TURN IT DOWN Low-flow capability is a plus — as long as providers take advantage.

Anesthesia machines and cars have a lot in common. Both are likely to run at least about $20,000 for new models — and can go much higher. Both can save money by being reliable and “gas” efficient. And in both cases, smart buying decisions depend on how long you plan to keep them, where and how hard you’re going to drive them, and who’s going to be doing the driving.

The bottom line with both, says Ashish Sinha, MD, PhD, vice chairman of anesthesiology and perioperative medicine at Drexel University College of Medicine in Philadelphia, Pa., is that it makes sense to balance your need for technology with your resources. “Technology creates its own need,” he says. “Once you get used to it, it’s hard to go back. You have a heated seat, now you want a heated steering wheel. Sometimes the things you want end up being for technology’s sake rather than for the sake of efficiency or patient safety. It can be a trap. So decide on the features you need before the features you want.”

Into the flow
The feature that every major manufacturer is touting is the capability, through various means, to reduce the volume of anesthetic gases needed per case. Drager and GE Healthcare, for example, offer visual displays that show how much anesthetic agent is being consumed and at what cost, along with displays that suggest reducing fresh gas flow when feasible. That can save money if providers heed the suggestion. Maquet’s “volume reflector” collects and returns up to 95% of exhaled gases to the patient, says the company, and delivers fresh gas mainly on inhalation, rather than wasting it on exhalation. Like a hybrid car, the upfront cost for that capability is steep, but over time, you’ll reap the rewards.

A lower-end machine won’t have all the features that the more expensive brands have, but they, too, will allow for lower flows — if anesthesia providers are willing and able to dial back. “Machines are built differently, but designed to do the same thing,” says Jeff Cryder, CRNA at Scott & White Hospital in Temple, Texas. “Manufacturers saying they offer low flows may be doing it a little differently, based on the way their machines are built, but they’re all probably within 0.1 to 0.2 L/min of each other, so the difference is probably negligible.”

The more significant variable may be who’s doing the driving, says Mr. Cryder. “Many providers just aren’t comfortable running low flows, or they’re lazy. You need to realize that it’s not just the machine, it’s also the clinician. I’ll often go into other [providers’] rooms and see them running their fresh gas way above what the machine is telling ?them they can run it at. They’re being very inefficient.”

Dr. Sinha agrees that low-flow techniques aren’t yet “ingrained in the culture of anesthesia.” Machines are making it safer and easier to use low flows, “with a lot of alarms and bells and whistles that keep us from not adequately oxygenating the patient,” he adds. “But still the easiest thing to do is to throw a lot of oxygen at the patient, and when people do that, it drives up costs.”

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Just the basics?
“The question is what do you need your anesthesia machines to do,” says William Landess, CRNA, MS, JD, director of anesthesia at Palmetto Health Richland Campus in Columbia, S.C. “If you’re in an endo outpatient facility, a cheaper machine is OK. You’re not doing general anesthesia, and the machine is only an expensive Ambu bag.”

In other words, there’s no reason to pay for features you don’t need. For example, if you’re going to be using only one or 2 anesthetic agents, you don’t need multiple vaporizers, says Dr. Sinha.

“The fewer bells and whistles, the fewer the breakdowns,” he adds. “What you want above all else are accurate measurements. How much carbon dioxide is being expelled? How much agent is the patient consuming? You want a machine that’s accurate and that rapidly calibrates when you make changes in the concentration you’re delivering. You want a quick response. Accuracy, quotability, simplicity of function — those are the keys.”

So be sure to take a test drive before you buy. “Most manufacturers are very confident and will let you trial their machines,” says Dr. Sinha. “That’s the best way to know if they provide the features you absolutely require.”

A less-expensive machine, such as those offered by Penlon or Oricare, may be the answer for a facility that wants scaled-down reliability. Penlon’s machines, says the company, have no substantial or frequent software upgrades, require little service and are designed to operate with minimum life costs. Oricare says its machines are designed to be robust and simple “without extra cost from rarely-used features.”

“The proof is in the pudding. I hear a lot of sales pitches from reps,” says Mr. Landess. “The question is, can you back it up? Real trials in your setting are the only way to know if that machine fits your facility.”

“Most machines are now pretty efficient when it comes to giving you feedback as to what gas is inside the patient,” says Mr. Cryder. “If all you need is a mid-range model that lets you wake the patient up quickly, there’s no need to pay an exorbitant amount for a machine.”

Other considerations
While most of the talk in sales presentations and at expos is about innovative ways to reduce anesthetic consumption, there are plenty of other considerations.

“If you’re transitioning to EMR, you absolutely need data integration,” says Dr. Sinha. “You want the machine to auto-populate those fields, so you don’t have to look at charts to do it. It’s also more accurate and honest, because if you’re involved with something else, you might not notice every change in monitoring right away.”

Does the machine you’re considering have a “sleep mode” to conserve energy while it’s not being used? “As machines become more electronic, they build up heat,” says Mr. Cryder, “so if a machine is always in active mode, it’s going to wear down quicker and components are going to wear out sooner. Sleep mode preserves electricity and prolongs the life of components.”

Still, nothing lasts forever, which raises another key point. “What are you going to do when I call on a Saturday morning and say I’m having a problem?” asks Dr. Sinha. “Most companies will fly in a technician or give you a temporary machine. That’s an important factor. Also, what if I try to fix the machine myself? Is that going to void the warranty?”

Wants vs. needs
“Everybody has a price point,” says Dr. Sinha. “Some people say, give me the most car I can get for $20,000. Others say, I can spend $100,000. But do you really need to have a lamp or a light that’s part of the machine and that you pay an extra $1,000 for? Maybe you can just stick a $10 lamp on top of the machine.”

Which is not to say that a more expensive car — or anesthesia machine — is never a smart investment.

“If the facility is busy, a more expensive machine that’s more durable may be more cost-effective in the long run,” says Mr. Cryder. “It comes down to: Which machine will hold up under our workload? Which machine will need servicing and repairs more often? Which will allow for fewer patient complications? Which will help us wake the patient up faster? Which will have fewer problems and help us avoid downtime in the OR?

“If you’re talking 50 (thousand) vs. 40 for a machine that’s a lot more efficient, that’s where it makes sense to spend the extra 10. But if two machines pretty much do the same thing and there’s a $10,000 difference, then it’s a no-brainer.”