'd be giving anesthesia... that's $5,000/yr I've saved... now, if everyone does it (14 ORs in my hospital), that's $70,000 per year...

Is that peanuts? You be the judge. Might be able to hire another anesthesia tech for that... No one the eff cares because no one follows that stuff that closely...

I think the guy has a point, personally.

-copro

What is the O.R./Anesthesia budget? $15 million? $20 million? How about saving just ONE PULSE OXIMETER from being crushed per week? Or, a piece of valuable equipment from getting lost? Or, improve O.R. turn-over efficiency?

Sure, save your $70,000 a year but just hope some CA-1 or CRNA doesn't give to much PAVULON near the end of the case. That ventilator in the PACU will eat up a lot of your savings in one fell swoop.

Blade

 

[dhb]

I agree with you partner Cop.
In newer anesthesia ventilators like the Drager ZEUS (i think you don't have it in the US because of FDA approval of all the electronics it has) allow you to do closed circuit anesthesia by flicking one button.
A 4h case will generally use 25-30ml of Des (and these were thoracotomies with leaks) and possibly less than 15ml of Sevo. Add a little fentanyl, decadron and you're set.

 

[dhb]

cleaning crews finishing the rooms between cases in less than 40 minutes.

I hope you meant less than 10 min.

 

[deleted126335]

.

 

[pgg]

Tangent on cheapest anesthetic: Ketamine 100mg/ml. 1 ml in which you dissolve sux powder or vecuronium powder. You can induce anesthesia with 1 ml. Never done it. Unsure of compatibility of the cocktail.

You could save on the IV supplies too if you skip the IV. One syringe, one needle, hit the antecubital Trainspotting-style, and there you are.


My personal biggest money-wasting irritation in the OR is all the non-sharp stuff that gets thrown into the sharps containers. Syringes aren't sharp. Neither are gauze, drug vials, towels, empty IV bags, spinal trays, gloves, infusion tubing, surgical pens, ET tubes, yesterday's schedule, or any of the other non-sharp stuff that seems to fill them up.

One of those expensive-to-dispose-of containers could last a month if people only put needles and broken glass ampules in it.

 

[pgg]

I guess you are saving money on NaCl by mixing it up like that Doze. Just kidding...it must be cool to see someone go out with a 1 ml injection. I wish we had those vials so I could try it.

Anyone have a link of how much each vial of common anesthesia drugs costs?

For the common stuff (except vapors), my understanding is that the packaging often costs more than the actual drug. Hospitals have bulk contracts for much better rates, but here are a couple off esurg.com ...

propofol: 25x 10mL vial for $57.60 ($2.30 per vial)

succinylcholine: 25x 10 mL vial for $61.00 ($2.44 per vial)
vecuronium: 10x 10 mg vials for $26.38 ($2.64 per vial)

fentanyl: 10x 5mL ampules for $5.02 ($.50 per ampule)
morphine: 25x 10 mg for $21.28 ($.85 per ampule)

sevoflurane: 250 mL bottle for $184.63
desflurane: 6x 240 mL bottle for $1,031.72 ($171.95 per bottle)
isoflurane: 100 mL bottle for $15.18

And that's just for me if I typed in my credit card number to order a couple items. 10 minutes of OR inefficiency is far more costly than using choosing sevo over iso, unless you're like me at a military hospital where there isn't any interest whatsoever in billing or cost containment.

I've also been told that it costs the hospital more (in lost pharmacy man-hours) to return an unused ampule of fentanyl, morphine, or other cheap controlled drug - that it's better to crack it open and squirt it in the trash than return it. I don't know if that's true, but it sounds reasonable to me.

 

[deleted50478]

I hope you meant less than 10 min.

I wish! Sometimes they don't even start for 10 minutes, and by start I mean turning on the radio and dancing around the fithy OR.

 

[coprolalia]

What is the O.R./Anesthesia budget? $15 million? $20 million? How about saving just ONE PULSE OXIMETER from being crushed per week? Or, a piece of valuable equipment from getting lost? Or, improve O.R. turn-over efficiency?

Sure, save your $70,000 a year but just hope some CA-1 or CRNA doesn't give to much PAVULON near the end of the case. That ventilator in the PACU will eat up a lot of your savings in one fell swoop.

