101
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Ghinea N, Lipworth W, Kerridge I, Little M, Day RO. Ethics & Evidence in Medical Debates: The Case of Recombinant Activated Factor VII. Hastings Cent Rep 2014; 44:38-45. [DOI: 10.1002/hast.287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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102
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103
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Davidson S. State of the Art - How I manage coagulopathy in cardiac surgery patients. Br J Haematol 2014; 164:779-89. [DOI: 10.1111/bjh.12746] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Simon Davidson
- Department of Haematology; Royal Brompton Hospital; London UK
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104
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Effects of recombinant activated factor VIIa on abdominal trauma patients. Blood Coagul Fibrinolysis 2014; 25:33-8. [DOI: 10.1097/mbc.0000000000000021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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105
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Abstract
BACKGROUND Previous reports have been published on the use of recombinant Factor VIIa for intractable bleeding after cardiac surgery; however, there is limited information on the use of Factor IX Complex in this population. METHODS A retrospective cohort study of adult patients who underwent cardiac surgery and experienced severe postoperative bleeding, defined as a mean chest tube output ≥300 mL/h. Primary outcomes were changes in chest tube output and blood product usage pre- and post-Factor IX Complex administration. RESULTS Eleven patients received Factor IX Complex for severe postoperative bleeding. The mean dose of Factor IX Complex was 35 (13-52) units/kg. Chest tube output was significantly reduced after Factor IX Complex administration (mean pre-Factor IX Complex 381 ± 49 mL/h, mean post-Factor IX Complex 151 ± 38 mL/h; P = 0.003). Blood product usage decreased after Factor IX Complex but was not statistically significant (mean pre-Factor IX Complex 373 ± 81 mL/h, mean post-Factor IX Complex 212 ± 48 mL/h; P = 0.669). Adverse events included 1 pulmonary embolism (postoperative day 43) and 2 episodes of acute renal failure requiring dialysis (postoperative days 2 and 5). CONCLUSIONS In this small group of patients, Factor IX Complex effectively controlled severe bleeding after cardiac surgery preventing the need for re-exploration.
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106
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Toole JM, Stroud MR, Ikonomidis JS. Salvage periaortic pericardial baffle equalizes mortality in bleeding patients undergoing aortic surgery. J Thorac Cardiovasc Surg 2013; 148:151-5. [PMID: 24113020 DOI: 10.1016/j.jtcvs.2013.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/16/2013] [Accepted: 08/03/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Bleeding is a potentially serious complication of aortic surgery. We report our experience with the use of a periaortic bovine pericardial baffle to control intractable intraoperative bleeding. METHODS All patients who underwent aortic root, ascending, or arch replacements between January 2002 and April 2013 were reviewed. A bovine pericardial periaortic baffle was created to shunt shed blood into the right atrium. The transverse sinus was sutured closed in patients undergoing primary sternotomy. Baffle recipients were compared with the remaining patients undergoing aortic surgery. The Fisher exact test was used to determine statistical significance for categoric variables. Continuous variables were compared using the nonparametric Wilcoxon rank-sum test. All factors with a P value less than .2 were considered for multivariate logistic regression to determine independent associations with baffle use. RESULTS A total of 413 patients were identified, of whom 23 received a baffle. Operative mortality for patients receiving a baffle was 4% (1/23) compared with 6% (25/390) (P = 1) for the remaining patients. Prolonged ventilation was more common in the baffle recipients (P < .0005); otherwise, there were no differences in postoperative morbidity. Multivariate analysis of all patients undergoing aortic surgery revealed infectious endocarditis (P < .0005; odds ratio, 15.1; 95% confidence interval, 4.8-47.2), redo sternotomy (P < .0005; odds ratio, 11.9; 95% confidence interval, 4.1-34.1), and male gender (P = .04; odds ratio, 4.6; 95% confidence interval, 1.1-19.3) to be predictive of baffle placement. CONCLUSIONS Patients requiring salvage periaortic pericardial baffle for intractable intraoperative hemorrhage experienced an operative mortality similar to that in the remaining patients undergoing aortic surgery. Infectious endocarditis requiring root replacement or reoperative aortic surgery should alert the surgeon to the potential need for baffle placement, including prophylactic transverse sinus closure.
