Pharmacoeconomic Evaluation of Xenon Use in Pediatric Outpatient Dental Practice

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BACKGROUND

Inhalation anesthesia using various volatile anesthetic agents (sevoflurane, isoflurane, desflurane, xenon, nitrous oxide) remains a leading modality in anesthesiology, including outpatient practice. When evaluating indications, contraindications, and both desirable and adverse effects, it is also essential to consider the pharmacoeconomic components associated with each anesthetic agent [1].

Currently used volatile anesthetics consist of relatively abundant elements—fluorine, carbon, oxygen, and hydrogen [2]. In contrast, xenon is a relatively rare element obtained from ambient air. Its extraction from the atmosphere is costly and requires specialized equipment [3]. Consequently, the price of medical-grade xenon cannot be low.

It is well established that the consumption of an inhaled anesthetic depends on fresh gas flow. Use of low-flow anesthesia during the maintenance phase has become common practice for several reasons, including drug-saving considerations [4]. However, reducing fresh gas flow requires vigilance and a high level of expertise from practicing anesthesiologists [5]. Maintaining anesthesia at a low flow of inhaled anesthetic in the inspired gas mixture closely correlates with the anesthesiologist’s individual clinical experience. Despite the published techniques for xenon anesthesia, their reproducibility remains highly individualized with respect to xenon consumption: the rate of filling the breathing circuit with xenon; the selected flow used in minimal-flow anesthesia; and the target concentration set by the anesthesiologist based on monitor readings (given that the minimum alveolar concentration of xenon for children has not yet been established). This underscores the importance of the anesthesiologist’s individual practical experience [6].

Inhaled xenon anesthesia, both in Russia and internationally, is determined not only by its pharmacologic characteristics but also by its cost. Accordingly, assessing its pharmacoeconomic profile in clinical practice is a relevant task. The present study attempts to evaluate expenditures associated with xenon anesthesia in an outpatient dental setting during dental treatment in pediatric patients.

AIM:

The work aimed to assess the pharmacoeconomic effect of xenon administration in pediatric outpatient dental practice.

METHODS

Study Design

We analyzed 117 general anesthesia procedures using xenon for outpatient dental interventions. The KseMed medical-grade xenon (registration No. LS-000121 of August 24, 2010; Akela-N, Russia) was used.

Eligibility Criteria

Inclusion criteria:

• Boys and girls aged 1–10 years;
• American Society of Anesthesiologists physical status classification ≤ III;
• Children requiring comprehensive dental care.

Exclusion criteria:

• Any acute respiratory illness or exacerbation of a chronic condition;
• American Society of Anesthesiologists physical status > III.

Study Setting

Procedures were performed in the Dental Forte clinic chain (Naberezhnye Chelny, Russia).

Intervention

Effectiveness and safety of anesthesia during dental treatment were assessed by monitoring arterial blood pressure (systolic, diastolic, and mean) and heart rate using the Solvo M 3000 monitor (Rochen, China); depth of anesthesia was monitored by bispectral index (BIS) using the MGA-06 anesthesia depth monitor (Triton, Russia). Ventilatory parameters included:

• airway pressure, mmHg
• minute ventilation, L/min
• expiratory volume
• inspiratory volume
• fraction of inspired oxygen
• end-tidal CO₂

These parameters were monitored using the built-in module of the anesthesia workstation.

Capillary blood gases were analyzed with the i-STAT analyzer (Abbott, USA); endotracheal tube cuff pressure was assessed with a cuff-pressure monitoring device (Portex, UK); and inspired xenon concentration was monitored with the GKM-03 gas analyzer (Insoft, Russia). All equipment underwent scheduled maintenance according to each manufacturer’s operating instructions.

Anesthetic management for dental procedures was performed without premedication. Induction was performed with sevoflurane using a bolus-dose induction technique. The breathing circuit of the VENAR Libera Screen (TS+AGAS) anesthesia workstation¹ (Chirana, Slovakia) was prefilled with a mixture of O₂ at 8 L/min and sevoflurane at an inspired concentration of 8 vol%. The breathing circuit was flushed with the anesthetic gas mixture using three cycles of filling and emptying the reservoir bag, after which the mixture was administered via a face mask. The vaporizer was set to 8 vol%, fresh gas flow to 5 L/min, and the fraction of inspired oxygen (FiO₂) to 100%. The adjustable pressure-limiting valve was opened to allow spontaneous ventilation (SPONT). Loss of consciousness occurred after 7–10 breaths. The inspired sevoflurane concentration was then reduced to 4–6 vol% and maintained until a surgical plane of general anesthesia was achieved, as indicated by a BIS value of 60. Intravenous access was obtained at this stage without changes in BIS values, without motor responses, and with stable hemodynamics. Fresh gas flow remained at 5 L/min throughout the induction phase. To reduce salivation and muscle tone, atropine 0.01 mg/kg and diazepam 0.3 mg/kg were administered intravenously, followed by tracheal intubation and initiation of pressure-supported mechanical ventilation. None of the children exhibited a cough reflex during tracheal intubation; glottic visualization and intubating conditions were satisfactory, and intubation was accomplished without difficulty. During general anesthesia, ventilation was provided with pressure-support ventilation.

