. 2021 Oct 7;73(3):316–339. doi: 10.1016/j.bjane.2021.09.012

Table 2.

Main findings of the selected studies about cost analysis and secondary outcomes.

	General anesthesia			Local/Regional anesthesia				Outcomes
Authors	Anesthetic	No. of patients	Average total costs (USD)	Type	Anesthetic	No. of patients	Average total costs (USD)	Main findings about cost analysis (primary outcome))	Other study findings (secondary outcomes)	Resources included for the calculation of costs
Li et al.¹⁰	NR	3,903	15,670	Loco-regional anesthesia	NR	1,576	19,929	Average total costs were significantly higher in patients undergoing regional anesthesia.	Several other contributors to higher costs are described.	Medical procedure costs
Bokshan et al.¹¹	NR	3,737	19,249	Loco-regional anesthesia	NR	10,976	17,469	Average total costs were significantly lower in patients undergoing regional anesthesia.	General anesthesia, Hispanic ethnicity, Chronic medical condition, male gender, operative time and age are predictors of increased costs.	Medical procedure costs
Gebhardt et al.¹²	Sulfentanil and Propofol	25	71.92	SA	Chloroprocaine 1%	25	41.02	Anesthesia costs are inferior in case of regional anesthesia.	Spinal had faster recovery with patients reaching discharge earlier (117 vs. 142 min)^*. Pain occurred earlier in the general anesthesia group. Patients felt significantly more uncomfortable after general anesthesia.	Anesthesia costs
Hamilton et al.¹³	Volatile anesthetics or intravenous with propofol	241	60	Interscalene brachial plexus single shot block, or catheter	20–40 mL of 0.5% ropivacaine with 1:400,000 epinephrine	1,382	82	No statistically significant difference between groups.	Increased risk of an emergency department visit within 30 days for patients who received a regional anesthesia.	Costs incurred after surgery
Chandran et al.¹⁴,^a	NR	6	2071	LA	NR	14	1251	Average total costs of injection laryngoplasty under LA are significantly lower than under GA with cost savings of 40%. Major contributors are direct and indirect operating theater costs.	Length of stay (h): 8.8 GA vs 6.4 LA^*	Medical procedure costs
Camponovo et al.¹⁵	Intravenous propofol and fentanyl	28	104	SA	Chloroprocaine 1%	28	63	SA for knee arthroscopy is associated with cost reductions per patient compared with GA. Cost reductions in the SA group are due to: the ability to systematically bypass the PACU, faster discharge time, the lower incidence of pain and postoperative nausea and vomiting.	Anesthesia time: 64 vs. 62 min.	Anesthesia supplies, drugs, staff
Camponovo et al.¹⁵	Intravenous propofol and fentanyl								Discharge time: 326 (GA) vs 203 min (SA)^*	Anesthesia supplies, drugs, staff
Penketh et al.¹⁶	NR	NR	1,485	LA in operatory room	NR	NR	LA in operatory room: 716	Operative hysteroscopic resection under LA is less expensive than under GA, especially if performed in the office compared to the OR. Reduced staff costs are the primary reason for saving.	NR	Medical procedure costs
				LA in office			LA in office: 482			Medical procedure costs
Sivalingam et al.¹⁷	NR	73	30,060	LA	Lidocaine 1%^b	46	7,770	Average total cost is nearly 4 times greater for the GA group compared to LA. Ureteral stent placement can be safely and effectively performed under LA in the office.	No difference in complications between GA and LA.	Medical procedure costs
Ahonkallio et al.¹⁸,^c	NR	20	2,333	Peripheral block	20 mL ropivacaine 2 mg mL^−1,^d	16	1,333	Endometrial thermal ablation under PB is cheaper than GA and results in significantly reduced health service costs. The difference is due to lower costs of the hospital ward and anesthesia, and partly to overhead costs.	NR	Medical procedure costs
Covarelli et al.¹⁹,^a	NR	41	373	LA	10−25 mL 1% mepivacaine and 0.5% L-bupicavaine in equal parts	112	258	Average total costs for groin and axillary sentinel lymph node biopsy under GA are significantly higher than those under LA.	No differences in the number of complications.	Operating room management, personnel, drugs, instruments
