[HSF] Aprotonin

Tea Acuff tacuff at swbell.net
Sun Nov 25 04:54:00 EST 2007 

I can get the real numbers, but I think that I took the rough cost per case and multiplied it times the number of doses (3), that is multiplied the unit dose cost time 3 twice.

tea


----- Original Message ----
From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, November 22, 2007 1:52:38 AM
Subject: Re: [HSF] Aprotonin

Is this a misteak re pricing?

WRT On vs Off it is nearer 7:1

>Ani,
>
>I did overstate the "cost" associated with aprotinin which is more 
>like $1000 or so.
>
>Although some surgeons work diligently to avoid transfusion (as in 
>the simplistic and misguided reinfusion of shed blood debate of the 
>1990's), I think there are several reasons to support my contention 
>that surgeons fear the unknown more than the know, which is 
>therefore more managable even if more common.
>
>This analogy is certainly true for financial markets where risk is 
>most greatly avoided even if desire for marginal improvement is 
>ubiquitious. I doubt that surgeons think differently in type in 
>their peculiar set of concerns.
>
>As a thought experiment which drug would you use most often assuming 
>only one could be used? Drug A that reduced blood loss by 500cc 
>regardless of the total loss, or Drug B that limited total loss to 
>say 1000cc (but some number more than the median in drug A)?
>
>In my personal experience the number of surgeons who reflexively 
>give blood products at the first (and usely immediate) sight of 
>"bleeding" is considerably higher than those that studiously avoid 
>blood products until clearly necessary. Surely this use of blood 
>product is not to "avoid" transfusion.
>
>The use of off pump surgery may corrrelate quite well, probably for 
>a spectrum of reasons, with diligence in bloodless surgery. Off pump 
>is incidentally well documented to have less transfusion at a level 
>similar to aprotinin. The reasonably well known ratio of off to on 
>pump surgeons is 1:4. This might well be a surrogate of similar 
>behavior decisions by surgeons. Only a smaller portion work to do 
>the "best" (least necessary transfusion or instrumentation) for 
>everyone, while the most worry about rare but adverse risk.
>
>
>Back to you. But you make me think harder and not just shoot from the hip.
>
>tea
>
>----- Original Message ----
>From: Ani Anyanwu <anianyanwu at hotmail.com>
>To: openheart-l at lists.hsforum.com
>Sent: Sunday, November 18, 2007 8:55:15 AM
>Subject: RE: [HSF] Aprotonin
>
>"Surgeons however are not primarily interested paying $5000 for a 
>drug that reduces the need for transfusion of a couple of units of 
>blood worth $500. What they are really interested in is the "black 
>swan" event of a patient dying from (near) exsanquination or near 
>exhaustion of the surgeon from reexplorations in prevention of that 
>death."
>
>Tea I disagree with your statement above. It is not primarily cost 
>or fear of exanguination that drives surgeons towards blood 
>conservation. Surgeons are the least interested in cost and have 
>minimal appreciation of health economics (as illustrated for example 
>in your questioning the rationale for using a 2000 USD annuloplasty 
>ring for prophylaxis when a suture could suffice). Also pharmacology 
>does not prevent life threatening haemorrhage - if you look back at 
>patients that have 'bled to death' would yu really think a vial of 
>aprotinin, or any other agent, could have prevented that? Maybe a 
>vial of prolene could but not aprotinin.
>
>What drives blood conservation is primarily a belief that blood 
>transfusion is a toxic drug so its use must be minimized to where 
>the benefits outweigh the risks. It certainly must not be (as it 
>often is in cardiac surgery) a convenience drug to compensate for a 
>team's lack of interest or effort in minimizing blood loss during or 
>after surgery. Remember that even in 2007 many patients die 
>worldwide from direct complications (mainly ABO incompatability) of 
>transfusion every year. In my career so far I have seen 4 patients 
>transfused with the wrong patient's blood during cardiac surgery, 
>the most recent few months ago in New York. These transfusion errors 
>will continue to occur as long as we use blood, regardless of all 
>the policies, protocols and education to prevent them. Then there is 
>the issue of disease transmission. UK is still waiting to see if an 
>epidemic of CJD will erupt in recipients of blood transfusion from 
>the 1990s. Only last week we heard
>  of four organ transplant recipients in USA who contracted *both* 
>HIV and Hepatitis C from an organ transplant done earlier this year. 
>And then of course there are all those other indirect consequences 
>of transfusions.
>
>While blood transfusion was one of the greatest medical discoveries 
>of the 19th centuries and has saved millions of lives since, there 
>are also a significant minority who have suffered death or major 
>illness as a result of transfusion. As has been said before if blood 
>transfusion had been discovered 150 years later we would still be 
>struggling (likely without success) to get it through the FDA. 
>Unlike agents like vioxx and aprotinin where while associations may 
>be spurious or debatable, and direct causation of adverse events 
>cannot be established, there are thousands and thousands dead, whose 
>deaths were incontrovertibly caused by a blood transfusion.
>
>It is a concern about the health of our patient, and not cost or 
>fear of patient exanguinating, that should drive us to minimize 
>blood transfusion. Havin said that Tea, I struggle to remember a 
>single death in the last few years that I can directly attribute to 
>post operative haemorrhage (i.e. patient bled to death) - surely 
>this is rare in the present era?
>
>Ani
>
>
>
>
>
>
>>  Date: Fri, 16 Nov 2007 21:48:12 -0800> From: tacuff at swbell.net> 
>>To: OpenHeart-L at lists.hsforum.com> CC: > Subject: [HSF] 
>>Aprotonin> > I just spent the last few days with Nassim Taleb's 
>>"Fooled by Randomness" there were several jewels and a lot to think 
>>about. I would like to put some form on the exuberant discussion 
>>that we have had on aprotonin. I won't say anything new, but as is 
>>my wont will try to provide some structure around the meaning of 
>>the discussion.> > Aprotonin reduces bleeding, but so do a lot of 
>>things like off pump approach to CAB, or careful technique, etc. 
>>Surgical coagulation is a complex process on top of a complex 
>>cascade confused by complex patients. However, because we lump 
>>everything together in a randomized study we are left with the 
>>simple finding that aprotonin causes less bleeding, nothing less 
>>and, particularly forgotten, nothing more. > > Surgeons however are 
>>not primarily interested paying $5000 for a drug that reduces the
>  need for transfusion of a couple of units of blood worth $500. What 
>they are really interested in is the "black swan" event of a patient 
>dying from (near) exsanquination or near exhaustion of the surgeon 
>from reexplorations in prevention of that death.> > Unfortunately we 
>do not have any way to test for this rare and "random" occurrence. 
>However, in testing for quantitative and manageable bleeding, we 
>approximate a "chaotic" surrogate (like spilling ones tea by adding 
>a large ice cube instead of a drop of water at a time) for the same 
>and "find" other random "consequences" such as renal failure in the 
>analysis.> > In toto, what has been shown is only that which we do 
>not actually care much about. That is, $5000 dollars of drug can 
>save $500 dollars of blood transfusion. Everything else is, or 
>rationally should be, inferred from this small (relatively) 
>objective point. Everything else statistically speaking is a "random 
>walk" or alternative bet or
>  outcome of our decision from whatever our thinking. Maybe some 
>patients don't die of bleeding or maybe some do die of ATN or 
>clotting. Who can tell?> > Why do we think what we do? Or why did 
>you feel what you felt? That is the interesting question.> > 
>"...mathematics is tool to meditate, not compute."> Nassim Taleb> > 
>Meditate for a moment my friends. It is a behavior that will help 
>your patients as much as, and perhaps more, than your 
>computations.> > tea> 
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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