We read with interest the study by Eberhardt and colleagues  suggesting that higher acquisition costs of propofol and remifentanil are not compensated by faster recovery. The authors concluded that a remifentanil/propofol technique is more expensive than balanced anaesthesia using isoflurane and alfentanil . We feel that some additional information is required to put the findings into proper perspective.
First of all, this study confirms our previously published finding that remifentanil-based anaesthetic techniques are more expensive than a conventional technique using alfentanil, isoflurane and nitrous oxide . Nevertheless, a recent study showed that total personnel costs were 15% lower using remifentanil/propofol compared to using a conventional etomidate/isoflurane/fentanyl technique . This was due to a lesser need for involvement of the anaesthesiologist in direct patient care and a shorter time interval between end of surgery and discharge from the post-anaesthesia care unit (average decrease 17 min per patient) in the remifentanil/propofol group. As a result, total costs per case were actually 7% lower in the remifentanil/propofol group than in the ‘conventional’ group. Differences in overall costs between Eberhardt's and other recent studies may in part be related to differences in the recovery profile. In Eberhardt's study, time to extubation was 50% longer compared to previous studies with equal duration of anaesthesia and surgery [4-6].
Second, Eberhardt and colleagues did not consider wastage of intravenous drugs, which contributes significantly to overall drug costs, in particular to those of remifentanil and propofol [2,3,6,7]. Lack of such wastage when using inhalational anaesthetics mostly explains why remifentanil-based techniques (particularly when combined with propofol) tend to be more expensive than a conventional alfentanil/isoflurane technique .
Third, at comparable anaesthesia times, the costs for propofol were 25% higher in Eberhardt's study than previously reported [2,4,6]. This is probably due to a higher propofol dosage (4-8 mg kg−1 min−1 vs. a lower fixed dosage in other studies) [2,4,6].
Finally, our previous study suggested a cost-saving effect of using low fresh gas flow . At fresh gas flows of 1L min−1 (instead of the previously reported 0.3-0.5L min−1), the isoflurane consumption (12.5 mL per patient) and cost (€2.68 per patient) were approximately 30% higher in the Eberhardt and colleagues study than in our previous study , despite comparable anaesthesia times and isoflurane concentrations. These various, at times counterbalancing, factors have to be taken into consideration when attempting to present a balanced view on the overall costs of an anaesthetic technique.
H. J. Priebe
Department of Anaesthesiology, University Hospital, Freiburg, Germany
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2. Loop T, Priebe HJ. A prospective, randomized cost analysis of anaesthesia with remifentanil combined with propofol, desflurane or sevoflurane for otorhinolaryngeal surgery. Acta Anaesthesiol Scand
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