hi my name is max feinstein and i'm an anesthesia resident at the mount sinai hospital in new york
city in this video i'm going to be showing you all of the medications that i use for
two spinal surgeries and keeping track of exactly how much all of it costs
if you find this video interesting or helpful i'd really appreciate it
if you liked it and subscribed to the channel. let's dive in
one of the things that, as a resident, i'm encouraged to think about as i'm learning
anesthesiology, is exactly how much money i'm spending as i provide my anesthetic. and so
today i'm taking care of two different patients who are both getting almost exactly the same type
of spine surgery and so i'm trying a couple of different types of anesthetic techniques, and
in addition to comparing how the patients do and how well their pain is controlled after surgery,
i thought it would also be really interesting to compare how much money i'm spending in terms
of the medications that i use for both of these surgeries. this is pretty much an opportunity to
do a back-to-back comparison of cost. get it? back-to-back spine surgery... yeah...
i'm just about to start preparing the operating room for the day and what i'm going to do is
highlight each one of the medications that i'm drawing up for this case and then i'll actually
save all of the empty medication vials and bags that i use during the cases and tally them up
afterwards and come up with a cost for each one of these anesthetics let's go ahead and get started
i'm going through my MS-MAIDS mnemonic right now and if you want to see a full video on
that you can check that out right here. and now i'm at the drugs part of the mnemonic and
so the first thing i'm going to do is wash my hands, and i put on a pair of gloves,
and now i'm going to go ahead and get out all of the syringes that i'm going to use
and i'll label them before i draw anything up, and i do that for safety
one of the things that helps me conceptualize the induction medications
is to just think about the order in which i'm going to be administering everything.
so starting from the time that we roll into the operating room get the patient connected to
monitors and then start administering medications, the first thing is going to be midazolam
and then once i start pre-oxygenating the patient
i'll go ahead and administer a little bit of fentanyl
next will be 2% lidocaine to help reduce the amount of stinging when the propofol is injected.
next and we actually have lidocaine that's in pre-drawn syringes now
next up is propofol and for induction i'll be using this 20cc vial
only after general anesthesia has been induced i will go ahead and administer
a depolarizing paralytic: succinylcholine. and the reason that i'm not going to plan on keeping the
patient paralyzed throughout the duration of the case is because there will be neural monitoring
to assess for any sort of changes in somatosensory evoked potentials or motor evoked potentials, so i
can't have the patient paralyzed for that however i will need the patient paralyzed in order to have
ideal intubating conditions and so i'll do that with the short acting paralytic succinylcholine
having said that i will plan on having a small dose of non-depolarizing, slightly longer acting,
paralytic rocuronium which can facilitate exposure as the surgeon gets to the exact operative area. i
don't plan on this dose lasting for very long so i'll just draw up a small amount of rocuronium.
as part of pain control for this case i'm actually going to be using a medication called methadone
which you might traditionally think of being used for outpatient management of substance abuse.
but it can actually be a really helpful medication for managing painful surgeries
and i get it directly from the pharmacy in a vial that looks just like this. you can check out a
link in the description below for an excellent review article highlighting the ways in which
a relatively low dose of methadone is safe and effective for analgesia for a lot of different
types of surgery. the last medication that i use as part of my induction plan is dexamethasone
which is actually just for anti-emesis and is most effective when given at the beginning of the case
now that i've drawn up all of the medications that i'll use for induction of anesthesia i'm
going to plan on keeping track of everything that i use for maintenance and emergence
so that at the end of the day we can sit down and tally up the cost of all of these medications.
now i'm going to finish setting up the room, i'll go meet the patient,
and we'll get the case started. and to protect patient privacy of course
i'm going to be turning off the camera so i'll catch up with you a little bit later
alright i'm just sitting down for a lunch break now with some really gourmet looking french fries
and lentil soup. and this doesn't contribute anything substantive to a video about medication
costs but it's really just more of a public service announcement regarding anesthesiology and
the fact that we prioritize normal human behavior like eating lunch in the middle of the day. and
i'll point out that anesthesiology is one of the few specialties that goes out of their way to
make sure that we actually get to eat throughout the course of the day. cheers to anesthesiology!
the first surgery has now ended and here's everything i used for maintenance which includes
three 100cc bottles of propofol, three 2cc vials of fentanyl,
one bag of 1000 milligrams of tranexamic acid, four grams of the antibiotic cefazolin,
and four milligrams of ondansetron, also known as zofran. now i've got a very short period of
time to get everything set up for the next case, and these are the induction medications that
we'll use for the second case. and i did find myself with a little bit of extra time to play
with this super fancy microscope. well that was fun. let's go ahead and start the second surgery.
i will just say that no matter how much i love my job, which i really do i think anesthesiology
is wonderful, it is difficult to be inside a windowless room when it's so beautiful outside.
but on the bright side i did get a new pair of shoes recently which i think are really awesome
anyways the afternoon break is over time to get back to the OR
as you can see i've got all the empty vials from the case so we'll go ahead and count them
right now. and also as you can see i've got more facial hair than the last time that i pulled out
my phone because this has been quite a long case, it's pretty late in the evening right now so this
will actually end up being a pretty substantial tally of medications reflecting just how long and
complex the case was that we just finished. ta-da! just about everything from the case except for
a couple bags of isolyte that left with the patient for PACU [post-anesthesia care unit]. okay
ready to tally the maintenance and emergence from the case: so maintenance included one,
two, three, four P100s, as we say, which would be 100cc vials of propofol.
additionally three P20s, or 20cc vials of propofol.
