Reducing anaesthetic drug wastage in hospitals is crucial for improving operating room efficiency and controlling costs, particularly in developing countries where resources are limited, say local researchers, who suggest that implementing cost-effective strategies could help reduce this wastage without compromising patient care.
The study team – P Majara and G Leballo from the Department of Anaesthesiology at the University of the Witwatersrand – undertook an observational study on wastage of commonly administered anaesthetic drugs, and to evaluate preventable and routine wastage and its cost, in the operating theatre at Chris Hani Baragwanath Academic Hospital.
In the SA Medical Journal, they write that previous studies have highlighted that large-scale wastage of anaesthetic drugs negatively impacts financial efficiency, and that routine wastage, often due to larger-than-required ampoules, is prevalent, especially in paediatric and neonatal cases where smaller doses are needed.
This issue is compounded by practices like the sharing of vials, which raises infection control concerns and goes against established guidelines.
Addressing anaesthetic drug wastage through thoughtful procurement, dosing and utilisation strategies can contribute significantly to both cost savings and enhanced patient safety, they say.
Lack of audits
In 2017, 10%-15% of the total healthcare cost in South Africa was attributed to the use of pharmaceutical agents.
Previous investigators have demonstrated adrenaline, atropine, succinylcholine, phenylephrine and propofol as the most commonly wasted intravenous anaesthetic agents, as they are often drawn up in anticipation of intraoperative emergencies. A 2013 study from Nigeria reported a wastage of more than 50% of intravenous anaesthetic agents, including propofol and 0.5% bupivacaine, over a three-month period.
In resource-limited developing countries with ongoing drug shortages, minimising pharmaceutical waste is essential, and can help optimise resource allocation and ensure the efficacy of available medications.
The authors said the absence of systematic audits in South Africa underscores the need for investigations aimed at identifying cost-reduction strategies through optimising anaesthetic practices, while maintaining safe and effective patient management.
The focus of this study was on intravenous and intrathecal drug administrations in theatre settings, aiming to educate and raise awareness among anaesthesia providers, while proposing future cost-saving measures that do not compromise patient safety.
Method used
Data of participants presenting for elective and emergency surgery at the JD-Allen Theatre Complex and the Neonatal and Maternity Theatres were collected over a two-week period between 11 and 22 July 2022. One researcher collected all data across the different theatres, following every theatre case in the time period.
Data comprised all adult and paediatric participants who presented for surgery, and included those who received anaesthesia as either general, regional or sedation. Data on drug wastage were collected after every case. Drug preparations and administration were decided by the anaesthesiologist conducting the case (not involved in the study).
Participant data were excluded when drug syringes were unlabelled or already discarded in the biohazardous sharps containers, or for participants who presented to remote site areas (gastroscope, magnetic resonance imaging, endovascular suites, etc.) for intervention procedures requiring anaesthesia care.
The amount of drug remaining in syringes and in opened ampoules was considered as wasted.
In this study, routine drug wastage was considered as the amount of drug remaining after a required dose was administered to the patient, while preventable drug wastage referred to drugs drawn up for anaesthesia purposes but not utilised during the surgical case and therefore discarded.
A data collection sheet was utilised to collect information that was captured electronically on to the Research Electronic Data Capture (REDCap) system. The cost of each drug was worked out according to CHBAH’s pharmacy acquisition cost per millilitre or milligram (mL or mg) of that drug.
High rates
At Chris Hani Baragwanath, propofol, fentanyl and paracetamol are the most commonly used anaesthetic drugs. Fentanyl, an opioid, is primarily used for induction, pain management and sedation; propofol is the standard agent for induction and maintenance; and intravenous paracetamol is employed as part of a multimodal approach for intra- and postoperative pain management.
Intravenous paracetamol is available as a standard 1g vial at this institution. In paediatric patients and neonates, where dosing is 15-20 mg/kg, this often leads to significant drug wastage. However, it was observed that some clinicians practise ‘sharing’ a 1g vial among multiple paediatric patients in an attempt to minimise wastage. This practice, however, contradicts the SA Society of Anaesthesia guidelines, as well as recommendations from the US Centres for Disease Control and Prevention and the World Health Organisation, which advise against sharing single-use vials.
