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Although the introduction of neuromuscular blocking drugs with intermediate and short durations of action has significantly changed the practice of providing neuromuscular blockade, the acquisition cost of these drugs is considerably greater than that of long-acting drugs such as pancuronium. In recent years, there has been pressure to reduce health care costs by reverting to more widespread use of long-acting neuromuscular blockers.[1124] [1125] It is appropriate to remember that the acquisition cost of anesthesia drugs is likely to amount to approximately 0.25% of the total hospital budget and is only a fraction of the cost of running an operating room.[263] Focusing on only drug acquisition costs while trying to reduce health care costs is a simplistic view,[1126] and the impact of the choice of neuromuscular blocker on patient outcome must also be considered. Outcomes that result in increased medical cost must also be included in a patient's total health care costs.[1127]
A prospective trial of anesthesiologists' practices demonstrated that anesthesiologists are not inclined to choose medications based on price alone. [1128] However, price labeling, associated with education regarding the cost of medications in another study, did reduce the cost of acquisition of neuromuscular blockers by 12.5% over a 12-month period. This reduction translated into a savings of just over $47,000.[1129] The decrease in expenses for neuromuscular blockers was accomplished by a 104% increase in the use of pancuronium. However, unless the educational programs are ongoing and the staff remains well motivated, cost savings from this type of practice modification are short lived.[1130]
If a reduction in drug acquisition costs is to be considered an appropriate means of decreasing health care cost, anesthesiologists may look at their own practices. A year-long survey was performed in one hospital for waste of six frequently used or expensive medications. These drugs included thiopental, succinylcholine, rocuronium, atracurium, midazolam, and propofol. The study demonstrated that the total cost of drugs drawn up but not administered amounted to more than $165,000. [1131] Waste of thiopental and propofol accounted for most of this expense. In this practice, rocuronium and atracurium each accounted for 2% of the total expense. Succinylcholine did not significantly contribute to the cost of drug wastage. Although efficiency in the dosing of neuromuscular blockers can be improved, decreasing the amount of neuromuscular blockers drawn up and not administered to patients may not be a truly significant way to decrease health care costs.
The adequacy of recovery of neuromuscular function is crucial because even minor degrees of residual neuromuscular blockade have significant adverse effects.[53] [54] [563] [565] The muscles of airway protection are very sensitive to residual block,[53] and this predisposes patients to pulmonary aspiration.[563] In addition, residual neuromuscular blockade may compromise a patient's "street readiness" in the postoperative recovery period.[54] Mounting evidence indicates that the standard for acceptable recovery of neuromuscular function is no longer a TOF ratio of 0.7, but in fact greater safety might be achieved at 0.9.[54] [563]
The relative incidence of residual neuromuscular blockade in the postoperative period is greater with neuromuscular blockers that have a longer duration of action. In 1979, a study by Viby-Mogensen and colleagues[58] showed that the incidence of residual weakness in the recovery room was higher than 40%. At that time, only long-acting drugs were available. With the introduction of vecuronium and atracurium, the incidence of residual weakness declined significantly to less than 10%.[59] If, however, a TOF ratio of 0.9 is to now be considered adequate, the incidence of unacceptable levels of neuromuscular block on admission to the PACU may be higher.[55]
Residual neuromuscular blockade caused by the administration of long-acting nondepolarizing neuromuscular blockers appears to predispose patients to a greater risk of postoperative pulmonary complications.[60] These complications constitute the greatest potential added expenses, and they accrue as a result of the choice of long-acting neuromuscular blockers over shorter-acting drugs. Delayed discharge from the PACU[1132] also has a significant cost impact. The increased length of stay in the PACU because of long-acting neuromuscular blockers has an estimated cost penalty to the institution of $40 per patient.[1132]
It is argued that the use of long-acting neuromuscular blockers is without adverse effect if strict practice guidelines regarding their use and dosing are implemented and continuously enforced.[1133] [1134] However, even with strict regulation, the use of pancuronium rather than an intermediate-acting neuromuscular blocker is associated with a delay (a mean of 3 minutes) in the time from the end of the surgical procedure until the patient reaches the PACU. Much debate has been generated about the importance of this 3-minute delay.
The risks of residual weakness associated with the use of long-acting neuromuscular blockers apply to situations in which the patient's trachea will be extubated at the end of the surgical procedure. After cardiac surgery, for instance, where the tracheal tube will remain in place and the patient's ventilation will be supported postoperatively for hours or days, the use of long-acting neuromuscular blockers does not incur a cost penalty.[1135] In this scenario, the use of intermediate-acting relaxants may decrease the time to extubation of the trachea and the incidence of residual neuromuscular block. They do not, however, shorten the length of ICU stay after bypass surgery.[1136] In the case of relaxant use for shorter surgical procedures, succinylcholine and mivacurium were found to be economically superior to all the other neuromuscular blockers for use during short operations when intense neuromuscular blockade was mandatory.[1137] However, once doses of neuromuscular blockers beyond the initial intubating dose are required, the cost of the use of mivacurium increases, and it becomes more expensive than intermediate-acting neuromuscular blockers.[1138]
The debate regarding cost and neuromuscular blocker use is ongoing. On one side, there is evidence that drug acquisition costs for nondepolarizing neuromuscular blockers can be decreased through physician education. On the other side is evidence suggesting that patients are placed at greater risk for complications associated with residual paralysis when long-acting nondepolarizing neuromuscular blockers are used. As described by Miller,[1139] any savings accrued by using long-acting as opposed to the shorter-acting neuromuscular blockers will be lost with the occurrence of a single adverse event as a result of residual neuromuscular blockade. For example, succinylcholine's side effects render it expensive to use despite its short duration of action. The true cost per dose of succinylcholine from society's perspective is not negligible and is more than 20 times the acquisition cost.[1140] Clinicians must constantly assess which neuromuscular blocking drug is best suited for their patients. The decision will be multifaceted and will have to include, in addition to the cost of the neuromuscular blocker, the duration and nature of the surgical procedure, as well as the patient's general health.
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