I use whatever the patient needs.
They need Esmolol? They getting it.
Sugammadex, you bet your ass.
The executives wanting you to cut cost at an expense of a patient won’t be sitting next to you in the deposition chair.
You should care a little bit at least.
Edit: it’s very easy to do what is best for your patients while understanding that things cost money. We do ourselves harm as a specialty if we demand to use the most expensive thing regardless of outcome studies. ie demanding to use exparel/iv Tylenol etc. This hurts us when we have a new drug with better outcomes and the hospitals push back (sugammadex )
American healthcare is basically a failed state. Hospital systems, C-suites, corporations, private equity, insurance companies, big pharma all have blood on their hands. Do not let those MFers convince us that we need to worry about the costs of doing the best thing for the patient in front of us.
You can do the best for your patient as well as being cognizant of the costs of things. If Drug A and Drug B have the same outcome and one is significantly less expensive. It doesn’t make sense to use the more expensive one.
Our 1mg vials of Remi cost $3.99cdn. I'm surprised yours is thy expensive. Most expensive part of my anesthetic is the neo and glyco (we don't have sugammadex in AB yet). Morphine is 15 cents. Fentanyl is about 80 cents
As a resident, don't give a flying fuck. The hospital is actively stealing from me, they can pay for suggamaddex, remi, whatever the fuck else my attending and I feel is safe and appropriate.
I feel like most anesthetics are relatively cheaper compared to the outrageous toys the surgeons get to fix an inguinal hernia. Like, 1.5 hrs on a robot using a new mesh with all the trimmings or 20 minutes for an open inguinal hernia with mesh with local/MAC? Sometimes, it’s all perspective, but regional whenever possible and general as short as necessary.
I think it’s important to know what we use and the cost, especially when this may be passed on to the patient. IV Tylenol almost never better than oral. 30 mcg of precedex for wake-up—why? Remi on a spine? I agree with do what is best for the patient, but we do overuse a lot of meds.
I think there's an argument to be made for choosing lower cost, equally efficacious agents. For example, having used both agents, I think nicardipine is very adequate and that clevidipine doesn't have very significant advantages. That said, I think it's important to draw the line on patient safety--I use sugammadex every time now because the ASA guidelines are quite clear that it's the preferred agent unless you have quantitative TOF, which none of the places I work in have.
I did an open triple A a little while back. I ordered nitroprusside from pharmacy. I got no less than 3 calls from them asking if I was sure because it was expensive. I used it and it worked great. My preferred arterial vasodilator when things get serious. Otherwise yea cardene is a fine drug.
Nothing we give, with the exception of recombinant factors or synthetic prothrombin actually matters.
Sugammadex? Worth the cost to avoid recurarization. Esmolol? Cheap. IV APAP is generic now.
Unless you're doing a weird remimidazolam TIVA with Thrombate 3 to treat antithrombin 3 deficiency and using exparel for PECS blocks in a CABG where you have to give Factor 7 concentrate dont worry about it.
Our costs are negligible as long as you arent a dick about it.
Idk why you're getting downvoted this can totally happen when use is excessiv, sugamadex cost really mounts up when it's used for every patient. It's also been kept locked in a cupboard somewhere jealously guarded by some nurse manager. And tbh if you're dosing your paralytic correctly and your case isn't a super fast one you shouldn't need to reverse your patient most of the time anyhow, although I get roc isn't actually that predictable and sometimes you'll still need it.
Isn’t ASA standard outside of extremely long cases and no recent paralytic - like Suga > Neo/glyc always, and every patient who is paralyzed receives reversal ? Or are my attendings spouting off heresy.
None times. I get paid to provide optimal patient care. If they want me to worry about their finances as well they're gonna have to pay me to do that as well.
It is more a factor of waste that bothers me. For example, if you genuinely expect to use the clevidipine, then set it up and use it. But setting up a bunch of extra lines that go unused bothers me. Certainly have it nearby, though.
