Anesthesia Alert

Anesthesia

By: Clifford Gevirtz

Published: 11/13/2010

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Cost-Cutting Benefits of Low-Flow Anesthesia


With the simple turn of a dial on the anesthesia machine, your anesthesia providers could be saving you thousands of dollars a year in costly inhalational anesthetics as well as shortening times to patient recovery and discharge. Get them involved in your facility's cost-cutting efforts by having them take the "25% challenge" as a quality improvement study. Here's how it works.

Dial Down the Oxygen Delivery During Sedation

When using monitored anesthesia care for sedation cases, such as during cataract surgery or endoscopy, encourage your anesthesia providers to use open oxygen delivery only when needed. Running 2 to 3 liters of oxygen through nasal cannulas or masks, which was once common practice, can increase the risk of fire when oxygen gets trapped under drapes. The Anesthesia Patient Safety Foundation has an educational video tackling frequently asked questions about the relationship between supplemental oxygen delivery and fire safety at www.apsf.org/resources_video_commentary.php. The APSF recommends that anesthesia providers eliminate open delivery of oxygen while sedating patients, except when the need for increased oxygen cannot be avoided.

— Clifford M. Gevirtz, MD, MPH

  • Get back to basics. Pick up Miller's Anesthesia or any other respected anesthesia textbook and look up the chapter on "Uptake and Distribution." There, you'll find that while anesthesia providers need higher gas flows — typically in the 4 liters to 5 liters per minute range — at the beginning of the case, they can dial the flows down significantly to less than 2 liters per minute (or even better, 1 liter per minute) during the maintenance portion of the case, raising oxygen levels again just at the end of the case to flush out the circuit. While we all learn this in residency, many anesthesia providers quickly forget it over time, slipping into complacency and leaving the flow set at the same rate from beginning to end. This is an unnecessary waste of expensive inhalational agents like sevoflurane and desflurane, as well as oxygen.
  • Audit your gas flows. Before you ask your anesthesia providers to change their ways, get an accurate portrait of their current behavior. Audit gas flow rates by taking a single operation, say a gall bladder case, tallying up the number of liters of inhaled anesthetics the anesthesia provider administered and averaging that number over 10 cases (preferably performed by the same surgeon). If you use electronic medical records, this data is fairly easy to obtain and analyze.
  • Challenge providers to reduce flows by 25%. With a good baseline of data to begin with, challenge your anesthesia providers to reduce their flow rates by 25%. Remind them that the textbooks say they don't need to maintain rates at 4 to 5 liters per minute throughout the duration of the case. In fact, 2 liters per minute should be the maximum flow rate used during maintenance. Don't set a one-size-fits-all solution, but rather let each provider decide where and when he can dial down the use of inhaled anesthetics and oxygen. Use the friendly competition among providers and the financial needs of your facility as incentives for those hesitant to take up the challenge.
  • Share your results. Continue to audit flow rates and see how they change from one month to the next. Tally up the cost savings, too, and share these with your anesthesia providers. Soon they will see that the 25% challenge is a simple way to cut costs without impacting the quality of patient care.

Schedule IV Propofol: Preparing for the Inevitable

Propofol will almost definitely become a controlled drug within the year. A proposal to reclassify propofol as a Schedule IV controlled substance both on the federal and state levels is currently circulating within the U.S. Drug Enforcement Administration. If we accept that this change is inevitable, every facility and anesthesia provider must now prepare for a fundamental shift in how you store, handle and document propofol. Start discussing these issues with your pharmacist or pharmacy consultant now, and be sure to keep an eye on changes at the state as well as the federal level, as some states have indicated they'll adopt an even stricter control plan. Formal implementation dates for drug policy changes are not all that generous once the comment period in the Federal Register is completed.

  • Storage. The storage requirements that accompany controlled drugs may be a quagmire when it comes to propofol, as the raw bulk of this product far exceeds most facilities' storage capacities. "Substantially constructed cabinets" is the regulatory language; each state has its own definitions and expectations of what exactly that means. In the most extreme cases, facilities might have to invest in secure cabinets or safes in which to lock up their propofol supplies.
  • Record-keeping. On a state-by-state basis, documentation of controlled drugs must contain all or most of these elements: date, patient name, prescriber's name, administered by name, dose, time, remaining quantity and witnessing of discards.
  • Discards and single-use vials. Every anesthesia record will have to document, patient by patient, that you discarded the unused remainder of each propofol vial. This information will be further declaration that your facility is using the product as intended: 1 single-use vial for 1 patient only.

Both the American Society of Anesthesiologists and American Association of Nurse Anesthetists support tighter controls on propofol. Some providers have even called the move "long overdue."

— Sheldon S. Sones, RPh, FASCP

Mr. Sones ([email protected]) is a pharmacy consultant and safe medication management officer at more than 130 ambulatory facilities in the Northeast and a member of Outpatient Surgery Magazine's Editorial Board.

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