The findings of the present randomised trial determined that the use of BIS and TOF monitoring have the potential to hasten postoperative recovery, and it can also decrease the total cost of anaesthesia drugs.  

Inadequate depth of anaesthesia is associated with significant morbidity. The risk of complications and cost of anaesthesia can increase with a rise in the required depth of anaesthesia. It can also lead to prolonged recovery time and increased health-care costs.  Inadequately light anaesthesia can maximize the risk of intraoperative awareness, whereas incomplete reversal of neuromuscular blockade results in residual neuromuscular weakness with undesirable consequences. Various monitoring techniques can be helpful in reducing complications of anaesthesia in the perioperative period. Only a few studies published on simultaneous monitoring of depth of anaesthesia with bispectral index (BIS) and neuromuscular blockade with train-of-four (TOF). The cost of these monitoring techniques influence the treatment methods, and it is vital to managing the costs of these techniques to reach maximal gains. The cost of a particular activity, treatment, working process constitutes fixed and variable parts.  There must be a balance between the values of various agents, pharmacodynamic advantages of anaesthetics (e.g. sevoflurane, propofol), perioperative complications, and patient monitoring techniques. Numerous studies have evaluated the cost-effectiveness of anaesthetic measures, but there is a lack of evidence that can depict the profitability of BIS and TOF  monitoring associated with anaesthesia.

Rationale behind research

• Previous research has focused only on the cost of maintaining anaesthesia and others additional costs, but there are just a few studies that have investigated simultaneous monitoring of depth of anaesthesia with bispectral index (BIS) and neuromuscular blockade with train-of-four (TOF). So, the present study was aimed to determine the cost-effectiveness of BIS and TOF monitoring associated with anaesthesia.  

Objective

The study aimed to compare drug dosage and total cost (direct plus additional fees) of anaesthesia maintained with sevoflurane or propofol with or without the combination of BIS and TOF monitoring, respectively. 

Study outcomes 

• Baseline: Patient demographic characteristics were studied at baseline
• Primary issues: The primary outcome studied was the total cost of anaesthesia
  
• Secondary outcomes: The secondary outcome studied was time spent in theatre and recovery room

·         Time Points: NA

Outcomes

Baseline: There were no significant differences observed at baseline

Study outcomes:

• There was a greater difference in the total cost of anesthesia per hour in group SEVO+ compared to SEVO [€ 19.95(8.53) vs. 12.15(5. 32), p < 0.001], and in group PROP+ compared to PROP (€ 22.11(8.08) vs. 13.23(4.23), p < 0.001] (Fig 2)

• The time of extubation was shorter in group SEVO+ compared to SEVO [11.1(4.7) vs. 14.5(3.9) min, p = 0.002], and in PROP+ compared to PROP [12.6(5.4) vs. 15.2(4.7) min, p < 0.001] (Fig 3)

• Arterial blood pressure returned to its initial values only in groups SEVO+ and PROP+, postoperatively

The results of the study indicated a lower drug cost of sevoflurane and propofol anaesthesia with BIS and TOF as compared to sevoflurane and propofol anaesthesia without BIS and TOF monitoring. The total cost of anaesthesia drug was reduced with BIS monitoring, but there was a rise in the total cost of anaesthesia. There was no effect of TOF monitoring observed the value of atracurium during anaesthesia. The lower price of propofol as induction agents on BIS monitoring depicts that depth of anaesthesia can cause a reduction of dose during the induction of anaesthesia. The lower hourly cost of fentanyl during anaesthesia in groups SEVO and SEVO+ compared to PROP, and PROP+ was due to the analgesic effect of sevoflurane rather than the use of depth of anaesthesia monitoring. It can be explained by the similar patient (e.g. age, body weight) and operational characteristics (the type of surgery, time of surgery and anaesthesia) in all groups. Besides, the cost associated with propofol anaesthesia with BIS monitoring was higher as compared to Sevoflurane anaesthesia without BIS monitoring (group SEVO).  The reason behind this was the higher cost of intravenous technique and the disposable BIS sensor. These results were not contradictory to previous studies, and this may occur due to the small number of recruited patients. The time of extubation become shorter when BIS and TOF monitoring was employed. The time to MAP restoration was independent of BIS monitoring. In summary, it was concluded that anaesthesia guided by BIS and TOF provides faster postoperative recovery with lower drug cost and higher disposable costs.