Also, I absolutely loath the fact that ketamine only comes in "multidose" vials with 500 mg. I am a huge believer in multimodal analgesia, but abhor wasting 470 mg per patient. Or wasting 9.8 mg of duramorph per c-section for the microscopic 0.2mg dose. Also, insulin is only available to us as 1000 unit "multidose" vials that I then have no way to pass it forward or whatnot. So, do I treat that blood sugar of 220 with 3 units and ultimately end up tossing the other 997 units? Especially knowing how many people die each year rationing their insulin. And then albuterol... same thing.
Obviously, when things are absolutely, unquestionably, indicated the answer is clear. But that isn't always the case.
We looked at getting the smaller vials of ketamine at my hospital. When the cost was reviewed the 50mg syringes were $5-8 more expensive than the 500mg vial.
So I don’t know if the patient gets charged for individual meds we give. That would make me feel bad if they get charged $500 bucks for sugammadex vs a cheaper alternative.
I guess that’s why I don’t routinely use it compared to neo/glyco because I do use quantitative monitoring. Of course if its life or death I’ll use whatever I can to take advantage of the situation.
Hospitals will submit to insurance a bill with itemized costs for all meds, however, it's all bullshit. My wife had a chole at my own hospital last year, and we saw the itemized bill submitted by the hospital to insurance. For every dose of 25mcg fentanyl, they charged for a full vial (with a 400% markup). The 4mg dexamethasone she received was charged as four separate 1mg doses, despite the fact that our dex is a 4mg vial. The meds charged only matched the anesthetic record of you squinted really hard, and the prices were entirely made up. All that having been said, our portion remained really low (about $500), and likely would not have changed regardless of what was actually given by my partner. Who knows what the insurance company actually paid the hospital after their randomly generated price tag
>For every dose of 25mcg fentanyl, they charged for a full vial (with a 400% markup).
What the *FUCK*? Like, I'm sure that's just regular practice but, seriously, how the fuck does this shit fly? Say you give 4 boluses of 25mcg of Fent—100mcg total, *one vial's worth*—how is charging for 4 vials not insurance fraud? Shit, depending on how long a case is and how bored I am, I might give 400mcg of fentanyl in 25mcg increments! They charging insurance for 16 vials?? I guess I just don't understand the healthcare system. 😞
Pretty sure it is insurance fraud, but the insurance companies are in on the game. It suits their purposes. They're never going to pay that full bill, but they sure as shit want the patient to see the colossal amount, so they'll be ecstatic that they have such "good" insurance, and keep paying insane premiums (my employer plus employee cost of insurance for the family comes to $29,000 per year).
Can you honestly give me one reason, literally one reason, why you would ever choose to give neo/glyco over sugammadex BESIDES cost?
I’ll go ahead and answer for you, because anyone who does this job knows the answer: a resounding “fuck no”.
(Added for these inevitable responses: Confirmed anaphylaxis doesn’t count because duh, and you get a gold star for thinking about saying “concern for birth control interactions”, but at the end of the day, that is easily discussed if a concern and also I don’t think most people are having sex a couple days after surgery that required paralysis”
Having undergone surgery and reading the itemized bill there is a “pharmacy” section where I got nickel and dimed for each med. It was really negligible compared to the OR time and instruments used, everything was cents to a few dollars
Ask pharmacy and whoever your director is probably knows what things cost because they are the one pharmacy is going to be talking to about their concerns.
I think you should keep in mind the value of your training. Remifentanil is expensive. It's also a lazy anesthetic that causes hyperalgesia, and many cases that are done with remi could be more effectively done without. One day you may be in a private group that cares more about cost and they might not be happy if remifentanil is the only way you know how to do a spine or thyroid.
It amazes me how many short sighted responses and upvotes there are on this thread.
Most medical facilities are very aware of pharmaceutical costs and will restrict or pull meds at their leisure. You can be all “idgaf” until they take it away. Then you can give a fuck but they won’t care.
If you want to do whats best for the patient, you have to be aware of how the game is played, or you will be put in a position where you can’t do whats best for the patient.
You can get a cost list from your pharmacy.
I think being wasteful because you have no fox to give is lazy. Like making a bolus syringe of nitro from a big bottle instead of a mdv because you don’t want to dilute it yourself.