For pulp therapy and tooth extraction, local infiltration anesthesia with articaine solution was used in accordance with current pediatric dentistry guidelines.

Xenon inhalation began once the dentist initiated the procedure, at which point sevoflurane delivery was discontinued. Xenon uptake was conducted in pressure-support ventilation mode. Ventilation parameters were adjusted individually for each child to maintain normoventilation. During xenon wash-in, fresh gas flow was reduced to 2.5 L/min. The adjustable pressure-limiting valve was set to 30 cm H₂O. FiO₂ was set to 30% (the minimum allowable on the VENAR Libera Screen (TS + AGAS) anesthesia workstation), which yielded an inspired xenon concentration of 70%. Achieving the target xenon–oxygen ratio of 50%–60% / 50%–40% required no more than 2 minutes in all cases. During maintenance in a closed circuit, fresh gas flow did not exceed 300 mL/min, and FiO₂ remained at least 35%.

At the end of treatment, xenon delivery into the circuit was stopped, fresh gas flow was set to 2.5 L/min, and FiO₂ to 100%. Tracheal extubation was performed once the xenon concentration in the breathing circuit decreased to 15% or less; extubation was uncomplicated in all cases. Endotracheal tube cuff pressure was monitored post-intubation and pre-extubation and was maintained within age-appropriate reference ranges.

No recycling of waste anesthetic gases was performed.

Xenon consumption during induction was calculated as the volume required to fill the anesthesia circuit from the moment of tracheal intubation until the inspired xenon concentration reached 50%.

For this study, xenon procurement prices from 2019 to 2024 were obtained from Dental Forte LLC, the medical facility where outpatient dental procedures under general anesthesia were performed (see Table 1). The annual xenon procurement volume during this period was constant at 200 L/year.

 

Table 1. Changes in xenon purchase price, 2019–2024

Year	Price per 1 L, rubles	Mean price per 1 L, rubles
2019	640	2804
2020	1375
2021	1665
2022	2885
2023	5845
2024	4415

 

Statistical Analysis

Statistical processing of the obtained data was performed using Statistica 10 (StatSoft Inc., USA). Data are presented as median and quartiles (Me [Q1: Q3]); the Mann–Whitney U test was used for intergroup comparisons. Differences were considered significant at p ≤ 0.05.

RESULTS

Participants

An open-label, prospective, randomized study included 117 pediatric patients of both sexes (45 girls, 72 boys). Patient characteristics are presented in Table 2.

 

Table 2. Characteristics of study participants, Me [Q1; Q3]

Parameter	Value
Age, years	4.0 [2.0; 5.5]
Body weight, kg	17 [13; 18]
Height, cm	102 [91; 110]
Anesthesia duration, min	110 [80; 135]
Dental treatment duration, min	108 [70; 130]

 

Primary Results

In the analyzed cohort, the mean xenon consumption was 13 L per anesthesia session (see Table 3). The highest xenon use occurred during circuit filling in the induction phase, totaling 3 L over 2 minutes in all evaluated cases. In monetary terms, this corresponded to 8412 rubles for this period of anesthesia (3000 rubles per minute). During the maintenance phase, xenon consumption averaged 10 L, with associated costs of 28,000 rubles (280 rubles per minute). The overall cost of xenon anesthesia per procedure averaged 36,000 rubles in this study.

 

Table 3. Xenon consumption and cost at different anesthesia stages, Me [Q1; Q3]

Parameter		Anesthesia stage			P-value
		Induction	Maintenance	Entire anesthesia period
Xenon consumption, L	Total Per 1 min	3 [2.6; 3.4] 1.5 [1.3; 1.7]	10 [6; 14] 0.10 [0.08; 0.10]	13 [9; 17] 0.11 [0.11; 0.12]	0.001 —
Cost, thousand rubles	Total Per 1 min	8 [7; 9] 3 [3.0; 4.8]	28 [17; 39] 0.28 [0.22; 0.28]	36 [25; 48] 0.31 [0.31; 0.34]	0.001 —

Note: Significant differences in xenon consumption and cost confirmed in practice were evaluated between the induction and maintenance stages.

 

Xenon expenditure—both in volume and in cost—during the circuit-filling stage differed significantly from consumption during the maintenance phase (p ≤ 0.05).