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Affiliation(s)
- John Matthew Toole
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC.
| | - Martha R Stroud
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - John S Ikonomidis
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
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107
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Gruber SN, Volles DF. Usefulness of laboratory values in predicting effectiveness of recombinant factor VIIa in surgical patients with bleeding. Am J Health Syst Pharm 2013; 70:1528-32. [PMID: 23943185 DOI: 10.2146/ajhp120651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The results of a study to determine whether certain laboratory values can predict the effectiveness of recombinant factor VIIa (rFVIIa) therapy to control postoperative bleeding in surgical patients are presented. METHODS In a retrospective observational study at a large university hospital, the records of all adult patients on the cardiothoracic surgery (CTS) and general or trauma surgery (GTS) units who received rFVIIa for treatment-refractory nonsurgical bleeding episodes (an off-label use) during a 17-month period were reviewed. Collected data included blood product requirements before and after administration of rFVIIa, selected periadministration laboratory values (e.g., International Normalized Ratio, platelet count, arterial pH, fibrinogen concentration), 24-hour and 30-day mortality, and documented adverse thrombotic events. RESULTS Among the 18 GTS and 32 CTS patients who received rFVIIa during the study period, hemostasis (as defined according to 12- and 24-hour transfusion requirements) was achieved in 50% of patients in both groups. Two of the evaluated laboratory values were found to be predictive of reduced rFVIIa effectiveness. Hemostasis was not achieved in any patient with an arterial pH of ≤7.1 or a fibrinogen concentration of <100 mg/dL. The study results did not support the hypothesis that a platelet count of <50,000 cells/L is associated with reduced effectiveness of rFVIIa therapy for the studied indication. Adverse thrombotic events occurred in 14 patients (28%) after rFVIIa administration. CONCLUSION CTS and GTS patients with bleeding episodes and an arterial pH of ≤7.1 or a fibrinogen concentration of <100 mg/dL were not likely to achieve hemostasis after rFVIIa therapy.
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Affiliation(s)
- Sarah N Gruber
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA.
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108
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Hvas AM, Andreasen JB, Christiansen K, Ravn HB. Ex-vivo response to blood products and haemostatic agents after paediatric cardiac surgery. Blood Coagul Fibrinolysis 2013; 24:587-92. [DOI: 10.1097/mbc.0b013e32836029d2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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109
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Bardon J, Fink J, de Montblanc J, Bergmann JF, Sarrut B, Benhamou D. [Off-label use of recombinant factor VII (rFVIIa) in teaching hospitals in Paris in 2010]. ACTA ACUST UNITED AC 2013; 32:659-64. [PMID: 23953834 DOI: 10.1016/j.annfar.2013.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 05/02/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Recombinant activated factor VII (rFVIIa) (Novoseven(®)) was initially developed as a substitutive treatment in haemophiliacs but has then been used in situations of major haemorrhage in non-haemophiliacs (off-label use). The goal of the present study was to assess the practice patterns when rFVIIa is used in off-label indications in major teaching hospitals of Paris in 2010. METHODS We retrospectively identified files of patients in whom rFVIIa had been used. Physicians in charge of these patients (or the most proxy physician available) were contacted and files analysed with one of the authors. Quality of rFVIIa used in these off-label situations was determined based on either French or European guidelines or the available literature when no guidelines could be found. Three categories were defined for indication, dosage, timing, associated biological factors and overall use: adequate, acceptable (mainly adequate but lacking some characteristics of an "ideal" prescription) and inadequate (lacking most of the necessary characteristics of an "ideal" prescription). RESULTS Among 59 patients who had an off-label prescription of rFVIIa, 49 prescriptions could be analysed. Indication for use and timing of administration were adequate in 100% of multiple trauma cases and 83% of obstetrical cases. Biological criteria associated with an improved efficacy were found in two thirds of prescriptions analysed. Overall, prescriptions were adequate or acceptable in 82% of cases. CONCLUSION In the vast majority of patients who received rFVIIa for off-label indications in teaching hospitals of the Paris area in 2010, prescriptions were in line with recommendations.