Stoffels et al.²⁰	NR	89	500	LA	450 mL physiological solution, 50 mL Lidocain 1%, 0.5 mg Epinephrin	211	47	The costs were significantly less in a procedures room performed under local anesthesia compared to general anesthesia in an operating room.	No differences in the number of postoperative complications nor in oncological outcomes.	Anesthesia costs
Mitchell et al.²¹,^a	NR	64	1,244	LA	NR	47	1,026	Sacral nerve stimulation under LA is associated with reduced costs compared to GA.	LA is associated with shorter hospital stay^e and quicker recovery.	Medical procedure costs
Mitchell et al.²¹,^a									Similar symptom score and success rate for both anesthesia.	Medical procedure costs
Kushwaha et al.²²	Propofol 1.5−2 mg kg⁻¹ and fentanyl 10 μg kg⁻¹ with sevoflurane^f	22	714	LA	20 mL 1% lidocaine with 1:10,000 epinephrine	19	503	Excluding the cost of post-operative follow-up, LA was 1.5 times cheaper than GA. This difference is due to the saving in GA and recovery room costs.	LA is associated with similar tolerance and clinical outcome compared to GA.	Suture materials, drugs, day surgery bed, staff costs, recovery room, post-operative medication.
Mostafa et al.²³	Intravenous remifentanil 0.5 μg kg⁻¹ min⁻¹ or alfentanil 2 μg kg⁻¹ min⁻¹ and propofol 9 mg kg⁻¹  h⁻¹	40	492 for remifentanil	Sciatic-femoral nerve block	25 mL ropivacaine	20	393	Costs of disposals, pre-operative and post-operative times are higher for the sciatic-femoral block group, however average total costs (including also drugs) are insignificant between GA and sciatic-femoral nerve block.	Length of stay in PACU: 28 min for remifentanil GA vs 25 min for alfentanil GA vs 28 for sciatic-femoral nerve block	Disposal, drugs, staff
Mostafa et al.²³			541 for alfentanil	Sciatic-femoral nerve block	25 mL ropivacaine					Disposal, drugs, staff
Horn et al.²⁴,^a	Propofol with sevoflurane or desflurane, fentanyl or sufentanyl	121	4,780	Peripheral nerve block	Mepivacaine 1.5% with 10% sodium bicarbonate	92	3,656	Perioperative costs in the peripheral nerve block group are significantly lower than in the GA group.	PACU time: 49 min (GA) vs 15 min (PNB)^*	Medical procedure costs
Horn et al.²⁴,^a				Peripheral nerve block	Mepivacaine 1.5% with 10% sodium bicarbonate			The use of peripheral nerve block in upper extremity surgery is feasible and associated to significant cost savings.	Postoperative complications: 11.7% (GA) vs 3.3% (PNB)^*	Medical procedure costs
Nishikawa et al.²⁵	Intravenous fentanyl 1 μg kg⁻¹ and propofol 6 mg kg⁻¹ h⁻¹	40	74	SA	Lidocaine 1% 1 m L	40	49	Average total costs are significantly lower in the SA group. Costs of drugs and supplies used in the operatory room are reduced for the SA, whereas the labor costs are higher in both operatory room and recovery unit.	Time to home-readiness: 30 min (GA) vs 38 min (SA)^*	Drugs, equipment, staff
									No pain in the recovery unit for 75% patients in GA vs 80% patients SA groups. ^*
								SA may be a suitable cost-effective alternative to GA for elderly ambulatory prostate biopsy.	No adverse events at home.
Nordin et al.²⁶,^a	NR	199	2,964	SA/epidural anesthesia	SA/epidural anesthesia: NR	SA/epidural anesthesia: 164/35 = 199	SA/epidural anesthesia: 3,010	Average total costs of LA are significantly lower than the other two groups. Intra-operative (anesthetic equipment, duration of surgery and anesthesia) and post-operative (time in recovery room, unplanned overnight admission) costs are reduced for LA compared to SA/epidural anesthesia and GA. No difference between SA/epidural anesthesia and GA.	NR	Medical procedure costs
Nordin et al.²⁶,^a				LA	LA: 50:50 mixture of 1% mepivacaine and 0.5% bupicavaine	LA: 205	LA: 2,508			Medical procedure costs
Spanknebel et al.²⁷	NR	85	3,153	LA	Lidocaine and bupicavaine	217	2,760	Average total costs are significantly higher for GA than LA. Extensive procedures and increased operating room times impact significantly on costs.	Thyroidectomy under LA results in similar outcome and morbidity rate to GA with reduced costs.	Medical procedure costs