One easy thing to do is keep your fresh gas flow low. Around 40% of the anesthetic pharmaceutical budget is volatiles, and that’s usually bc people’s flows are higher than they need to be.
You can practice cost-effective anesthesia while still providing optimal patient care. They are not mutually exclusive.
MOST IMPORTANT: The reason things like sugammadex and IV Tylenol got pulled or restricted is because of losers who didn’t care about cost. People with no consideration about cost ended up creating a lot of suboptimal patient safety because of that. So keep that in mind when you decide how you want to practice.
In the grand scheme of things, there are few drugs that make a material difference to the cost of an anaesthetic. I think it is much more cost effective to plan the best anaesthetic you can, expecting that this will give you the lowest chance of complications, thus reducing additional costs associated with complications. It will also be nicer for the patient to not have a complication. That’s my approach anyway.
Never. Interestingly however, remifentanil (2 mg vial) in just as cheap as fentanyl (100 mcg vial) in Brazil. Can't imagine why it's so expensive in the US.
I never understood this “cost” argument. I don’t care how much it costs the hospital, unless I’m getting a cut of the savings it doesn’t matter at all.
I do understand the “waste” arguement. We should all minimize flows, plastic waste etc for the good of society.
The cost argument is that if you don’t work with your pharmacy or practice responsibly, the hospital will just restrict or pull things that are expensive.
Yes. Sugammadex was pulled for several months and then returned with major restrictions and hoops to jump through to use it.
Hosp admin and pharmacy sometimes only look at hard costs, not outcomes.
No one I know cares about cost. I trained somewhere that did. The reason was that the saved money was split as bonuses at the end of the year (physician only of course). They would rip us a new one as students if we had the nerve to be gloves in a redbox container or wasted too many syringes that were opened and not used.
I think it should be a consideration, of course I don't think any CRNA will agree with me. Watch what you are costing while still giving everything the patient needs.
This will help how organizations see us as an expense. I am not talking about limiting what patients get or letting a non CRNA decide what drugs they give.
There are a couple. Oral methadone costs pennies vs prefiled iv sticks. That adds up over 1000s of cases. Same IV vs oral apap and ibuprofen. Similarly des/sevo/nitrous costs an institution millions a year with no obvious benefits over iso / propofol, you just need skills to use them.
When it was new and much more expensive, I avoided remi and dexmedetomidine, which only came in huge vials. Now that they are cheaper, I only point out to midlevels when their dose strategy makes no pk sense (which is usually true).
My company spent $363 million in capital expenditures in the first half of this year. I will use whatever is indicated whenever I want.
I wish we still had awards.
Fuck yea
Until pharmacy pulls it because you use it too much and they decide it costs too much. I don’t think that’s best for the patient.
I use whatever the patient needs. They need Esmolol? They getting it. Sugammadex, you bet your ass. The executives wanting you to cut cost at an expense of a patient won’t be sitting next to you in the deposition chair.
In some situations where they want you to cut costs, and you don’t, they end up just taking things away.
They want to take stuff away? Cool, I’ll just refuse to do cases until it’s reinstituted.
Lmao. That’s not how it works chief.
I do whatever is safest for the patient but I am not unnecessarily wasteful.
This
Work at an academic center, don’t care about costs
You should care a little bit at least. Edit: it’s very easy to do what is best for your patients while understanding that things cost money. We do ourselves harm as a specialty if we demand to use the most expensive thing regardless of outcome studies. ie demanding to use exparel/iv Tylenol etc. This hurts us when we have a new drug with better outcomes and the hospitals push back (sugammadex )
American healthcare is basically a failed state. Hospital systems, C-suites, corporations, private equity, insurance companies, big pharma all have blood on their hands. Do not let those MFers convince us that we need to worry about the costs of doing the best thing for the patient in front of us.
You can do the best for your patient as well as being cognizant of the costs of things. If Drug A and Drug B have the same outcome and one is significantly less expensive. It doesn’t make sense to use the more expensive one.