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Affiliation(s)
- J Bardon
- Service d'anesthésie-réanimation, hôpitaux universitaires Paris-Sud, France; Hôpital Bicêtre, AP-HP, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France
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110
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Abstract
PURPOSE OF REVIEW On the one hand, cardiac and aortic surgery is associated with a high rate of allogeneic blood transfusion. On the other hand, both bleeding and allogeneic blood transfusion is associated with increased morbidity, mortality, and hospital costs in cardiac and aortic surgery. This article reviews the current literature between 1995 and 2012 dealing with transfusion protocols in cardiovascular surgery. The 16 studies fitting these search criteria have evaluated the impact of the implementation of ROTEM/TEG based coagulation management algorithms on transfusion requirement and outcome in overall 8507 cardiovascular surgical patients. RECENT FINDINGS The use of point-of-care (POC) transfusion and coagulation management algorithms based on viscoelastic tests such as thromboelastometry (ROTEM) and thrombelastography (TEG) in combination with POC platelet function tests such as whole blood impedance aggregometry (Multiplate) have been shown to be associated with reduced allogeneic blood transfusion requirements, reduced incidence of thrombotic/thromboembolic and transfusion-related adverse events, and improved outcomes in cardiac surgery. SUMMARY Implementation of POC algorithms including a comprehensive bundle of POC diagnostics (thromboelastometry and whole blood impedance aggregometry) in combination with first-line therapy using immediately available specific coagulation factor concentrates (fibrinogen and prothrombin complex concentrate) and defining strict indications, calculated dosages, and clear sequences for each haemostatic intervention seems to be complex but most effective in reducing perioperative transfusion requirements and has been shown to be associated with a decreased incidence of thrombotic/thromboembolic events, transfusion-related adverse events, as well as with improved patients' outcomes including 6-month mortality.
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111
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112
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Rujirojindakul P, Rujirojindakul P, McNeil EB, Geater AF, Chanchayanon T, Sangthong B, Chittithavorn V. Prediction score for effective bleeding control using recombinant activated factor VII in perioperative nonhemophilic patients. Am J Surg 2013; 206:326-32. [PMID: 23726232 DOI: 10.1016/j.amjsurg.2012.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 10/05/2012] [Accepted: 11/05/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although there has been growing evidence from off-label use of recombinant activated factor VII (rFVIIa) in surgical bleeding, there is limited information on prediction scores. METHODS A retrospective study was conducted from 2004 to 2009. The primary outcome was efficacy of bleeding control. Multivariate logistic regression was performed to develop a new prediction score for success of rFVIIa. RESULTS A total of 320 bleeding episodes from 243 nonhemophilic patients who underwent surgery were analyzed. Effective bleeding control was demonstrated in 153 patients. The overall in-hospital mortality rate was 40%. Multivariate analysis identified 4 independent predictors for effective bleeding control: timing of rFVIIa administration, intraoperative blood loss, postoperative international normalization ratio values, and total units of platelets transfused. A rFVIIa success prediction score was developed. CONCLUSIONS The use of this new prediction score may support decision making by identifying patients with a high probability of obtaining effective bleeding control from rFVIIa therapy.
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Affiliation(s)
- Panthila Rujirojindakul
- Department of Anaesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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113
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Tanaka KA, Mazzeffi MA, Grube M, Ogawa S, Chen EP. Three-factor prothrombin complex concentrate and hemostasis after high-risk cardiovascular surgery. Transfusion 2013; 53:920-1. [DOI: 10.1111/trf.12110] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kenichi A. Tanaka
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh; PA
| | - Michael A. Mazzeffi
- Department of Anesthesiology; Emory University School of Medicine; Atlanta; GA
| | - Matthias Grube
- Department of Anesthesiology; Emory University School of Medicine; Atlanta; GA
| | - Satoru Ogawa
- Department of Anesthesiology; Emory University School of Medicine; Atlanta; GA
| | - Edward P. Chen
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta; GA
