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首页> 外文期刊>The Internet Journal of Emergency and Intensive Care Medicine >Transfusions And Their Costs: Managing Patients Needs And Hospitals Economics
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Transfusions And Their Costs: Managing Patients Needs And Hospitals Economics

机译：输血及其费用：管理患者需求和医院经济学

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Are bloodless cardiac surgery programs a fallacy? For the most part, the simple answer is yes they are; unless of course, your cardiac surgery program exists only on the healthiest patients, with active lifestyles, few if any co-morbidities, and not on Clopidogrel and Aspirin. Of course, those cardiac surgery programs are also a fantasy. “With rare exceptions,” Bloodless surgery programs do exist, e.g. Jehovah Witness programs, though truly bloodless surgery programs in the general population are rare. Allogeneic blood transfusions are a necessary staple of any diverse cardiac surgery program. Nevertheless, the scientific literature is replete with irrefutable data showing that allogeneic transfusions, although at times an absolute necessity, are in fact detrimental to short, intermediate, and long term outcomes, increased infection rates, prolonged ventilator times, disease transmission, allergic reactions, cross match errors, lung injury, increased mortality 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 and are very expensive (Tables 1 and 2). It is estimated that a single unit of packed red blood cells (PRBC's), with an acquisition cost of two hundred U.S. dollars ($200.00) has an actual cost of between one thousand six hundred ($1,600.00) and two thousand four hundred dollars ($2,400.00) to transfuse it to the patient 9 . This actual cost includes all of the direct and variable personnel costs (Figures 1 and 2) along with the increased costs to any one patient's hospital stay as a result of a transfusion-associated morbidity (Figure 3). The acquisition cost for a unit of aphaeresed platelets is above five hundred U.S. dollars ($500.00 Table 2). Based on the formula used for PRBC's the actual cost of platelets is also incredibly higher. In addition, platelets have also been associated with serious adverse events in cardiac surgery 10 .Blood banks and collection centers are also feeling the pinch. With Nucleic Acid Amplification (NAT) testing, irradiation, and other tests and treatments to make the available blood supply safer, an already strained system is becoming more expensive coupled with the fact that the allogeneic blood supply operates on a margin of only about ten percent of supply versus demand (Source – America's Blood Centers). The blood supply is safer than ever before, however emerging pathogens are the new concern. West Nile Virus was recently added to blood testing, Chagas disease has been reported to have been transmitted in the US through transfusion and there is no current test available for T.cruzi. Today, cardiac surgery utilizes approximately twenty to twenty-five percent of the national blood supply and depending on practice, between forty and seventy percent of cardiac patients receive transfusion during their hospital stay 11 . Based on these facts therefore, the national average for blood transfusions in all cardiac patients, not risk stratified, is 7.6 of any blood component per patient.Following a review of our practice of about 500 cases per year, as well as, a review of several other similar programs, we identified several areas where tools and techniques employed were the greatest contributors to blood transfusion requirements. What we discovered was that the bypass circuit was one area where we could make the greatest impact. However, we discovered that this alone, would only take us so far. What we really needed was a team approach.We changed our entire perfusion circuit 12 , added full biocompatibility, vacuum assisted venous return, reduced our circuit prime with our own innovative design, matched oxygenator size to patient size, instituted aggressive hemofiltration, became aware and corrected areas of iatrogenic blood loss in the operating room, added full dose Aprotinin 13 , incorporated platelet quality analysis, and elicited the involvement of the entire cardiac surgical team. Today, our blood utilization is approximately two units of any blood product, averaged over all cardiac patients, e.g. CABG/Val
机译：无血的心脏手术程序是谬论吗？在大多数情况下，简单的答案是肯定的。除非当然，除非您的心脏手术计划仅适用于最健康，生活方式活跃，合并症很少（如果有的话）的患者，而不适用于氯吡格雷和阿司匹林。当然，那些心脏手术程序也是一个幻想。 “除了极少数例外，”确实存在无血手术程序，例如耶和华见证人计划虽然在普通人群中很少有真正不流血的手术计划。同种异体输血是任何各种心脏外科手术计划的必要主旨。然而，科学文献中充斥着无可辩驳的数据，这些数据表明异体输血虽然有时绝对必要，但实际上不利于短期，中期和长期结果，感染率增加，呼吸机时间延长，疾病传播，过敏反应，交叉比赛错误，肺部损伤，死亡率增加1、2、3、4、5、6、7、8且非常昂贵（表1和2）。估计单个单位的包装红细胞（PRBC）的购置成本为200美元（$ 200.00），实际成本为1600美元（$ 1,600.00）至$ 2440（$ 2,400.00）把它输给病人9。该实际费用包括所有直接和可变人员费用（图1和2），以及由于与输血有关的发病率而增加的任何患者住院费用（图3）。一个单位的无孔血小板的购置成本在五百美元以上（500美元，表2）。根据PRBC使用的公式，血小板的实际成本也高得多。此外，血小板也与心脏手术中的严重不良事件有关[10]。血库和采集中心也感到不舒服。随着核酸扩增（NAT）测试，辐射以及其他测试和治疗方法的出现，使可用的血液供应更加安全，已经紧张的系统变得越来越昂贵，而且同种异体血液供应的利润率仅为百分之十左右。供应与需求的关系（来源–美国血液中心）。血液供应比以往任何时候都更安全，但是新出现的病原体是新的关注点。西尼罗河病毒最近被添加到血液检测中，据报道恰加斯病已通过输血在美国传播，目前尚无可用于T.cruzi的检测。如今，心脏外科手术约占全国血液供应的百分之二十至二十五，并且根据实际情况，有百分之四十至百分之七十的心脏病患者在其住院期间接受输血11。因此，基于这些事实，所有心脏病患者的全国平均输血（未分层风险）为每位患者任何血液成分的7.6％。根据我们每年约500例的实践回顾以及在其他几个类似的程序中，我们确定了几个领域，其中所使用的工具和技术是输血需求的最大贡献者。我们发现旁路电路是我们可以产生最大影响的领域。但是，我们发现仅此一项就只能将我们带走。我们真正需要的是团队合作的方法。我们改变了整个灌注回路12，增加了完全的生物相容性，通过真空辅助静脉回流，通过我们自己的创新设计减少了回路灌注，将氧气发生器的尺寸与患者的尺寸相匹配，进行了积极的血液滤过，意识到并纠正了手术室中的医源性失血区域，添加了全剂量抑肽酶13，结合了血小板质量分析，并引起了整个心脏外科团队的参与。如今，我们的血液利用率几乎是任何血液制品的两个单位，在所有心脏病患者（例如CABG / Val

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