Blade

So, are you saying that using Pavulon increases the risk that someone will create an error? I'm not sure what your point is.

I don't think that we need to be quite so extreme or too penurious with our techniques, but I think the guy has a point about how wasteful we are. And, just because you save money somewhere doesn't mean that you're going to blow it somewhere else. We need to be, as a profession, far more cost conscious than we currently are.

I like the idea of publishing how much stuff costs. Personally, we don't even get isoflurane as a choice to be hung on our vaporizers in PP land. I was quite adept at using it in residency. I'm sure I'm going to forget how to be slick with it if I don't use it, but my choices are Sevo and Des now... and I'm slick with those, too. But, they are easier drugs to titrate... but, as you can see above, they are far more costly (although I think Sevo is around $80 a bottle now that it's generic).

I liked this discussion because, I think, most of us all think about how slick we can do an anesthetic... but the cost of that anesthetic, both in terms of actual dollar value of the options we choose as well as what we are throwing in the trash bin or pumping into the ozone layer, is something I don't think we routinely consider.

Just something to chew on. And, because I eff'ing care, so should you.

-copro

 

[urge]

I'm not pro multidose vials for different pts. However, I cannot imagine a 100ml propofol being more expensive than 60ml brevital when used for multiple pts.

The pavulon is silly IMHO. Just one complication will kill your LIFETIME savings. Plus, every minute in the OR is now supposed to cost $90. So, you are either fooling yourself into thinking the pt is relaxed because you gave too little or you are waiting a long time to reverse the pt. Not to mention the 5 min plus you have to wait for pavulon to work.

The only commendable thing your partner is doing is using low flows.

Blade is right. We are in a sad state of affairs if we are worrying for the I tip my pizza delivery guy.

 

[OB1🤙]

This is another huge, huge pet peeve of mine.

My personal biggest money-wasting irritation in the OR is all the non-sharp stuff that gets thrown into the sharps containers. Syringes aren't sharp. Neither are gauze, drug vials, towels, empty IV bags, spinal trays, gloves, infusion tubing, surgical pens, ET tubes, yesterday's schedule, or any of the other non-sharp stuff that seems to fill them up.

One of those expensive-to-dispose-of containers could last a month if people only put needles and broken glass ampules in it.

 

[OB1🤙]

You wouldn't like me then. If there isn't a trash can around, I throw everything in there. If the sharps container was in the bathroom, I would take a **** in it.

Solution: obtain trash can.

 

[Bertelman]

This is another huge, huge pet peeve of mine.

ditto.

 

[SiberianBear]

Cheap option from real world:
Premed: atropin + diazepam
Induction: sux + fent + ketamine (or thiopental)
Maintance: ketamine 50mg + fent 50mcg q30 min boluses + pipecuronium (like panc minus autonomic side effects)
+/- Droperidol 2.5-5mg or +/- Clonidine 0.5-1mg

 

[coprolalia]

The pavulon is silly IMHO. Just one complication will kill your LIFETIME savings.

For a four-hour abdominal case? Again, does Pavulon cause "complications", or is that user error?

Plus, every minute in the OR is now supposed to cost $90.

Source? (You're essentially saying that a four hour case, in the OR, "costs" $21,600. I think you're WAY off. You can't make such a blanket statement... or, better still, those who did shouldn't lump everything together and compare apples to oranges, as is often the case. Different cases may or may not be more complex than others... and more necessary [or not] than others.)

So, you are either fooling yourself into thinking the pt is relaxed because you gave too little or you are waiting a long time to reverse the pt. Not to mention the 5 min plus you have to wait for pavulon to work.

Again, pancuronium was, for a long time, the ONLY "safe" (read that benzylisoquinolinium) non-depolarizer that was around, and a lot of anesthetists got quite adept at using it without problem (this guy happens to be in his late 50's). It's pre-mixed and it's cheap. So, again, I ask you: are any problems with the drug inherent to it... or with the person administering it?

I'm not saying you don't evolve and adapt. I'm not saying that you don't use best practices (e.g., "standard" monitors, etc.) or otherwise do things that compromise care by cutting corners.

I am saying that, if the pizza guy is coming to your house twice a day - AND you're overtipping him each time - it's gonna add up. And, this is far easier to reconcile with yourself, especially if you're buying that pizza with other people's money.

