Harmon D E
Department of Cardiovascular and Transplant Anesthesia, Alton Ochsner Clinic, New Orleans, Louisiana 70121, USA.
Ann Thorac Surg. 1996 Feb;61(2 Suppl):S21-5; discussion S33-4. doi: 10.1016/0003-4975(95)01079-3.
Surgical bleeding with possible associated coagulopathies is a major source of morbidity and mortality. More than 27% of patients receive unnecessary blood or blood-product transfusions during cardiac operations. Analysis of the cost-benefit of pharmacologic hemostasis can be accomplished by relating all the components of cost, which include both direct and indirect costs to both direct and indirect benefits to the patient.
A significant reduction in transfusion requirements can be achieved by the systematic application of a clinical algorithm. An alternative is to use drugs that enhance hemostasis. Four such drugs commonly used are desmopressin acetate, tranexamic acid, epsilon-aminocaproic acid, and aprotinin. All these agents have been shown to successfully reduce bleeding and the need for transfusion. It appears that the order of efficacy (greatest to least) is aprotinin, tranexamic acid, epsilon-aminocaproic acid, and desmopressin acetate.
Cost/benefit analysis associated with the use of these agents is complex. The direct costs of these drug treatments can be balanced against the costs related to blood and blood-product administration. Using epsilon-aminocaproic acid, blood used is valued at $30, whereas the drug treatment cost is less than $2. Aprotinin use results in costs of more than $500, with the drug costing $900.
Improved hemostasis should also result in indirect cost savings from reduced operating room time, reduced intensive care unit and hospital stay, and the avoidance of reoperation for bleeding.
手术出血及可能伴发的凝血功能障碍是发病和死亡的主要原因。超过27%的患者在心脏手术期间接受了不必要的血液或血液制品输血。通过关联成本的所有组成部分（包括直接成本和间接成本）与患者的直接和间接收益，可以完成药物止血的成本效益分析。
通过系统应用临床算法可显著减少输血需求。另一种方法是使用增强止血的药物。常用的四种此类药物是醋酸去氨加压素、氨甲环酸、ε-氨基己酸和抑肽酶。所有这些药物均已证明能成功减少出血和输血需求。疗效顺序（从高到低）似乎是抑肽酶、氨甲环酸、ε-氨基己酸和醋酸去氨加压素。
与使用这些药物相关的成本效益分析很复杂。这些药物治疗的直接成本可与血液和血液制品管理相关的成本相平衡。使用ε-氨基己酸时，所使用血液的价值为30美元，而药物治疗成本不到2美元。使用抑肽酶的成本超过500美元，药物成本为900美元。
改善止血还应通过减少手术室时间、缩短重症监护病房和住院时间以及避免因出血再次手术来实现间接成本节约。
