◊ BACKGROUND:
This study investigated the cost-effectiveness of ultrasonographic-guided interscalene brachial plexus blockade (ISB) in comparison with general anaesthesia (GA) for arthroscopic shoulder surgery.
◊ METHODS:
Forty patients undergoing arthroscopic shoulder surgery received either an ultrasonographic-guided ISB or GA. ISB was performed outside the operation room (OR) and patients were transferred in the OR at the earliest 20 min after block performance. All drugs and disposables were recorded to evaluate the costs for both techniques. The following anaesthesia-related times were defined: ready for surgical preparation (from arrival in the OR until end of anaesthesia induction), OR emergence time (from end of dressing until leaving the OR), anaesthesia control time (from patient's arrival in the OR until readiness for positioning plus time from the end of surgery to patient's discharge from the OR), and post-anaesthesia care unit (PACU) time (from patient's arrival in the PACU to the eligibility for discharge to normal ward). Personnel costs were excluded from statistical analysis.
◊ RESULTS:
The total costs were [mean (SD)] 33 (9)€ for patients with ISB and 41 (7)€ for those who received GA (P<0.01). The anaesthesia-related workflow was improved in the ISB group when compared with the GA group [ready for surgical preparation 8 (3) vs 13 (5) min, P<0.001; OR emergence time 4 (3) vs 10 (5), P<0.001; anaesthesia control time 12 (4) vs 23 (6), P<0.001; and PACU time 45 (17) vs 70 (20), P<0.001].
◊ CONCLUSIONS:
Ultrasonographic-guided ISB is a cost-effective method for arthroscopic shoulder surgery.
◊ Reviewed by M. Mulroy, MD.
Faculty Anesthesiologist
Virginia Mason Medical Center, Virginia Mason Hospital, Seattle, WA, USA
Gonano and colleagues report lower drug and equipment costs associated with the use of the regional technique in a group of 40 patients randomized to receive either an interscalene block performed with ultrasound or a general endotracheal anesthetic for shoulder surgery. As a secondary outcome, they also found shorter “anesthesia controlled time” in the operating room with the regional block, as well as more rapid eligibility for PACU discharge. These findings corroborate the earlier data by D’Alessio [1] and Brown [2], who also found shorter operating room times, faster recovery, and fewer overnight admissions associated with regional techniques. Their finding of reduced cost is also similar to the related analysis by Williams et al [3] of regional techniques for knee surgery. Part of the reason for their impressive findings is the implementation of ultrasound in performance of the blocks, which reduces the time required for anesthesia and has the potential to improve the reliability of the blocks.
While this information is exciting and supportive to enthusiasts of regional anesthesia, there are several caveats. First of all, as the authors themselves admit, the drug costs are a relatively trivial part of the entire operative experience. The major costs of personnel remain relatively fixed regardless of the anesthetic technique, unless an institution makes a commitment to regional anesthesia alone and thus has an ability to reduce the recovery room staff or discharge a larger number of patients with the same staff.
The authors also acknowledge that the successful implementation of regional techniques requires the use of a separate space, an anesthesia induction area. This allows the performance of the block to be separated from the operating room time, and thus is effective in reducing the “anesthesia controlled time” in the operating room. The absence of an induction room explains the previous report by Chan and colleagues who found that brachial plexus block was more expensive than intravenous regional anesthesia for arm surger[4]. An induction room also allows longer time for the onset of block, which does not appear to have been measured in the current report. The cost of the space and the additional personnel required to staff such a room is not factored into the authors’ equations. Their findings are also based on the assumption of a highly skilled and competent anesthesia staff that would be able to perform the blocks quickly and reliably in this induction space. This level of competence may not be available in all centers. Likewise, the ability to reap full advantage of these positive aspects of interscalene block would require a practice that includes acceptance of a high percentage of regional techniques.
It is unfortunate that their data do not include other benefits of regional anesthesia, such as the degree of patient satisfaction and the decreased use of opioid-based analgesics in the recovery period with their associated side effects of nausea and disorientation. Likewise, the ability in other situations to discharge patients home on the same day is enhanced with regional techniques. These non-tangible benefits may be equally important as the economic advantage of the regional techniques.
Nevertheless, the authors have added a useful aspect of information regarding the advantages of regional techniques, specifically the reduced cost. Taken in the overall context of “regional vs. general” this study provides one more argument for inclusion of regional techniques as a routine part of orthopedic surgery. Even though the authors do not practice on an “ambulatory” basis, it is obvious that their results would also support the wider application of interscalene blocks in the outpatient setting.
◊ REFERENCES
[1] D'Alessio JG, Rosenblum M, Shea KP, Freitas DG. A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy. Regional anesthesia. 1995 Jan-Feb;20(1):62-8.
[2] Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU. Interscalene block for shoulder arthroscopy: comparison with general anesthesia. Arthroscopy. 1993;9(3):295-300.
[3] Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, et al. Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge. Anesthesiology. 2004 Mar;100(3):697-706.
[4] Chan VW, Peng PW, Kaszas Z, Middleton WJ, Muni R, Anastakis DG, et al. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis. Anesthesia and analgesia. 2001 Nov;93(5):1181-4.
|