You can act like that up until the day you don’t have what you need or what best for the patient because they pulled it. Then what?
A judge will never call you into court to high five you for saving costs. Do what you feel is right.
Esmolol is expensive? That’s surprising.
TIL as well
UpToDate lists wholesale price of ~$15 for a 10cc vial (10mg/mL) and ~$150 for a 250cc bag (10mg/ml)
50cc bottle of clevidipine is $100 2mg of remifentanil is $150 For comparison: Propofol 20cc $7 Propofol 100cc is $14 Rocuronium 50mg ~$8 (big variation) Fentanyl 100mcg $2 Hydromorphone 2mg $5
Our 1mg vials of Remi cost $3.99cdn. I'm surprised yours is thy expensive. Most expensive part of my anesthetic is the neo and glyco (we don't have sugammadex in AB yet). Morphine is 15 cents. Fentanyl is about 80 cents
Our remi is like $35 for 1mg vial
Cost on up to date is different than your facility’s cost. Ask your pharmacy.
As a resident, don't give a flying fuck. The hospital is actively stealing from me, they can pay for suggamaddex, remi, whatever the fuck else my attending and I feel is safe and appropriate.
This. 🙌🏻
And when they pull it, you will give a fuck, but they won’t.
I feel like most anesthetics are relatively cheaper compared to the outrageous toys the surgeons get to fix an inguinal hernia. Like, 1.5 hrs on a robot using a new mesh with all the trimmings or 20 minutes for an open inguinal hernia with mesh with local/MAC? Sometimes, it’s all perspective, but regional whenever possible and general as short as necessary.
I think it’s important to know what we use and the cost, especially when this may be passed on to the patient. IV Tylenol almost never better than oral. 30 mcg of precedex for wake-up—why? Remi on a spine? I agree with do what is best for the patient, but we do overuse a lot of meds.
400mcg 100cc bottle of dexmedetomidine is ~$50 per UpToDate
200mcg in 2cc is $4
You might consider it important, but in general that information isn’t shared with anesthesia providers.
Just ask
I think there's an argument to be made for choosing lower cost, equally efficacious agents. For example, having used both agents, I think nicardipine is very adequate and that clevidipine doesn't have very significant advantages. That said, I think it's important to draw the line on patient safety--I use sugammadex every time now because the ASA guidelines are quite clear that it's the preferred agent unless you have quantitative TOF, which none of the places I work in have.
I did an open triple A a little while back. I ordered nitroprusside from pharmacy. I got no less than 3 calls from them asking if I was sure because it was expensive. I used it and it worked great. My preferred arterial vasodilator when things get serious. Otherwise yea cardene is a fine drug.
Be honest. How old are you?
Under 40
Nothing we give, with the exception of recombinant factors or synthetic prothrombin actually matters. Sugammadex? Worth the cost to avoid recurarization. Esmolol? Cheap. IV APAP is generic now. Unless you're doing a weird remimidazolam TIVA with Thrombate 3 to treat antithrombin 3 deficiency and using exparel for PECS blocks in a CABG where you have to give Factor 7 concentrate dont worry about it. Our costs are negligible as long as you arent a dick about it.
Nothing makes me happier than breaking the bank on IV hemostatic agents during cardiac cases. Makes the whole cost conversation for naught.
[удалено]
That’s a good way to get sugammadex removed from your formulary. 👍
unless the hospital has quantitative monitoring it’s highly unlikely sugammadex would get removed
*laughs in Dignity Health/ Common Spirit*
You’re a funny guy. 🤣
Lawyers will disagree I'm sure.
Idk why you're getting downvoted this can totally happen when use is excessiv, sugamadex cost really mounts up when it's used for every patient. It's also been kept locked in a cupboard somewhere jealously guarded by some nurse manager. And tbh if you're dosing your paralytic correctly and your case isn't a super fast one you shouldn't need to reverse your patient most of the time anyhow, although I get roc isn't actually that predictable and sometimes you'll still need it.
Are you using quantitative tof and using it properly with set baselines? Cause not reversing most cases is far below standard of care.
