RESUMEN
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
Asunto(s)
Aprotinina/economía , Puente de Arteria Coronaria/economía , Hemostasis Quirúrgica/economía , Hemostáticos/economía , Ácido Aminocaproico/economía , Ácido Aminocaproico/uso terapéutico , Aprotinina/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea , Análisis Costo-Beneficio , Desamino Arginina Vasopresina/economía , Desamino Arginina Vasopresina/uso terapéutico , Hemostasis Quirúrgica/métodos , Hemostáticos/uso terapéutico , Humanos , Reoperación , Ácido Tranexámico/economía , Ácido Tranexámico/uso terapéuticoRESUMEN
Lung transplantation is a successful alternative treatment for a variety of end-stage lung diseases. The first 20 lung transplants performed in Louisiana between November 1990 and July 1994 are reported from Ochsner Foundation Hospital. Transplant procedures included 1 heart-lung, 11 bilateral sequential lung, and 8 single-lung transplants in 8 males and 11 females (1 retransplantation). The average age was 38 years (range 7-60), and the median waiting time was 34.5 days (range 1-329). Indications for transplant included emphysema, pulmonary fibrosis, pulmonary hypertension, cystic fibrosis, bronchiectasis, and bronchiolitis obliterans. Overall 1-year and 3-year survival were 65.0% and 58.5%, respectively. Infection was the major cause of morbidity and mortality. Rejection episodes were observed but treated successfully in all 20 patients. Lung transplantation has proved to be a successful treatment for a variety of severely limiting and terminal pulmonary conditions for patients in our state.
Asunto(s)
Enfermedades Pulmonares/cirugía , Trasplante de Pulmón/tendencias , Complicaciones Posoperatorias/etiología , Adolescente , Adulto , Causas de Muerte , Niño , Femenino , Estudios de Seguimiento , Humanos , Louisiana , Enfermedades Pulmonares/mortalidad , Trasplante de Pulmón/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
The records of 150 consecutive patients undergoing thoracoabdominal aortic replacement from 1980 to 1991 were retrospectively reviewed. There were 89 men and 61 women; mean age was 67.8 years (range: 33 to 88 years). Since June 1989, a multimodality prospective perioperative protocol was used to reduce the risk of spinal cord dysfunction. Ischemia is minimized by complete intercostal reimplantation whenever possible, cerebrospinal fluid drainage, and maintenance of proximal hypertension during cross-clamping. Spinal cord metabolism is reduced by moderate hypothermia, high-dose barbiturates, and avoidance of hyperglycemia. Reperfusion injury is minimized by the use of mannitol, steroids, and calcium channel blockers. Ninety-seven percent of patients survived long enough for evaluation of their neurologic function. Spinal cord dysfunction was reduced from 6 of 108 (6%) in the preprotocol group to 0 of 42 in the protocol group (0%) (p less than 0.01). The overall 30-day operative mortality was not significantly different between the groups (9% versus 12%, p = NS). A multimodality protocol appears to be effective in reducing the risk of spinal cord injury during thoracoabdominal aortic replacement.
Asunto(s)
Aneurisma de la Aorta/cirugía , Enfermedades de la Aorta/cirugía , Complicaciones Posoperatorias/epidemiología , Enfermedades de la Médula Espinal/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Aorta Abdominal , Aorta Torácica , Aneurisma de la Aorta/mortalidad , Enfermedades de la Aorta/mortalidad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , RiesgoRESUMEN
Duane's retraction syndrome (DRS) is a congenital abnormality of ocular motility that occurs in about 1% of strabismic patients. Three types have been described and the clinical features include incomitant horizontal strabismus, restricted motility and globe retraction. Head turn, upshoot or downshoot of the adducted eye, and bilaterality may occasionally be present. Since strabismus is invariably present in DRS, careful assessment of extraocular motility should be performed on all children with a suspected or confirmed eye turn. Early diagnosis may save practitioners and parents hours of time and financial investment with orthoptic and surgical management attempts. A case of DRS is presented.