Anaesthetic drug wastage in the operating rooms of a tertiary cancer centre: ‘Sustainable anaesthesia, need of the hour’

INTRODUCTION The operating room (OR) of a tertiary oncological hospital is a complex and highly dynamic environment, characterised by high volumes of long-duration oncological surgeries associated with considerable fluid shifts, with potential for haemodynamic instability and major blood loss. An anaesthesiologist should be prepared to respond immediately to unpredictable physiological changes during the intra-operative period, thus requiring the prior preparation of routine anaesthetic drugs and emergency interventions to prevent catastrophic situations.[1,2] Although preloading drugs before oncosurgeries improves efficiency and ensures patient safety, it may lead to significant drug wastage, particularly when anticipated medications are not used.[2,3] Drug wastage imposes a financial burden on healthcare institutions and contributes to environmental pollution.[3] Therefore, minimising drug wastage is crucial for cost containment and optimal resource utilisation in developing countries.[4,5] Anaesthetic drugs have significant environmental effects. Propofol persists in the environment and requires high-temperature incineration for proper disposal. Other agents, including opioids, antibiotics, and local anaesthetics, have toxic effects on the ecosystem.[6,7] Anaesthesiologists are often unaware of the economic and environmental consequences associated with drug wastage.[7,8] Institutional audits are therefore essential to quantify drug wastage, evaluate cost implications, and identify opportunities for sustainable practice. This study was conducted to estimate the extent of anaesthetic drug wastage, determine the associated economic loss, and suggest strategies to minimise wastage without compromising patient safety. METHODS This prospective observational study was conducted over an 8-month period in the ORs of a tertiary cancer centre after institutional ethics committee approval. A waiver of informed consent was granted because no patient contact or intervention was involved. All adult patients (>18 years) undergoing elective surgeries under general anaesthesia were included. Surgeries performed under regional or local anaesthesia, emergency surgeries, or cases with adverse intra-operative events were excluded. The details of drugs loaded, administered, and left unused were recorded for each case. Data collection was performed by independent anaesthesiologists not involved in the case in order to minimise bias. The total medication dosage for each patient was recorded from the patient’s case record form and from electronic medical records at the end of each case, and verified by the research nurse. The drug wastage included unused or partially used quantities remaining in syringes, ampoules, or vials, drugs prepared but not administered, and ampoules or vials broken during preparation. Inhalational agents were excluded as they could be reused. The cost estimation was done by multiplying the unit price of each drug with the amount of unused drug. The total drug wastage cost and per-case wastage were calculated. The data were analysed using descriptive statistics and presented as mean ± standard deviation (SD) or median with interquartile range (IQR). The waste proportion was calculated for each drug. All cases during the study period were included for analysis {number of patients (n) =1000}. RESULTS A total of 1000 consecutive patients were included. The median surgery duration was 317.50 (230–480) min. General anaesthesia alone was the most commonly used anaesthetic technique (75.30%), followed by general anaesthesia with epidural analgesia (18.60%) and with regional blocks (6.10%). Head and neck surgeries (30.20%) and gastrointestinal surgeries (28.10%) constituted the largest proportion of procedures [Table 1].Table 1: Anaesthetic technique and surgical characteristics (n=1000)Anaesthetic drug wastage is detailed in Table 2. A considerable variability in wastage was observed across different drug classes. Among anticholinergics, atropine demonstrated the highest percentage wastage (93.10% 95% confidence interval [CI]: 91.36–94.82%). Propofol, atracurium, cisatracurium, and mephentermine contributed substantially to the total wastage cost. Mephentermine accounted for the largest share of total wastage cost (37.18%, 95% CI 34.15–40.24%), followed by atracurium (15.0%, 95% CI 12.36–18.07%) and propofol (13.20%, 95% CI 11.24–15.43%). The mean wastage cost per case showed the highest wastage for rocuronium, etomidate, dexmedetomidine, and cisatracurium.Table 2: Anaesthetic drug wastageDISCUSSION This prospective, observational study found substantial anaesthetic drug wastage in the ORs of a tertiary cancer hospital, resulting in significant financial losses. Oncosurgeries are prone to increased drug wastage owing to prolonged operative duration, major fluid shifts, and need for immediate access to emergency drugs during critical intra-operative phases. These workflow requirements in high-risk, long-duration oncologic procedures may therefore contribute to wastage rates exceeding those reported in shorter, lower-risk general surgical cases. The drugs with the highest percentage wastage by volume were atropine (93.10%), mephentermine (68.89%), dexmedetomidine (38.88%), and morphine (31.51%). The