Bedside rationing

A fifty-five-year-old man with severe type-A hemophilia (factor-VIII deficiency) and high-titer antibodies to factor All sustained an intertrochanteric hip fracture. Open reduction and internal fixation was performed uneventfully with intraoperative infusion of recombinant activated factor VII (rFVIIa), a new and expensive product used to treat factor-VIII deficient patients with antibodies to exogenous factor All. On the second postoperative day, the rFVIIa was discontinued and an activated prothrombin complex concentrate (aPCC), a less expensive product, was given. Substantial bleeding ensued over the next twenty-four hours, necessitating transfusion of six units of packed red blood cells to maintain hemodynamic stability. The rFVIIa was restarted, resulting in prompt control of the bleeding. This medication was continued for the remainder of the postoperative period, with adequate hemostasis. The cost for treatment with aPCC is $10,400 per day. The cost for treatment with rFVIIa is $92,400 per day. This patient consumed $1.2 million worth of rFVIIa during his hospital stay.