TIME-TESTED APPROACH Understanding and optimizing the many variables involved in anesthesia can improve the bottom line.

If you're looking to save money on anesthesia, your technique can be just as important as the machine you buy. I've been refining my technique over the last several years. I believe it saves my hospital thousands of dollars.

Choice of gas. I almost always use desflurane instead of sevoflurane, including when I use LMAs for my anesthetic. Some do just the opposite, and it's true that desflurane costs a little more per bottle. But it can save in the long run, because it allows for lower flows and quicker recovery, and it's more forgiving. With sevoflurane, the manufacturer recommendation is not to exceed 2 MAC hours with fresh flows between 1 to ?< 2 L/min, or to run ?flows below 1 L/min. Otherwise, patients may be exposed to Compound A, which can damage kidneys. To my knowledge, desflurane doesn't have a minimum flow rate. I typically run fresh gas at 0.6 L/min, which, based on my research, makes it about one-third as expensive as sevoflurane, per minute.

Flow. I use the lowest, safest flow I can, depending on the surgery being performed. These are the parameters I use to determine what's safe:

• Is the patient's oxygen saturation staying at an acceptable level, and what are the fraction of inspired oxygen (FiO2) requirements for the anesthetic?
• Is the reservoir bag staying inflated, or is there a leak in the system that I need to address?
• Is the end tidal carbon dioxide (EtCO2) level staying at an acceptable level?
• Is the fraction of inspired ?carbon dioxide (FiCO2) staying low?

If all of these indicators allow for it, I usually keep the fresh gas flow between 0.5 to 0.7 L/min.

It's not uncommon to see patients who receive 1.3 to 1.5 MAC of gas and have their blood pressure supported by vasoactive drips or frequent boluses. Sometimes we do have to take patients that deep. I use the lowest MAC of agent that lets the patient be deep enough for that specific surgery, but with a larger amount of narcotic to offset surgical stimulus. The inhaled agent we use is bundled into the anesthetic charge, so a more efficiently run anesthetic means more net ?revenue from insurance reimbursement. The IV drugs, on the other hand, are ?separate from the bundled charge. ?I find that with this technique, patients usually wake up quicker and have less pain than those who are more deeply anesthetized intraoperatively and then wake up in recovery with a smaller narcotic load on board. Those patients seem to have to stay in recovery longer while their pain is addressed and also typically have more nausea.

Narcotics. For TIVA cases, especially spine cases with neuromonitoring, I use remifentanil, instead of the much more common sufentanil infusion. I may have to use 2 vials of remifentanil, versus 1 vial of sufentanil, which initially doubles the cost, but the technique I use more than offsets the additional cost by dramatically shortening recovery times. I do it by carefully working in fentanyl, Dilaudid/morphine and IV acetaminophen toward the end of the case. That lets most patients wake up within 30 seconds to 2 or 3 minutes of the time they're flipped over. They can respond to commands and move all extremities, with little to no pain. The bottom line is less OR time, less recovery time, fewer anesthesia-related post-op complications and reduced manpower requirements. With sufentanil drips, I've seen cases in which the infusion wasn't cut off in time and the patient had to be taken to PACU while still intubated. Even when patients are cut off at the appropriate time, sufentanil drips usually force them to stay in recovery a lot longer.

The ending. For the last 10 or 15 minutes of a case, I cut the gas off completely and cut flows down to 0.5 L/min, the idea being to approximate a closed system as much as possible. I try to use about 150 mg of propofol on induction, so I'll have enough at the end of the case if the patient gets a little light while closing. I let the patient wake up slowly during closure, and flush out the system at the end for a fast wakeup. The patient stays asleep and doesn't require any new inhaled agent while closure, which is less stimulating, is occurring.

The bottom line: Patients wake up faster with less pain and fewer complications, and as a result, many bypass recovery and go straight to an area where they're able to eat and talk to their families. Now they're getting sugar in their blood and their brains are more alert, because they're talking and not just lying there. And the more they talk, the faster they're getting the anesthesia out of their bodies. Meanwhile, the PACU isn't getting backed up or using its resources on patients who don't need to be there. Your facility will save money and your patients will go home faster.

SUCTION TUBING
Two Snips and a Good Fit Keep Suction Flowing

NO MORE CLOGS Instead of plugging the non-sterile end into the molded tip of the sterile tubing, I snip both tubes and plug the latter into the former.

Here's a great way to keep bone chips and tissue from clogging up suction tubing during orthopedic procedures. Instead of plugging the small-bore, non-sterile end of the tubing into the molded (usually blue) section at the tip of the sterile tubing (left), reverse the fit. Cut the molded section completely off and at a slight angle, then plug it into the sterile tubing, which I cut at its widest point (right). Everything flows better, and I no longer have surgeons complaining that they've lost their suction.

Jeannie Wermuth, RN
VA Medical Center
Richmond, Va.
[email protected]