highest contributors to cost wastage included mephentermine (37.18%, 95% CI 34.15–40.24), atracurium (15.04%), propofol (13.24%), and cisatracurium (9.47%). The total cost of drugs prepared was 311291.26 Indian rupees (INR), of which INR 76662.23 (24.63%) was wasted. When extrapolated to the whole year, this represented an estimated annual financial loss of approximately INR 1.1–1.2 lakhs. The economic burden associated with anaesthetic drug wastage should be interpreted cautiously as our hospital is a public-sector institution where drugs are procured at highly subsidised rates, potentially underestimating the actual wastage cost. Their high wastage, particularly mephentermine (68.89%), contributed significantly to cost burden which may be due to the routine practice of prior loading of emergency drugs to allow immediate intervention during perioperative significant bradycardia and hypotension. Atropine wastage in our study (93.10%) was comparable to previously reported rates of 67–100%.[4] This suggested that high wastage of emergency drugs is a systemic issue related to safety-driven preparation practices rather than solely institutional factors. Hence, strategies should focus on context-specific drug utilisation and safe reuse across consecutive cases by maintaining sterile emergency trays with unused drugs.[4] Propofol accounted for 21.74% of the volume waste and significantly contributed to cost loss. This may primarily be due to infection control and safety regulations requiring disposal within a limited time after opening vials. The use of smaller vials and patient-specific dosing can be effective waste-reducing strategies.[4,9] Neuromuscular blocking agents wastage could be due to prolonged oncological procedures and variations in intra-operative dosing requirements. Hence, the usage of multi-dose vials may limit wastage.[2] Dexmedetomidine wastage (38.88%) was frequently associated with early discontinuation occurring secondary to significant bradycardia or hypotension in the intra-operative period. Using smaller vial sizes or patient-specific dilute preparations could reduce the volume of discarded drug.[4] Although opioids such as morphine showed a high percentage of wastage (31.51%), the total economic impact was limited due to lower unit costs. Strict monitoring of opioid prescription, preparation, dispensing, and evaluation of opioid wastage is important because inappropriate handling of unused opioids carries a potential risk of misuse, especially in high-turnover ORs in a tertiary cancer hospital. A rational opioid preparation policy, secured management of unused drugs, and appropriate disposal protocols are important strategies to reduce wastage and prevent opioid misuse.[10] In a developing country such as India, the environmental consequences of anaesthetic drug wastage should be considered.[4,5] Drugs such as propofol, opioids, and antibiotics can persist in the environment, bioaccumulate, and can adversely affect ecosystems.[11,12] Various measures for reducing drug waste include the implementation of institutional standardised drug preparation protocols, patient-specific drug dosing, and avoiding ‘just in case’ drug preparation. The use of prefilled syringes for emergency drugs can significantly reduce preparation time and reduce waste. Maintenance of sterile emergency trays for sequential cases to safely reuse unopened emergency drugs and usage of smaller volume vials or ampoules for drugs prone for wastage may be cost-effective. Multi-dose vial utilisation may reduce wastage but must be balanced against infection control guidelines, drug stability, labelling practices, and institutional policies. Periodic staff sensitisation and education through training and audits will increase cost awareness, promote hospital wide sustainability policies, and help understand the financial and environmental consequences of wastage. Our study will help provide baseline data that can be used to initiate future quality-improvement projects aimed at sustainable anaesthesia practices in ORs in a cancer hospital. Our study has some limitations as it was a single-centre design that may not reflect drug wastage in other institutions, and there was a lack of inter-OR comparisons. CONCLUSION Anaesthetic drug wastage in the ORs of a tertiary cancer centre is significant and results in substantial financial loss and environmental burden. Sustainable anaesthesia is the need of the hour. Although some drug wastage is unavoidable to ensure patient safety, strategies to limit it can reduce unnecessary disposal. This is important as drug wastage reduction not only decreases financial strain on hospitals but also contributes to the broader goal of environmentally responsible healthcare in developing countries. Study data availability The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The authors declare that no artificial intelligence (AI)-assisted technologies were used in the preparation of this manuscript. Author Contributions MJ: Concept and design of study. RM: Data collection, analysis and initial draft. AK (He has sadly passed away): Reviewed initial draft. SB: Concept and design of study and critical revision of draft. All authors except AK reviewed the final version of the manuscript. Financial support and sponsorship Nil. Conflicts of interest The authors declare that there are no conflicts of interest.