another component of the maintenance anesthetic for this case was remifentanyl which comes in
one milligram vials that look just like this. and get ready to tally: we had one, two, three, four,
five, six, seven milligrams of remifentanyl. oh missed one-- this is eight. also part of
the maintenance, so to speak, were doses of tranexamic acid-- we have two doses.
and there were also two doses of cefzol [cefazolin]. each dose was two grams
and i also ended up giving three liters of isolyte, but
two of those three ended up going with the patient to PACU, and then as the case was
coming to a close, because remifentanyl is such a short-acting opioid, i gave a longer-acting opioid
to help with post-operative pain management, which is hydromorphone, also known as dilaudid.
then the last medication that i gave on the way out was ondansetron, also known as zofran,
which is an anti-emetic that's best given approximately a half hour before emergence
from anesthesia. and that is everything i gave for a long and pretty complex spine surgery, but i'm
happy to say the patient is awake, comfortable and sipping on some water in the recovery room
test test test test
so even though it's late right now i'm actually on overnight call and we don't have any cases going
so i'm going to use this opportunity to actually go ahead and go through the prices for everything
that i've used today for the two spine surgeries that i just provided anesthesia for. before we
start i do just want to point out that the prices i'm referencing are not actually from mount sinai
hospital but rather from UpToDate. and these prices are what are called the "average wholesale
price" which are to be used just for reference for approximately how much these medications may cost.
so keep in mind that the prices that we use here at mount sinai or that you may use at
your hospital may differ from what's listed on UpToDate. so to start with the first case,
and beginning with the induction medications, we had one vial of midazolam which is a 2cc vial,
at a cost of $1.80. next is fentanyl, and we used two vials that are each 2ccs,
and those cost $2.02 per each vial, so this is a total of $4.04 of fentanyl
next is lidocaine. we used one syringe, and a syringe according to UpToDate is $2.50. next is a
20cc vial of propofol, also affectionately referred to as a p20, that costs approximately
$6.20. next up was one vial of the paralytic agent succinylcholine which costs approximately $24.00.
next i drew up one vial of rocuronium that was 5ccs which cost approximately $11.40.
i will say that the surgeon elected not to have rocuronium administered to assist with the
exposure for this case so this actually ended up not being used
and this next medication isn't really an induction medication per se
but is typically given at the beginning of cases which is dexamethasone,
and i used two vials that were 1cc each for a total cost of $8.16
okay now for the maintenance and emergence medications used in the rest of the case.
we used p100s which are the 100cc vials of propofol, and we used three of those
at a cost of $30 each so that's $90 worth of propofol for maintenance.
we also used at the very beginning of this case methadone for long-acting pain control. and a 1cc
syringe, or 10 milligrams, of methadone was $22. we also used
three additional vials of fentanyl that were 2ccs each for an additional cost of $6.06
other medications that were given throughout the course of the case included tranexamic
acid, and we gave one bag which cost $4.57. and then we gave four grams of
cefazolin throughout the course of the case, with each gram costing $3.28 for a total of
$13.12 of cefazolin. and then to help prevent postoperative nausea and vomiting at the end of
the case i administered a 2cc, or 4 milligram dose, of ondansetron, also known as zofran,
which costs approximately $1.62. this brings our total anesthetic cost for this case to $215.47
okay for the second case that i did today we actually started with exactly the same
induction strategy except i did not draw up any rocuronium so we can copy and paste all of the
induction medications and those costs. and then moving along to the maintenance of anesthesia:
this case was actually quite a bit longer, and for reasons that pertain to the patient,
there was actually quite a bit more medication administered per hour as compared to the first
case. so going through this piece by piece: for the maintenance of the second case i used
three p20s for a total cost of $18.62. and then i used four p100s for a total cost of
$120. and then i also used for this case a medication called remifentanyl which is a
very short-acting, potent opioid that is particularly useful for certain types of
surgeries including certain types of spine cases. remifentanyl can be a very expensive medication,
but it also might not be depending on the billing circumstances of the hospital. but just going by
what's on UpToDate, a one milligram vial of remifentanyl costs $73.55, and for this case
i used eight of them and so at that price it would be $588.40 worth of remifentanyl
the other medications that were administered throughout the course of the case include isolyte,
and i used two 1-liter bags for a cost of $20. and then i also administered four grams of cefazolin
for a total cost of$13.12. and then an additional two bags of tranexamic acid for a total cost
of $9.14. and then at the end of the case i wanted to provide a longer acting analgesic so
i administered one milligram of hydromorphone for a cost of $3.58 as well as one vial of
ondansetron which was $1.62. this brings the (theoretical) total cost of this case to $821.16
overall the amount of money that i theoretically spent to provide anesthesia
for approximately fourteen hours worth of spine surgery was $1,036.63
when talking about medications and different ones that can be used to provide anesthesia
it's really important to consider that a lot of different anesthetic plans can
often be used to accomplish the same purpose, which is keeping the patient safe
and comfortable during and after surgery. when you're a junior resident just getting started,
your attending anesthesiologist will probably pick out several different strategies for providing
anesthesia for similar types of surgeries which can be very eye opening in terms of seeing how
many different ways you can provide anesthesia. and then as you progress through residency and
you gain knowledge of all the different types of medications that can be used,
you can actually propose your own anesthetic plans. and as long as your attending deems those
to be safe, then you can try those out during residency, so by the time you graduate residency
you'll have a very good understanding of the broad range of pharmacologic agents that are available
to us to safely get patients through surgery and have them be comfortable once they're all done. if
you liked this video, you might also want to check out this video where dr erica fagelman
narrates all of the different medications that are kept inside the anesthesia cart
inside the operating room. thanks very much for watching! i'll see you next time