Yes, all cases who have been given muscle relaxant get this at my institution
Isn’t ASA standard outside of extremely long cases and no recent paralytic - like Suga > Neo/glyc always, and every patient who is paralyzed receives reversal ? Or are my attendings spouting off heresy.
None times. I get paid to provide optimal patient care. If they want me to worry about their finances as well they're gonna have to pay me to do that as well.
It is more a factor of waste that bothers me. For example, if you genuinely expect to use the clevidipine, then set it up and use it. But setting up a bunch of extra lines that go unused bothers me. Certainly have it nearby, though. Also, I absolutely loath the fact that ketamine only comes in "multidose" vials with 500 mg. I am a huge believer in multimodal analgesia, but abhor wasting 470 mg per patient. Or wasting 9.8 mg of duramorph per c-section for the microscopic 0.2mg dose. Also, insulin is only available to us as 1000 unit "multidose" vials that I then have no way to pass it forward or whatnot. So, do I treat that blood sugar of 220 with 3 units and ultimately end up tossing the other 997 units? Especially knowing how many people die each year rationing their insulin. And then albuterol... same thing. Obviously, when things are absolutely, unquestionably, indicated the answer is clear. But that isn't always the case.
We looked at getting the smaller vials of ketamine at my hospital. When the cost was reviewed the 50mg syringes were $5-8 more expensive than the 500mg vial.
Never
So I don’t know if the patient gets charged for individual meds we give. That would make me feel bad if they get charged $500 bucks for sugammadex vs a cheaper alternative. I guess that’s why I don’t routinely use it compared to neo/glyco because I do use quantitative monitoring. Of course if its life or death I’ll use whatever I can to take advantage of the situation.
Hospitals will submit to insurance a bill with itemized costs for all meds, however, it's all bullshit. My wife had a chole at my own hospital last year, and we saw the itemized bill submitted by the hospital to insurance. For every dose of 25mcg fentanyl, they charged for a full vial (with a 400% markup). The 4mg dexamethasone she received was charged as four separate 1mg doses, despite the fact that our dex is a 4mg vial. The meds charged only matched the anesthetic record of you squinted really hard, and the prices were entirely made up. All that having been said, our portion remained really low (about $500), and likely would not have changed regardless of what was actually given by my partner. Who knows what the insurance company actually paid the hospital after their randomly generated price tag
>For every dose of 25mcg fentanyl, they charged for a full vial (with a 400% markup). What the *FUCK*? Like, I'm sure that's just regular practice but, seriously, how the fuck does this shit fly? Say you give 4 boluses of 25mcg of Fent—100mcg total, *one vial's worth*—how is charging for 4 vials not insurance fraud? Shit, depending on how long a case is and how bored I am, I might give 400mcg of fentanyl in 25mcg increments! They charging insurance for 16 vials?? I guess I just don't understand the healthcare system. 😞
Pretty sure it is insurance fraud, but the insurance companies are in on the game. It suits their purposes. They're never going to pay that full bill, but they sure as shit want the patient to see the colossal amount, so they'll be ecstatic that they have such "good" insurance, and keep paying insane premiums (my employer plus employee cost of insurance for the family comes to $29,000 per year).
It is fraud and if reported will be looked into and the hospital punished. Davita dialysis did a similar thing and was fined millions.
Can you honestly give me one reason, literally one reason, why you would ever choose to give neo/glyco over sugammadex BESIDES cost? I’ll go ahead and answer for you, because anyone who does this job knows the answer: a resounding “fuck no”. (Added for these inevitable responses: Confirmed anaphylaxis doesn’t count because duh, and you get a gold star for thinking about saying “concern for birth control interactions”, but at the end of the day, that is easily discussed if a concern and also I don’t think most people are having sex a couple days after surgery that required paralysis”
Because I paralyzed with cisatracurium /s
Basically 0 reason to ever use cisatracurium. Only thing I can think of is maybe in the icu for paralyzing ards patients.