Propofol was available in 20 mL and 50 mL ampoules with a 1% concentration, with 50 mL ampoules reserved for total intravenous anaesthesia. The majority of waste is routine, as patients typically do not require the full 20 mL ampoule.
This is particularly relevant in paediatric and neonatal surgical cases, where much smaller amounts of propofol are required for both the induction and maintenance of anaesthesia. This finding is consistent with other studies, such as one by Mankes, where propofol was among the most commonly wasted drugs, with an average of 69.86 mg wasted per case, accounting for 45% of the total wastage.
Some studies have suggested that smaller ampoules, such as 10 mL vials of 1% propofol, should be made available, particularly for paediatric cases and smaller adult patient populations. Using smaller vials in these patients could help to reduce the routine drug wastage of propofol.
To date, no audits have compared drug wastage in healthcare institutions by evaluating smaller volume drug vials v. standard vials, owing to the unavailability of smaller vials
In this study, P Majara and G Leballo found the percentage of routine drug wastage was more than 2.5 times that of preventable wastage. Although preventable drug wastage was significantly lower than routine drug wastage (8.4% v. 21.3%), emergency anaesthetic drugs, including adrenaline (94.4%), atropine (85.7%) and suxamethonium chloride (36.2%), exhibited considerably higher percentages of preventable wastage than routine.
The four surgical categories with the highest routine drug wastage percentages were neurosurgery (55%), obstetrics (51.86%), gynaecology (44.86%) and paediatric surgery (42.46%), despite neurosurgical cases accounting for only 0.3% of the total observations.
Preventable drug wastage was highest in neonatal surgical cases, accounting for 33.33%.
Procedures
Data points of 373 patients who presented for surgery were collected. Most cases were elective at a frequency of 58% (n=216), while 42% of cases were emergencies. Obstetric and orthopaedic cases (97 and 61 cases, respectively) were the most commonly performed procedures.
Acute care surgical cases encompass surgical emergencies excluding trauma-related surgeries. These cases include emergency laparotomies for acute abdominal pathologies (e.g. appendectomies, perforated hollow viscera), incision and drainage of abscesses, and other septic surgical conditions.
General anaesthesia was more frequently performed (n=190; 51%) than regional anaesthesia (n=165; 44%) and the sedation technique (n=18; 4.8%). Spinal anaesthesia (n=185) was the most frequently performed regional anaesthetic technique.
Caesarean sections (obstetrics procedures: 26%) and lower-limb orthopaedic procedures are regularly performed under spinal anaesthesia in this institution.
A total of 1 864 drug preparations, which represent the total number of ampoules of anaesthetic drugs used during the study period, were prepared and administered to 373 participants. Some participants received up to 12 different drug preparations per surgical procedure.
Discussion
The authors said distinguishing between routine and preventable drug wastage is essential for accurately quantifying the potential waste of pharmacological agents in theatre settings. In this audit, overall wastage was higher for routine drug wastage (21.3%) than preventable drug wastage (8.4%). This difference can be attributed to the fixed dosages per ampoule of various pharmacological agents, which are often supplied in volumes exceeding the required amount.
As a result, excess drug amounts that are not administered to the patient contribute to routine drug wastage.
This is particularly relevant in paediatric anaesthetic cases, where smaller drug volumes are required, which are often further diluted to administer a calculated dose, leading to potential wastage.
Adrenaline, suxamethonium chloride and atropine were among the individual drugs with the highest levels of preventable drug wastage. Suxamethonium chloride, a muscle relaxant, is crucial in emergency situations where the risk of aspiration is elevated, and during preparations for difficult airway management. It is also routinely drawn up as an emergency drug for the treatment of anticipated laryngospasms, particularly in paediatric cases.
