Coagulation Diseases — a Challenge for Patient, Cardiac Surgeon and the Economy of the Hospital: A Single Center Experience with ITP - Patients

Objectives: The most common complication in surgery is bleeding complication. Patients with Werlhof disease (ITP) need consequently a well and differentiated pre-, intra-, and postoperative coagulation management with regard to the negative effects of the heart lung machine to the clotting system.Thus,ITP has not only influence on patients' health, but also length of hospital stay, the ventilator time, blood and coagulation products, which are a kind of natural resource.

Methods: We analyzed ITP cases (n = 11) in a single-center study of the past 12 years in our institute (CABG and combined procedures = 7, isolated valve surgery = 1, VAD = 2, TAH = 1). Furthermore we analyzed the literature from 1973 till 2015 with PubMed in view of complications, death, preparation for operation, need of blood and coagulation products and costs.

Results: 1 TAH, 2 CABG, 1 valve patient were discharged at home. 63% patients died in hospital (POD range 3 - 15): 5 patients due to bleeding complications and consecutive multi-organ failure, 1 postoperative aortic dissection, 1 electro-mechanical decoupling. Cumulative blood loss of all patients of 60.090ml (range 360 - 15.600 ml; average 5008 ml). On average each patient needed blood products of 4.943€ and diverse clotting products of 4.860€ at a total amount of 107.837€ through discharge on POD 17 (range 3 - 87 days). The average ventilation time of all patients was 82 hours (range: 5 - 333 hour) with length of ICU-stay on average of 7 days (max. 17 days). Literature: To our best knowledge we found 63 cases and 6 reviews over 42 years, mainly from Asian language area.17 full text in English language.28 cases were written in Japanese language and no available full text.Amazingly 4 (3%) patients died. Bleeding complications were described in 1.4%. Moreover 50% were treated with intravenous immunoglobulin and 43 patients with cortisone (partly in different dose rates). Splenectomy was performed in 9 patients (in 6 cases simultaneously). A very small minority of patients were single treated with blood products or not mainstream drugs like danazol. Unfortunately many cases have incomplete data about clinical course and treatment algorithm.

Conclusion: The ITP patients represent a small group in surgery. However, in view of the dramatic course and costs a well adjusted pre-, intra-, and postoperative treatment is necessary. We consider the development of treatment algorithms for urgent, elective and emergency cases as of vital importance.

Table 1 Blood and clotting products

Blood and Clotting Products -Erlangen
	Platelets	Red blood	Fresh frozen plasma	Beriplex® P/N (1.000IE)	Anti-thrombin III (1.000IE)	NovoSeven® (mg = 250 kIE)	Fibriongen (1 gr)	F XIII (1.250IE)
∑ units / IE	50	197	245	46.500	14.000	1.455	48	1
price / unit	390 €	85 €	74 €	250 €	60 €	4.463 €	302,00 €	526,00 €
total costs	19.500 €	16.745 €	18.130 €	11.625 €	840 €	25.975 €	14.496 €	526,00 €
Ø cost / patient	1.773 €	1.522 €	1.648 €	1.057 €	76 €	2.361 €	1.318 €	48 €