Casati et al.²⁸	Intravenous remifentanil 0.1−0.3 μg kg⁻¹ min⁻¹ and propofol 2−4 μg mL⁻¹	40	317	sciatic-femoral nerve block SA	sciatic-femoral nerve block: 25 mL 2% mepivacaine	sciatic-femoral nerve block: 40	sciatic-femoral nerve block: 220	The use of sciatic-femoral nerve block results in the lowest total costs. Costs of drugs and disposable material required for anesthesia are lower in the SA group than the others.	Regional anesthesia techniques reduce the rate of admission and the duration of stay in the PACU as compared with GA.	Drugs, devices, staff
Casati et al.²⁸					SA: 8 mg 0.5% bupicavaine	SA: 40	SA: 308		The time readiness for home discharge are shorter in the GA group than regional anesthesia.	Drugs, devices, staff
Forssblad et al.²⁹	Propofol and alfentanil	88	236	LA	LA: 30 mL 0.5% prilocaine with 4 μg mL⁻¹ adrenaline	LA: 181	LA: 76	The knee arthroscopy in LA is associated with lower cost than knee arthroscopy in SA and GA, because of the shorter recovery time of LA that reduces the need for recovery beds and postoperative care.	Recovery time: 139.1 min (GA) vs 33.6 min (LA) vs 230.1 min (SA).	Drugs, devices, staff
Forssblad et al.²⁹	Propofol and alfentanil			SA	SA: 60−90 mg 5% lidocaine with 5−10 mg ephedrine	SA: 74	SA: 219		Time in hospital: 280.4 min (GA) vs 130.4 min (LA) vs 350.3 min (SA)	Drugs, devices, staff
Casati et al.³⁰	Intravenous remifentanil 0.1−0.3 μg kg⁻¹ min⁻¹ and propofol 2−4 μg mL⁻¹	20	291	Sciatic-femoral nerve block	25 mL 2% mepivacaine	20	288	Average total costs between GA group and sciatic-femoral block group in patients undergoing knee arthroscopy are not statistically significant. Costs related to the time spent in the PACU are statistically significant lower for the sciatic-femoral block group (USD 2.0) compared with the GA group (USD 55.7).	Time in the hospital: 170 min (GA) vs 277 min (Sciatic-femoral block)^*	Disposable materials, drugs, staff
									Length of stay in PACU: 23 min (GA) vs 5 min^*
									VAS pain: 7 (GA) vs 0^*
Danelli et al.³¹	Intravenous remifentanil 0.25 μg kg⁻¹ min⁻¹ and propofol 4 μg mL⁻¹	20	260	SA	10 mg 0.5% bupivacaine	20	282	No differences in average total costs between the two groups.	Hospital discharge time: 156 min (GA) vs 296 min (SA)^*	Disposable materials, drugs, staff
Danelli et al.³¹					10 mg 0.5% bupivacaine				Pain control is similar.	Disposable materials, drugs, staff
Lennox et al.³²	Fentanyl 2 μg kg⁻¹ and propofol 2 mg kg⁻¹, 65% nitrous oxide	10	127	SA	3 mL 10 mg lidocaine and 10 μg sufentanil	10	94	Average total cost of anesthesia and recovery is significantly less for patients in the SA group than the GA group. Recovery costs are similar, whereas mean costs of anesthesia is significantly less in the SA group. Cost savings are due to lower cost of anesthetic supplies, sterilization, drugs.	Anesthesia time: 6.6 min (GA) vs 6.6 min (SA)	Supplies, drugs, staff
									PACU time: 112 min (GA) vs 101 min (SA)
									Postoperative pain: 50% (GA) vs 0% (SA)^*
									Nausea/vomiting: 0% (GA) vs 30% (SA)
Chan et al.³³	Propofol, fentanyl, with isoflurane (up to 1.5%), 60% nitrous oxide	39	718	Intravenous regional anesthesia	Intravenous regional anesthesia: 35−45 mL 0.5% lidocaine	Intravenous regional anesthesia: 45	Intravenous regional anesthesia: 513	The intra- and post-operative costs are the least in the intravenous regional anesthesia group than GA and axillary block, reflecting cost savings of approximately 30% in both cases. intravenous regional anesthesia is associated with short induction time, lower anesthetic drug and equipment costs in the operatory room, and with less demand on nursing time and lower drug and supply costs in the PACU.	Total hospital stay time: 240 min (GA) vs 180 min (intravenous regional anesthesia)^*vs 244 min (axillary block)	Disposable materials, drugs, staff
				Axillary block	Axillary block: 40−50 mL 3% chloroprocaine and 2% or 1.5% lidocaine with 1:200,000 epinephrine	Axillary block: 42	Axillary block: 755		Anesthesia time: 83 min (GA) vs 72 min (intravenous regional anesthesia)^*vs 106 min (axillary block)
									PACU recovery time: 70 min (GA) vs 45 min (intravenous regional anesthesia)^*vs 63 min (axillary block)