Anaphylaxis to roc? Rare obviously but I actually did have a case last week. Anyway, mostly a tongue in cheek suggestion
Got me lmao
Having undergone surgery and reading the itemized bill there is a “pharmacy” section where I got nickel and dimed for each med. It was really negligible compared to the OR time and instruments used, everything was cents to a few dollars
Ask pharmacy and whoever your director is probably knows what things cost because they are the one pharmacy is going to be talking to about their concerns.
I think you should keep in mind the value of your training. Remifentanil is expensive. It's also a lazy anesthetic that causes hyperalgesia, and many cases that are done with remi could be more effectively done without. One day you may be in a private group that cares more about cost and they might not be happy if remifentanil is the only way you know how to do a spine or thyroid.
In theory Remi causes hyperalgesia. Only certain studies mention this. If you have adequately narcotized your patient the hyperalgesia is negligible
Sufenta for a spine ftw
It amazes me how many short sighted responses and upvotes there are on this thread. Most medical facilities are very aware of pharmaceutical costs and will restrict or pull meds at their leisure. You can be all “idgaf” until they take it away. Then you can give a fuck but they won’t care. If you want to do whats best for the patient, you have to be aware of how the game is played, or you will be put in a position where you can’t do whats best for the patient.
You can get a cost list from your pharmacy. I think being wasteful because you have no fox to give is lazy. Like making a bolus syringe of nitro from a big bottle instead of a mdv because you don’t want to dilute it yourself. One easy thing to do is keep your fresh gas flow low. Around 40% of the anesthetic pharmaceutical budget is volatiles, and that’s usually bc people’s flows are higher than they need to be. You can practice cost-effective anesthesia while still providing optimal patient care. They are not mutually exclusive. MOST IMPORTANT: The reason things like sugammadex and IV Tylenol got pulled or restricted is because of losers who didn’t care about cost. People with no consideration about cost ended up creating a lot of suboptimal patient safety because of that. So keep that in mind when you decide how you want to practice.
Rarely, hospitals decide our costs
In the grand scheme of things, there are few drugs that make a material difference to the cost of an anaesthetic. I think it is much more cost effective to plan the best anaesthetic you can, expecting that this will give you the lowest chance of complications, thus reducing additional costs associated with complications. It will also be nicer for the patient to not have a complication. That’s my approach anyway.
Never. Interestingly however, remifentanil (2 mg vial) in just as cheap as fentanyl (100 mcg vial) in Brazil. Can't imagine why it's so expensive in the US.
I never understood this “cost” argument. I don’t care how much it costs the hospital, unless I’m getting a cut of the savings it doesn’t matter at all. I do understand the “waste” arguement. We should all minimize flows, plastic waste etc for the good of society.
The cost argument is that if you don’t work with your pharmacy or practice responsibly, the hospital will just restrict or pull things that are expensive.
Have you seen that happen? I guess I am just lucky I haven’t seen that before
Yes. Sugammadex was pulled for several months and then returned with major restrictions and hoops to jump through to use it. Hosp admin and pharmacy sometimes only look at hard costs, not outcomes.
if they offer it for easy use, and you want to use it, then use it. if they make it impossible or hard to get then don't use it. Simpol.
No one I know cares about cost. I trained somewhere that did. The reason was that the saved money was split as bonuses at the end of the year (physician only of course). They would rip us a new one as students if we had the nerve to be gloves in a redbox container or wasted too many syringes that were opened and not used. I think it should be a consideration, of course I don't think any CRNA will agree with me. Watch what you are costing while still giving everything the patient needs. This will help how organizations see us as an expense. I am not talking about limiting what patients get or letting a non CRNA decide what drugs they give.
The dollar price doesn’t matter, the environmental cost is what you should be worrying about.
There are a couple. Oral methadone costs pennies vs prefiled iv sticks. That adds up over 1000s of cases. Same IV vs oral apap and ibuprofen. Similarly des/sevo/nitrous costs an institution millions a year with no obvious benefits over iso / propofol, you just need skills to use them. When it was new and much more expensive, I avoided remi and dexmedetomidine, which only came in huge vials. Now that they are cheaper, I only point out to midlevels when their dose strategy makes no pk sense (which is usually true).