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114
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Brophy GM, Candeloro CL, Robles JR, Brophy DF. Recombinant activated factor VII use in critically ill patients: clinical outcomes and thromboembolic events. Ann Pharmacother 2013; 47:447-54. [PMID: 23535812 DOI: 10.1345/aph.1r729] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hemorrhage and coagulopathy are associated with morbidity and mortality in critically ill patients. Recombinant activated factor VII (rFVIIa) is frequently used in these situations to control bleeding; however, few controlled clinical trials have demonstrated clinical benefit and prolonged survival. OBJECTIVE To compare clinical outcomes and thromboembolic events in intensive care unit (ICU) patients who received rFVIIa versus ICU patients who did not between 2000 and 2005. METHODS A total of 2918 nonhemophiliac adult ICU patients, which included 1459 who received at least 1 dose of rFVIIa and 1459 matched controls who did not, were included in a retrospective database study. Data were extracted from the Solucient ACTracker database, which included 550 hospitals across the US. Measures included patient demographics, rFVIIa prescribing, death, thromboembolic events, discharge disposition, length of stay, and transfusion data. RESULTS The most common primary diagnoses for patients receiving rFVIIa included traumatic brain injury, cirrhosis, and nontraumatic intracranial hemorrhage. Patients receiving rFVIIa were more likely to have comorbidities, including mechanical ventilation, acute kidney injury, sepsis, hemodialysis, and gastrointestinal bleeding (p < 0.0001). The average rFVIIa dose was 4.8 mg and 82% of patients received 1 dose. Compared to controls, patients receiving rFVIIa had greater odds of death (OR 2.1, 95% CI 1.8-2.6, p < 0.0001), transfusion (OR 2.1, 95% CI 1.8-2.5, p < 0.0001), and longer length of stay (p < 0.001). There was no significant difference in thromboembolic events between groups. CONCLUSIONS While we cannot show direct causality between rFVIIa and the poor clinical outcomes documented in ICU patients, they provide important insight for critical care clinicians.
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Affiliation(s)
- Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA
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115
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Leal-Noval SR, Muñoz M, Asuero M, Contreras E, García-Erce JA, Llau JV, Moral V, Páramo JA, Quintana M, Basora M, Bautista-Paloma FJ, Bisbe E, Bóveda JL, Castillo-Muñoz A, Colomina MJ, Fernández C, Fernández-Mondéjar E, Ferrándiz C, García de Lorenzo A, Gomar C, Gómez-Luque A, Izuel M, Jiménez-Yuste V, López-Briz E, López-Fernández ML, Martín-Conde JA, Montoro-Ronsano B, Paniagua C, Romero-Garrido JA, Ruiz JC, Salinas-Argente R, Sánchez C, Torrabadella P, Arellano V, Candela A, Fernández JA, Fernández-Hinojosa E, Puppo A. [The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. Med Intensiva 2013; 37:259-83. [PMID: 23507335 DOI: 10.1016/j.medin.2012.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 12/12/2012] [Accepted: 12/19/2012] [Indexed: 02/06/2023]
Abstract
Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?» All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.
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Affiliation(s)
- S R Leal-Noval
- Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias.
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116
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Tanaka KA, Kor DJ. Emerging haemostatic agents and patient blood management. Best Pract Res Clin Anaesthesiol 2013; 27:141-60. [DOI: 10.1016/j.bpa.2013.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 12/20/2022]
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117
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Dutta TK, Verma SP. Rational Use of Recombinant Factor VIIa in Clinical Practice. Indian J Hematol Blood Transfus 2013; 30:85-90. [PMID: 24839361 DOI: 10.1007/s12288-013-0240-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 02/09/2013] [Indexed: 10/27/2022] Open
Abstract
In the United States, the FDA-approved indications for recombinant factor VIIa is for bypassing inhibitors to factors VIII and IX in patients with hemophilia A and B respectively and for treatment of congenital factor VII deficiency. In European countries, rFVIIa is licensed for the above indications as well as for Glanzmann's thrombasthenia. In absence of high-quality data favoring off-label use of this agent and laboratory test to predict response to this agent, and in view of high cost of rFVIIa, off-label use of recombinant factor VIIa should be restricted to only when hemorrhage has not responded to transfusion or other conventional therapy. It appears, two such conditions where recombinant factor VIIa may be beneficial are traumatic and postpartum hemorrhages.