-copro

 

[urge]

For a four-hour abdominal case? Again, does Pavulon cause "complications", or is that user error?



Source? (You're essentially saying that a four hour case, in the OR, "costs" $21,600. I think you're WAY off. You can't make such a blanket statement... or, better still, those who did shouldn't lump everything together and compare apples to oranges, as is often the case. Different cases may or may not be more complex than others... and more necessary [or not] than others.)



Again, pancuronium was, for a long time, the ONLY "safe" (read that benzylisoquinolinium) non-depolarizer that was around, and a lot of anesthetists got quite adept at using it without problem (this guy happens to be in his late 50's). It's pre-mixed and it's cheap. So, again, I ask you: are any problems with the drug inherent to it... or with the person administering it?

I'm not saying you don't evolve and adapt. I'm not saying that you don't use best practices (e.g., "standard" monitors, etc.) or otherwise do things that compromise care by cutting corners.

I am saying that, if the pizza guy is coming to your house twice a day - AND you're overtipping him each time - it's gonna add up. And, this is far easier to reconcile with yourself, especially if you're buying that pizza with other people's money.

-copro

You lead a horse to water but you cannot make him drink.


Anyway, do you honestly think you can provide good enough muscle relaxation and then reverse it appropriately a few minutes later with pavulon?


The $90/min comes from my hospital. I imagine every place is different.

This article claims it's over $20/min. https://www.marshallsteele.com/OREfficiencyProgramOverview.pdf

Plus, haven't you had cases scheduled for over 4hr that are done in 30min? Pavulon is a great choice for those.

Pavulon is cheaper only in the mind of those who cannot think 2 minutes in the future.

1 minute you f-up every day(either waiting for the drug to kick in, wear off, or extubating floppy patients-you know those- they are not fully back but they might be ok since you are so cheap to use a vent circuit in the pacu...) and the pizza tip is gone.

 

[Licoricestick]

Again, pancuronium was, for a long time, the ONLY "safe" (read that benzylisoquinolinium) non-depolarizer that was around

Or perhaps aminosteroid?

 

[Consigliere]

Just something to chew on. And, because I eff'ing care, so should you.

-copro

Not unless my paycheck is dictated by how "cheap" or "expensive" my anesthetic technique is. 🙂

 

[BLADEMDA]

Residents and Fellows, here is my opinion:

I believe in safe, cost-effective, efficient anesthesia. But, in no way should $5-$10.00 be the FINAL deciding factor in my choices. I choose the best anesthetic for the patient period.

Second, as a seasoned attending I will not allow CRNAs to use pancuronium in cases which are going to be extubated at the end. THe sole exception is extremely long Neuro cases where NO ADDITIONAL muscle relaxants will be given during the case. I strongly encourage you to do the same as "weakness" post anesthesia can be a common occurence due to residual muscle relaxant ( I have posted references on other threads).

Those who believe their anesthetic is the reason for rising health care costs in the USA are delusional. The $15,000 operation your patient is going to receive deserves a "state of the art" anesthetic. If you want to "chince" on anesthesia then do it on the no pay or Medicaid case. The commercial insurance patient is PAYING THROUGH THE NOSE for a good, premium product.

Blade

 

[coprolalia]

Or perhaps aminosteroid?

Correct. "-uriums" are the former, "-oniums" are the latter. I misspoke. Thanks for the clarification.

-copro

 

[coprolalia]

If you want to "chince" on anesthesia then do it on the no pay or Medicaid case.

I'm not telling anyone how to do anything. I'm just providing food for thought. I can count on both hands and feet the total number of times, in the literally thousands of anesthetics I've given to date, I've used pancuronium.

(And the word, just for the record, is chintzy.)

-copro

 

[BLADEMDA]

I'm not telling anyone how to do anything. I'm just providing food for thought. I can count on both hands and feet the total number of times, in the literally thousands of anesthetics I've given to date, I've used pancuronium.

(And the word, just for the record, is chintzy.)

-copro

I never said you were advocating a ketamine/N20/Pavulon anesthetic.
I just want to remind everyone that those of us paying 16-20K per year for health care want a PREMIUM Anesthetic and not the EL CHEAPO version which your partner dishes out on a regular basis.

When ObamaCare becomes the norm we can revisit the topic.🙂