Cost Effectiveness General Anesthesia Combined With Scalp Block Compared To General Anesthesia In Patients Undergoing Removal Tumor Craniotomy In Dr. Sardjito Hospital

Background: Providers of anesthesia services have many opportunities to reduce these costs, of course with the aim of maintaining balance between profit, security and costs. Craniotomy surgery removal of the scalp block tumor is an alternative option that can be combined with general anesthesia. The scalp block itself can blunt stress response in craniotomy and can maintain unwanted hemodynamic instability . Purpose: Find out the cost effectiveness of the scalp block in craniotomy patients removing tumors at Dr. SARDJITO Hospital. Method: Twenty patients ranging in age from 18 - 65 years with intracranial tumors who underwent tumor binding craniotomy at RSUP Dr. SARDJITO is grouped into two treatment groups with general anesthesia and general anesthesia with a combination of scalp blocks, both techniques are calculated using drugs and consumables during the operation. Results: Total cost on the general anesthesia combined scalp block was Rp. 1,347,276 lower Rp. 377,833 compared to general anesthesia Rp. 1,725,109 with a significant difference (p = 0.005). Similarly, the hourly cost of the group in the combined general anesthesia scalp block was Rp. 286,351 Rp. 97,107 lower than general anesthesia Rp. 383,457 with a significant difference (p = 0.038). Conclusion: Combination of general anesthesia and scalp block using 0.5% levobupivacaine more cost effective than general anesthesia and scalp block with placebo in supratentorial tumor patients undergoing tumor removal craniotomy.


Introduction
Brain tumors are about 85-90% of all tumors in the central nervous system (CNS).In the United States, the data from the Central Brain Tumor Registry of the United States 2015 shows that incidence of brain tumors is 21.42 per 100,000 population per year.The incidence rate for brain tumors around the world based on the world population standard is 3.4 per 100,000 population with mortality rate of 4.25 per 100,000 per year.Astrocytomas and glioblastomas account for about 38% of the total central nervous system, while meningioma and other mesenchymal tumors are about 27%.The remainder consists of a variety of brain tumors, including the pituitary, schwannoma, CNS lymphoma and others. 1 In a prospective study, about two-thirds of patients reported moderate to severe pain after craniotomy.Analgesia management surveys show there is few consensus about good analgesia in craniotomy.For this reason, regional blocks of sensory innervation to the scalp have become a frequently used addition to systemic analgesia for craniotomy.intraoperative anesthesia, minimal side effects, reduced recovery time, and excellent postoperative pain control.The choice of regional anesthesia may be economically more advantageous than general anesthesia 3 .
The nerve block technique on the scalp (scalp block) can be used for all supratentorial intracranial procedures.Scalp blocks can minimize hemodynamic responses to surgical stimulation, can reduce the use of intraoperative anesthetic drugs, and can reduce postoperative pain and analgesic consumption 4 .

Methods
The study design used in this study was a retrospective Cohort design, to determine the price comparison using general anesthesia combined with scalp blocks compared with general anesthesia alone.The study was taken from medical record data in the period of August, September and October 2019.The study was divided into groups where each group was given parallel treatment.The target population was patients with supratentorial tumors in Dr. Sardjito General Hospital.Samples were divided into general anesthesia combined with scalp blocks using Levobupivacaine 0.5% and general anesthesia combined with scalp blocks using saline as control.This study has received ethical clearance approval.Subjects were patients who underwent scheduled supratentorial tumor removal craniotomy in the surgical center building (GBST) of Dr. Sardjito General Hospital in the period August, September and October 2019, aged 18 -65 years old, underwent the first tumor removal craniotomy, and ASA II physical status.Exclusion criteria were patients with local anesthetic agents allergic and patients with surgical plans longer than 6 hours.

Results
Research has been taken from medical record data in the period of August, September and October 2019.The sample consisted of 20 patients who were included in the inclusion criteria (Patients who underwent tumor removal craniotomy (supratentorial) with a scalp block, in the surgical center building (GBST) of Dr. Sardjito General Hospital, aged 18 -65 years old, underwent the first tumor removal craniotomy, and ASA II physical status).The total patients for 3 months were 39 patients, who were divided into 2 groups, namely general anesthesia combined with scalp blocks (treatment), and general anesthesia alone (control).The study was taken from a medical record that was obtained in the medical records room of Dr.

Conclusion
The combination of general anesthesia and scalp block using 0.5% levobupivacaine proved to be more cost effective than general anesthesia and scalp block using placebo in supratentorial tumor patients who underwent tumor removal craniotomy.

2
Perioperative interventions that aimed at improving the quality of anesthesia and are expected to reduce costs have become increasingly popular in recent years.Anesthesiologists are often faced with choices among different treatment strategies with few data available on comparative cost effectiveness.Multidisciplinary interventions are the most cost-effective overall "dominant" interventions (better results, lower costs), including fast recovery and standardization, and a bundle of perioperative delirium prevention 1 .The choice of anesthesia technique is usually associated with an increase in the quality of DOI: 10.22146/jka.v11i1.10199e-ISSN 2354-6514 The mean age of the treatment group was 46.5 years and the control group was 45.7 years.The proportion of men and women in the treatment group was equal, while in the control group the majority were women (80.0%).All patients were in ASA II.The average duration of the two groups was 4.8 hours.There were no significant differences in age, sex, ASA and duration Fentanyl is often used in anesthesia, because it has fast onset of action and relatively short duration.This is consistent with studies conducted in India with 60 sample patients with craniotomy tumor removal of supratentorial tumors performed with scalp blocks using 0.5% Bupivacaine that showed a significant decrease in intraoperative Fentanyl use compared with scalp blocks using saline. 7 DOI: 10.22146/jka.v11i1.10199e-ISSN 2354-6514 was Rp 1,347,276, it was Rp 377,833 lower than the control group which was Rp. 1,725,109 with a significant difference (p = 0.005).Likewise, the cost per hour in the treatment group was Rp. 286,351, it was Rp. 97,107 lower than the Discussion The sample of this study were 20 patients with inclusion criteria were aged 18 -65 years old, underwent the first tumor removal craniotomy, and ASA II physical status.The mean age of the treatment group was 46.5 years and the control cardiovascular and as postoperative analgesia with minimal side effects.It can reduce the use of inhalation agents too.The ideal opioids used