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Affiliation(s)
- T K Dutta
- Division of Clinical Hematology, Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006 India
| | - S P Verma
- Division of Clinical Hematology, Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006 India
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118
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Leal-Noval SR, Muñoz M, Asuero M, Contreras E, García-Erce JA, Llau JV, Moral V, Páramo JA, Quintana M, Basora M, Bautista-Paloma FJ, Bisbe E, Bóveda JL, Castillo-Muñoz A, Colomina MJ, Fernández C, Fernández-Mondéjar E, Ferrándiz C, García de Lorenzo A, Gomar C, Gómez-Luque A, Izuel M, Jiménez-Yuste V, López-Briz E, López-Fernández ML, Martín-Conde JA, Montoro-Ronsano B, Paniagua C, Romero-Garrido JA, Ruiz JC, Salinas-Argente R, Sánchez C, Torrabadella P, Arellano V, Candela A, Fernández JA, Fernández-Hinojosa E, Puppo A. [The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. ACTA ACUST UNITED AC 2013; 60:263.e1-263.e25. [PMID: 23415109 DOI: 10.1016/j.redar.2012.12.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/12/2012] [Indexed: 12/21/2022]
Abstract
Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.
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Affiliation(s)
- S R Leal-Noval
- Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).
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120
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Ragni MV. The old and new: PCCs, VIIa, and long-lasting clotting factors for hemophilia and other bleeding disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:44-51. [PMID: 24319161 DOI: 10.1182/asheducation-2013.1.44] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
What is the correct use of established clotting factors, prothrombin complex concentrates (PCCs), and activated factor VII in bleeding complications of trauma, surgery, and old and new oral anticoagulants? How will new clotting factors, specifically the long-acting factors, change the hemostatic management of coagulation deficiency disorders? From bench to bedside, comparative coagulation studies and clinical trials of modified clotting factors are providing insights to help guide hemostatic management of congenital and acquired bleeding disorders. Comparative thrombin-generation studies and preclinical and clinical trials suggest that PCCs and fresh-frozen plasma are effective in reversing the anticoagulant effects of warfarin, yet there are few data to guide reversal of the new oral anticoagulants dabigatran and rivaroxaban. Although coagulation studies support the use of PCCs to reverse new oral anticoagulants, correlation with clinical response is variable and clinical trials in bleeding patients are needed. For congenital bleeding disorders, exciting new technologies are emerging from the bench. Data from clinical trials of molecularly modified coagulation factors with extended half-lives suggest the possibility of fewer infusions, reduced bleeds, and better quality of life in persons with hemophilia. Preclinical studies of other novel prohemostatic approaches for hemophilia and other congenital coagulation disorders include RNA interference silencing of antithrombin, monoclonal anti-tissue factor pathway inhibitor (anti-antibody, anti-tissue factor pathway inhibitor) aptamer, bispecific anti-IXa/X antibody, and fucoidans. Understanding the comparative coagulation studies of established prohemostatic agents, the pharmacokinetics of new long-acting clotting factors, and their correlation with bleeding outcomes will provide opportunities to optimize the hemostatic management of both congenital and acquired hemostatic disorders.
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Affiliation(s)
- Margaret V Ragni
- 1Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh, Pittsburgh, PA
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121
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Goodnough LT, Shander A. Current status of pharmacologic therapies in patient blood management. Anesth Analg 2012; 116:15-34. [PMID: 23223098 DOI: 10.1213/ane.0b013e318273f4ae] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patient blood management(1,2) incorporates patient-centered, evidence-based medical and surgical approaches to improve patient outcomes by relying on the patient's own (autologous) blood rather than allogeneic blood. Particular attention is paid to preemptive measures such as anemia management. The emphasis on the approaches being "patient-centered" is to distinguish them from previous approaches in transfusion medicine, which have been "product-centered" and focused on blood risks, costs, and inventory concerns rather than on patient outcomes. Patient blood management(3) structures its goals by avoiding blood transfusion(4) with effective use of alternatives to allogeneic blood transfusion.(5) These alternatives include autologous blood procurement, preoperative autologous blood donation, acute normovolemic hemodilution, and intra/postoperative red blood cell (RBC) salvage and reinfusion. Reviewed here are the available pharmacologic tools for anemia and blood management: erythropoiesis-stimulating agents (ESAs), iron therapy, hemostatic agents, and potentially, artificial oxygen carriers.
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Affiliation(s)
- Lawrence Tim Goodnough
- Pathology Department, Stanford University, 300 Pasteur Drive Room H-1402, M/C 5626 Stanford, CA 94305, USA.