Martikainen et al.³⁴	Intravenous propofol 2 mg kg⁻¹ and alfentanil 1 mg with sevoflurane (up to 8%)	30	333	SA	3 mL 2% lidocaine	30	293	Average total costs are significantly reduced for SA. However, GA is more cost-effective than SA in ambulatory knee surgery, if a short recovery unit time is required.	Recovery unit time: 218 min (GA) vs 224 min (SA)	Disposable materials, drugs, staff
									Time to home-readiness: 96.4 min (GA) vs 140.8 min (SA)^*
									Post-operative pain low (VAS < 4 in 100% patients in SA vs in 86.7% in GA groups).
Chilvers et al.³⁵	Propofol, fentanyl or sufentanil, and mivacurium or succinylcholine, with isoflurane nitrous oxide	28	99	SA	2−2.5 mL 1% lidocaine and 10−25 μg fentanyl	24	107	Average total costs for anesthesia and recovery are similar between the two groups. Use of SA in alternative to GA does not reduce costs or improve efficacy of anesthesia and recovery for outpatient laparoscopy.	Anesthesia time: 10 min (GA) vs 18 min (SA)^*	Disposable materials, drugs, staff
									PACU recovery time: 94 min (GA) vs 123 min (SA)^*
									Time to discharge: 124 min (GA) vs 150 min (SA)
Li et al.³⁶	Intravenous propofol 2.5 mg kg⁻¹, fentanyl 1−2 μg kg⁻¹ with 0.5−2% sevoflurane, 65% nitrous oxide	31	289	SA	SA: 30 mg lidocaine and 20 μg fentanyl^g	SA: 31	SA: 208	Average total costs are significantly decreased for LA than SA and GA because both intraoperative and recovery costs are the lowest. Patients in the LA group are able to by-pass phase 1 recovery unit requiring less nursing labor (thus less costs). GA is associated to the highest costs.	Anesthesia time: 40 min (LA) vs 72 min (SA)^* vs 75 min (GA)^*	Drugs, supplies, staff
				LA with sedation	SA: 30 mg lidocaine and 20 μg fentanyl^g	LA: 31	LA: 138		Phase 1 stay: 0 (LA) vs 52 min (SA)^vs 44 min (GA)^
					LA: topical 2% lidocaine gel and sedation-analgesia with propofol 75 μg kg⁻¹ min⁻¹ and 0.5 μg kg⁻¹ fentanyl. 15 mL 2% lidocaine, 15 mL 0.5% bupicavaine, 0.5% epinephrine (1:200,000)				Time to home-readiness: 76 min (LA) vs 193 min (SA)^vs 171 min (GA)^
									Hospital stay: 116 min (LA) vs 266 min (SA)^vs 247 min (GA)^
									No differences in post-operative side effects or unanticipated hospitalizations.
Song et al.³⁷	Propofol 2.5 mg kg⁻¹ min⁻¹ 1% sevoflurane, 65% nitrous oxide	28	369	SA	SA: 1.2−1.5 mL 0.75% bupicavaine and 25 μg fentanyl	SA: 25	SA: 330	Average total costs are the lowest for the ilioinguinal-hypogastric nerve block group (reduced supplies during the intraoperative period, reduced labor during post-operative period). No difference between GA and SA.	Anesthesia time: 109 min (ilioinguinal block) vs 119 (GA) vs 116 (SA)	Drugs, staff, resources
				Ilioinguinal-hypogastric nerve block	Ilioinguinal-hypogastric nerve block: 30 mL of 0.25% bupivacaine, 1% lidocaine and propofol 25−150 μg kg⁻¹ min⁻¹	Ilioinguinal-hypogastric nerve block: 28	Ilioinguinal-hypogastric nerve block: 288	Ilioinguinal-hypogastric nerve block is the most cost-effective techniques for outpatients undergoing unilateral herniorrhaphy with respect to recovery, patient comfort, and associated incremental costs.	Phase 1 PACU: 5 min (ilioinguinal block) vs 40 (GA)^vs 35 (SA)^
									Phase 2 unit: 153 min (ilioinguinal block) vs 168 (GA) vs 276 (SA)^*
									Time to home-readiness: 133 min (ilioinguinal block) vs 171 (GA)^vs 280 (SA)^
									Time to actual discharge: 158 min (ilioinguinal block) vs 208 (GA)^vs 309 (SA)^
									Maximum pain VAS: 15 (ilioinguinal block) vs 39 (GA)^vs (34) SA^
									Maximum nausea VAS: 1 (ilioinguinal block) vs 27 (GA)^vs 4 (SA)^

NR, not reported; PACU, post-operative anesthesia care unit. Currency is expressed with United States dollars (USD). Type of anesthesia: GA, general anesthesia; LA, local anesthesia; SA, spinal anesthesia.

Day-case setting.

Four patients received also i.v. midazolam.

Day-case setting (8 h) for general anesthesia and outpatient setting (4 h) for paracervical block.

When necessary also Alfentanil 0.5 mg.

Overnight stay for 38% of patients of the GA group due to adverse effects of the anesthesia.

This group received also a perianal block as for the LA group.

Patients received also 1−2 mg midazolam i.v. for sedation.

Statistically significant.