The Financial and Environmental Cost of Anaesthetic Emergency Drugs: Comparing Ampoules With Prefilled Syringes

Introduction Anaesthetic emergency drugs are essential for safe practice; however, when prepared from ampoules, they are frequently wasted when unused. Prefilled syringes (PFS) may reduce waste as they can be opened at the point of use. Additional benefits may include reducing medication errors and saving clinician time, although higher initial purchasing costs have been a barrier to universal adoption across the NHS. We undertook two quality improvement cycles to quantify the use and waste of anaesthetic emergency drugs before and after transitioning from ampoules to PFS for metaraminol, ephedrine, and atropine, measuring cost, waste generated, and environmental impact. Methods This was a prospective, observational study conducted across nine operating theatres at Queen Elizabeth the Queen Mother Hospital, Margate, United Kingdom, quantifying the use and waste of anaesthetic emergency drugs. Surveys were distributed to each theatre and completed by anaesthetic teams through February 2024 for cycle 1 and February 2025 for cycle 2. Cycle 1 collected baseline data on emergency drug use and waste for metaraminol, ephedrine, atropine, propofol, and glycopyrrolate. We repeated this for cycle 2 after transitioning to PFS for metaraminol, ephedrine, and atropine. Annual use and waste of emergency drugs were estimated with costs of ampoules, PFS, and equipment, including syringes, sharps bin disposal, and waste incineration provided by hospital pharmacy and facilities teams. Kilograms of carbon dioxide equivalent (kgCO2e) were estimated using emission and conversion factors based on NHS financial expenditure and incineration of the generated waste weight according to the Sustainability in Quality Improvement guidelines. Results Cycle 1 returned 28 surveys describing 87 surgical cases. Of 208 emergency drugs prepared from glass ampoules, 100 (48.1%) were wasted, costing an estimated £23,348 a year, equivalent to £2,594/theatre/year and producing 196.8 kg of waste. This corresponded to an annual production of an estimated 3,372 kgCO2e, equivalent to 52 flights from London to Paris. Cycle 2 returned 87 surveys comprising 270 surgical cases. Wasted drugs reduced to 15/159 (9.4%), with the cost of waste falling by 91.1% to £231/theatre/year. Waste weight reduced by 93.0% to 13.8 kg, with associated emissions falling by 91.3% to 294 kgCO2e. Replacing metaraminol, ephedrine, and atropine ampoules with PFS yielded an estimated annual cost saving of £14,042 (31.6%), equivalent to £1,560/theatre/year. Conclusions Replacing metaraminol, ephedrine, and atropine ampoules with PFS was associated with substantial reductions in anaesthetic emergency drug costs, medication waste, and the environmental impact associated with pharmaceutical disposal. These reductions were accompanied by changes in drug preparation practices in the theatre. Limitations include self-reported survey data, the use of NHS-specific conversion factors for kgCO2e estimation, and not assessing the financial or human costs of potential medication errors. Generalisability may be limited by the single-centre study design. PFS may represent a useful strategy to reduce waste, costs, and environmental impact while supporting medication safety in anaesthetic practice.