Chaudhary et al observed that suxamethonium chloride wastage accounted for 92.63% of the total drug wastage in their study. It is possible to prevent the wastage of this muscle relaxant without compromising patient safety.
It has been suggested that placing an unopened ampoule at the anaesthetic station, along with a prefilled syringe of saline, could potentially reduce suxamethonium wastage.
The 0.5% bupivacaine-hydrochloride with dextrose had one of the lowest preventable drug wastages. It is produced as a 4 mL volume vial of a 5 mg/mL concentration, and is commonly used in obstetric cases for C-sections performed under spinal anaesthesia.
In SA hospitals, dosing is guided by the Essential Steps in the Management of Obstetric Emergencies (ESMOE) guidelines, which recommend using 1.8 mL of 0.5% bupivacaine hydrochloride with dextrose.
This results in routine wastage of 2.2 mL per obstetric case, and owing to infectious disease protocols, the ampoules are not shared – another example where the availability of smaller volume ampoules could reduce both routine and preventable drug wastage.
The average cost per case of routine drug wastage was R3.85, while preventable drug wastage was R1.32. A total of 373 cases were included in this cohort, resulting in a total cost of R1 436.05 for routine wastage and R492.36 for preventable wastage during the study period.
The estimated annual costs of routine and preventable drug wastage at this institution are R11 816.64 and R34 465.20, respectively.
The amount might seem low, but when bearing in mind the number of cases per year, this amounts to a significant fraction of total healthcare expenditure.
The primary finding of a 2024 systematic review was that significant wastage of anaesthetic drugs is linked to decreased financial efficiency in healthcare institutions. This was further supported by a review that demonstrated that the cost-effective utilisation of surgical supplies and anaesthetic agents reduces expenses while maintaining high-quality patient care.
Adopting these practices is essential, particularly in developing countries.
Study details
Evaluation of wastage of commonly used anaesthetic agents in the operating theatres of a South African teaching hospital
P Majara, G Leballo.
Published in SA Medical Journal in March 2025
Background
Anaesthetic drug wastage negatively impacts the already constrained economy in developing countries such as South Africa. However, safe anaesthetic drug administration during both elective and emergency surgeries can be achieved without increasing wastage or costs. Drugs frequently wasted include those required in emergencies. Cost-reduction strategies, particularly in drug wastage, represent a potential area for short-term savings in hospital drug budgets. Increasing clinician awareness of drug wastage can help modify practices, leading to reduced waste while maintaining high-quality patient care.
Objective
To evaluate wastage of commonly administered anaesthetic drugs, and to evaluate preventable and routine drug wastage and its cost. Methods. A prospective observational study was conducted in the operating theatre of Chris Hani Baragwanath Academic Hospital, a tertiary hospital. Prospective data were collected for all patients who presented for elective and emergency surgical procedures at this institution over a 2-week period. Drug preparation and administration were determined by the treating anaesthesiologist. The amount of remaining drug in syringes and opened ampoules was considered as wasted. Routine drug wastage was defined as the remaining drug after the required dose was administered, while preventable drug wastage referred to drugs drawn but not administered to the patient.
Results
Data were collected from 373 participants, of whom 58% were undergoing elective surgery. The average drug wastage was 29.7%, comprising 21.3% routine wastage and 8.4% preventable wastage, with an effect size of 0.47 (p<0.001). Propofol accounted for the highest frequency of routine drug wastage, while preventable wastage was predominantly attributed to adrenaline, atropine and suxamethonium (emergency pharmacological agents). The average cost of routine wastage was ZAR3.85, significantly higher than the ZAR1.32 for preventable drug wastage (p<0.001). Multivariate regression analysis revealed a significant association between paediatric surgical cases and increased anaesthetic drug wastage (p=0.004).
Conclusion
The cost and wastage of anaesthetic drugs pose significant challenges in healthcare institutions, particularly in developing countries with limited resources. Implementing cost-effective strategies, such as using smaller ampoules and prefilled syringes, has been demonstrated to reduce drug wastage without compromising patient care.
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