Atropine and ephedrine: a significant waste in the operating theatre

Atropine and ephedrine are often given during anaesthesia. The time to prepare the drugs in a syringe can delay treatment; in France, our standard practice is therefore to prepare the drugs before induction of anaesthesia. However, pre-filled syringes may eliminate dilution error and lead to cost savings due to the elimination of waste [1]. This topic has not been widely examined [2, 3], so we conducted a retrospective audit (November 2008 to October 2009) in a university teaching hospital, to determine the number of patients given atropine and ephedrine. Data were extracted from our anaesthesia software database (Fusion Pegase 3.7.1, Thélème, Angers Technopole, Angers, France). The number of ampoules administered was compared with that registered by the hospital pharmacy for each surgical unit. We analysed 27 705 operations (54% ASA 3-4, 3% under spinal anaesthesia, 16% under 15 years of age). Ephedrine had been administered to 30% of the patients (Table 2); of these 4% received central neuraxial blocks (mainly for caesarean sections and urology operations), 0.7% peripheral nerve blocks, and 95% general anaesthetics. A total of 144 127 mg ephedrine had been injected. In 91% of cases requiring ephedrine, a single ampoule had been used. The rate of wastage differed between units with extremes of 39% and 67%. Only 7% of the patients received atropine (Table 2). The rate of atropine wastage varied between 69% and 91%. We calculated the unit cost of preparing a syringe of ephedrine (£0.83) or atropine (£0.36) from the cost of ephedrine (£0.71 for a 30-mg, 10-ml ampoule) and atropine (£0.26 for two 0.5-mg, 1-ml ampoules) and the consumables (£0.06 for a 10-ml syringe, £0.04 for a 5-ml syringe, £0.01 for a hypodermic needle, £0.03 for a packet of sterile gauzes to disinfect ampoules and injection site on the infusion line and £0.02 for a printed label). The costs of nursing time and water-alcoholic solutions for hand hygiene were not taken into account. If a patient required the injection of several ampoules of ephedrine, we assumed that the syringe and needle were re-used. We calculated the cost of treatment with ephedrine requiring two, three, or four ampoules as £1.54, £2.25 and £2.96 respectively. The cost for systematic preparation of ephedrine and atropine during the study period was £14 216 and £4707, respectively. On the basis of the number of patients who required administration of drugs and the number of ampoules required for each case, the cost of preparation on demand can be calculated to be £ 7413 for ephedrine and £757 for atropine. Systematic preparation where unused drugs were discarded after each case thus wasted £6803 for ephedrine and £3950 for atropine over the study period. On the basis of the actual annual consumption of 9267 ampoules of ephedrine and 4164 (corresponding to 2082 treated patients) ampoules of atropine, a unit price of £1.53 for prefilled syringes of ephedrine and £2.26 for atropine would result in no extra cost compared to a strategy of systematic preparation. In conclusion, systematic preparation of atropine and ephedrine is rarely justified. In a large organisation, quantification of waste can determine the budget to be allocated for the use of prefilled syringes without overspending.