DISCUSSION

In this study, balanced anesthesia with xenon inhalation delivered at metabolic fresh gas flow was used for outpatient dental procedures in children. This approach provided effective and safe anesthesia comparable to low–fresh gas flow inhalational anesthesia [7].

Other authors have reported xenon volumes of 4–6 L required to fill the breathing circuit and achieve an inspired concentration of 70% [8, 9], referring to anesthetic management for adult inpatients. In our study, 3 L of xenon was sufficient for circuit filling.

Moreover, published data indicate xenon consumption ranging from 15 to 36 L per anesthesia session [2, 10] in adult inpatients classified as ASA physical status I. In our cohort, xenon use was 13 L per procedure (7 L/h), which can be attributed to the minimally invasive nature of the dental interventions. Using xenon at an inspired concentration of 50%–60% with a fresh gas flow ≤ 300 mL/min resulted in substantial anesthetic savings. Potential leaks from the breathing circuit or into the endotracheal tube cuff should also be considered [11]. The average cost of xenon anesthesia in our study was 36,000 rubles (310 rubles per minute), which is notably higher than the cost of commonly used pediatric inhaled anesthetics (sevoflurane and desflurane). According to Gubaidullin et al. [12], the cost of sevoflurane anesthesia is 105.85 rubles for induction, 197.25 rubles for wash-in phase, and 2160.28 rubles for maintenance. The cost of desflurane anesthesia is 105.85 rubles for induction, 145.49 rubles for wash-in phase, and 2567.39 rubles for maintenance. Expenses for medical oxygen amount to 2539 and 2107 rubles, respectively.

Although xenon anesthesia is more expensive than halogenated volatile anesthetics, the selection of anesthetic agent should also consider factors such as the pharmacologic safety profile, organ-protective properties, controllability of anesthesia, and other pertinent characteristics [13–16], as well as environmental impact [17].

With ongoing advances in xenon production technology, it is reasonable to expect that this inhaled anesthetic may become more accessible for widespread clinical use in the future [2].

CONCLUSION

The highest xenon consumption rate (1.5 L/min) and the peak cost (3000 rubles per minute) were observed during the induction phase.

The overall mean cost during the entire anesthesia session was nearly 10 times lower than during induction and did not exceed 310 rubles per minute.

In the future, technical solutions and technologies aimed at reducing xenon loss to the atmosphere during induction will likely help decrease the overall cost associated with its use.

ADDITIONAL INFORMATION

Author contributions: D.M. Haliullin: investigation, resources, writing—original draft; V.V. Lazarev: writing—original draft, writing—review & editing; I.A. Shugailov: writing—original draft, writing—review & editing; E.S. Gracheva: investigation, writing—original draft. All authors approved the version of the manuscript to be published and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics approval: The clinical study was approved by the Local Ethics Committee of the Faculty of Continuing Professional Education, The Russian National Research Medical University named after N.I. Pirogov (Approval No. 1/2018, dated December 1, 2018). All participants provided written informed consent prior to inclusion in the study.

Funding sources: No funding.

Disclosure of interests: The authors have no relationships, activities, or interests for the last three years related to for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

Statement of originality: No previously published material (text, images, or data) was used in this work.

Data availability statement: All data generated or analyzed during this study are included in this article.

Generative AI: No generative artificial intelligence technologies were used to prepare this article.

Provenance and peer review: This paper was submitted unsolicited and reviewed following the standard procedure. The peer review process involved two external reviewers, a member of the editorial board, and the in-house scientific editor.

¹ Touchscreen display (TS); integrated gas analysis module (AGAS).

About the authors

Dinar M. Khaliullin

Dental Forte Elite LLC

Author for correspondence.
Email: dr170489@yandex.ru
ORCID iD: 0000-0003-2771-3134
SPIN-code: 7165-1859

MD, Cand. Sci. (Medicine)

Russian Federation, Naberezhnye Chelny

Vladimir V. Lazarev

Pirogov Russian National Research Medical University; Voyno-Yasenetsky Scientific and Practical Center of Specialized Medical Care for Children

Email: lazarev_vv@inbox.ru
ORCID iD: 0000-0001-8417-3555
SPIN-code: 4414-0677

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow; Moscow

Igor A. Shugailov

Russian Medical Academy of Continuous Professional Education

Email: 9978753@mail.ru
ORCID iD: 0000-0001-5304-6078
SPIN-code: 5681-7569

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow

Elena S. Gracheva

Good Dental LLC

Email: murzic_elena@icloud.com
ORCID iD: 0000-0002-2758-8065
Russian Federation, Naberezhnye Chelny

References

Supplementary files