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„Bedside“-Thrombelastographie

Kostenreduktion in der Herzchirurgie

Bedside thrombelastography

Cost reduction in cardiac surgery

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Zusammenfassung

Hintergrund

Demographische Änderungen und aggressive Medikation mit Thrombozytenaggregationshemmern haben einen erheblichen Anstieg der Kosten des Blut- und Blutprodukteverbrauchs in der Herzchirurgie nach sich gezogen. Um einen kosteneffizienten Behandlungspfad zu generieren, wurde die Qualität der Gerinnselbildung mithilfe der „Bedside“-Rotationsthrombelastographie (ROTEM) evaluiert.

Patienten und Methoden

Die Behandlungskosten von herzchirurgischen Patienten wurden retrospektiv vor (729 Patienten) und nach (693 Patienten) Implementierung des Bedside-ROTEM analysiert. Kumulative Zahlen und Kosten von Thrombozytenkonzentraten (TK), Fresh Frozen Plasma (FFP), Erythrozytenkonzentraten (EK) und den Gerinnungsfaktoren: Prothrombinkomplexkonzentrat, rekombinanter Faktor VIIa (NovoSeven®), Faktor XIII (Fibrogammin®) und Fibrinogen (Hämocomplettan®) wurden erfasst. Durchschnittliche monatliche Zahlen und Kosten wurden verglichen. Die Anzahl der Rethorakotomien und die Frühletalität wurden in beiden Perioden erhoben und gegenübergestellt.

Ergebnisse

Nach ROTEM-Implementierung sanken der kumulative EK-Verbrauch um 25% und der TK-Verbrauch um 50%. Der FFP-Verbrauch änderte sich hingegen nicht. Prothrombinkomplexkonzentrat und Fibrogammin® wurden zu 80% weniger eingesetzt; auf NovoSeven® konnte gänzlich verzichtet werden. Der Hämocomplettan®-Verbrauch verdoppelte sich. Die kumulativen monatlichen Kosten aller Blutprodukte sanken von 66.000 EUR auf 45.000 EUR (−32%). Die monatlichen Kosten für Gerinnungsfaktoren verringerten sich von 60.000 EUR auf 30.000 EUR (−50%), sodass sich eine kombinierte Ersparnis von 44% ergab. Im Gegensatz dazu beliefen sich die monatlichen Kosten für ROTEM auf 1580 EUR. Die Gesamtzahl der Rethorakotomien sank von 6,6 auf 5,5%, während die Frühletalität (5,9%, 6,0%) stabil blieb.

Zusammenfassung

Die kumulativen Kosten für die Behandlung von perioperativen Gerinnungsstörungen wurden durch ein selektives Substitutionsmanagement unter Zuhilfenahme von Bedside-ROTEM erheblich gemindert. Die eingesparten Kosten für Blut- und Gerinnungsprodukte kompensierten dabei klar die Aufwendungen für das ROTEM. Ein adäquates differenziertes Gerinnungsmanagement kann daher durchaus kosteneffizient sein.

Abstract

Background

Demographic changes and aggressive medication with platelet aggregation inhibitors have resulted in a marked increase in blood and coagulation product expenditure and costs in cardiac surgery. We analyzed the bedside coagulation test (ROTEM) in order to verify clot forming quality and to find a cost-effective treatment algorithm.

Patients and methods

Annual treatment costs of all cardiosurgical patients were retrospectively analyzed before (729 patients) and after (693 patients) implementation of the bedside ROTEM test. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and the coagulation factors prothrombin complex concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. The number of rethoracotomies and early mortality were assessed and compared in both periods.

Results

After ROTEM implementation cumulative RBC expenditure showed a 25% decrease and PltC a 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (-80%) while rFVIIa was entirely omitted. Fibrinogen, however, showed a two-fold increase. Cumulative average monthly costs of all blood products decreased from 66,000 EUR to 45,000 EUR (–32%). Coagulation factor average monthly costs decreased from 60,000 EUR to 30,000 EUR (–50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1,580 EUR. The total number of rethoracotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable.

Conclusions

Cumulative costs for treatment of perioperative coagulation disorders were reduced by bedside ROTEM analysis to achieve a selective substitution management. Saved costs for blood and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.

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Authors and Affiliations

  1. Herzchirurgie, Herzzentrum Brandenburg, Ladeburger Straße 17, 16321, Bernau bei Berlin, Deutschland

    G.J. Spalding, M. Hartrumpf & J.M. Albes

  2. Anaesthesiologie und Intensivtherapie, Herzzentrum Brandenburg, Bernau bei Berlin, Deutschland

    T. Sierig, N. Oesberg & C.G. Kirschke

Authors
  1. G.J. Spalding
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  2. M. Hartrumpf
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  3. T. Sierig
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  4. N. Oesberg
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  5. C.G. Kirschke
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  6. J.M. Albes
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Correspondence to G.J. Spalding.

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Spalding, G., Hartrumpf, M., Sierig, T. et al. „Bedside“-Thrombelastographie. Anaesthesist 56, 765–771 (2007). https://doi.org/10.1007/s00101-007-1200-2

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  • DOI: https://doi.org/10.1007/s00101-007-1200-2

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