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122
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Donovan PJ, Iedema J, McLeod DS, Kubler P, Pillans P. Off-label use of recombinant factor VIIa in two tertiary hospitals in Queensland. ANZ J Surg 2012; 83:149-54. [PMID: 23137066 DOI: 10.1111/ans.12005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2012] [Indexed: 01/21/2023]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is used for many off-label indications without high quality evidence to support its efficacy. The aim of this study was to determine indications for use of off-label rFVIIa, efficacy and safety, and adherence to institutional guidelines. METHODS We performed a retrospective review of off-label rFVIIa at two tertiary hospitals from 2007 to 2010. RESULTS One hundred forty-five administrations were identified and analysed. Haemorrhage associated with cardiac surgery made up one-third of all rFVIIa usage, with trauma (20%) and other surgery (11%) the next most frequent indications. Compared with all others, cardiac surgery patients were older (60.0 years versus 47.4 years, P < 0.001) and had lower pre-rFVIIa transfusion requirements, a higher subjective response rate (88% versus 46%, P < 0.001) and lower mortality rates (6.1% versus 33%, P < 0.001), but higher rates of arterial thrombormbolic events (16.7% versus 2.1%, P = 0.002). Most patients received only one or two doses (n = 137; 95%), with no subject receiving a third or subsequent dose having an appreciable reduction in bleeding. Only a small number of patients (n = 15; 10.3%) had rFVIIa administered in accordance with our institutions' guidelines. CONCLUSION Patients administered rFVIIa for haemorrhage not associated with cardiac surgery were severely unwell. Despite lack of evidence, administration of rFVIIa may be justified by the high mortality rate, but more than two doses are unlikely to provide further benefit. The high rate of arterial thromboembolism in cardiac surgical patients raises risk-benefit considerations. Adherence to our institutions' guidelines was poor.
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Affiliation(s)
- Peter J Donovan
- Department of Clinical Pharmacology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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123
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DeAnda A, Hymes K. Thrombosis and Recombinant Factor VIIa: Letter 1. Ann Thorac Surg 2012; 94:1783. [DOI: 10.1016/j.athoracsur.2012.04.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 03/07/2012] [Accepted: 04/16/2012] [Indexed: 11/15/2022]
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124
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Stéphan F. [Managing of excessive bleeding after cardiac surgery under cardiopulmonary bypass]. Transfus Clin Biol 2012; 19:159-64. [PMID: 23039953 DOI: 10.1016/j.tracli.2012.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 07/21/2012] [Indexed: 11/19/2022]
Abstract
The occurrence of abnormal bleeding in postoperative cardiac surgery performed under cardiopulmonary bypass is relatively common. If the option of reoperation is not retained, the initiation of medical treatment is inevitable. Next to the transfusion of blood products, other therapies were often used empirically and as "off-label". The place of each in a future regimen should be based on well-conducted clinical studies to determine the optimal risk/benefit ratio.
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Affiliation(s)
- F Stéphan
- Réanimation adulte, centre chirurgical Marie-Lannelongue, 133, avenue de la Résistance, 92350 Le Plessis Robinson, France.
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125
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Affiliation(s)
- L. Yang
- Department of Haematology; Addenbrooke's Hospital; Cambridge; UK
| | - S. Stanworth
- NHS Blood and Transplant; John Radcliffe Hospital; Oxford; UK
| | - T. Baglin
- Department of Haematology; Addenbrooke's Hospital; Cambridge; UK
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126
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Guzzetta NA, Russell IA, Williams GD. Review of the Off-Label Use of Recombinant Activated Factor VII in Pediatric Cardiac Surgery Patients. Anesth Analg 2012; 115:364-78. [DOI: 10.1213/ane.0b013e31825aff10] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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127
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Ranucci M, Solomon C. Supplementation of fibrinogen in acquired bleeding disorders: experience, evidence, guidelines, and licences. Br J Anaesth 2012; 109:135-7. [DOI: 10.1093/bja/aes227] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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128
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Rozental T, Shore-Lesserson L. Pharmacologic Management of Coagulopathy in Cardiac Surgery: An Update. J Cardiothorac Vasc Anesth 2012; 26:669-79. [DOI: 10.1053/j.jvca.2012.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Indexed: 11/11/2022]
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129
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Lin Y, Moltzan CJ, Anderson DR. The evidence for the use of recombinant factor VIIa in massive bleeding: revision of the transfusion policy framework. Transfus Med 2012; 22:383-94. [PMID: 22630348 PMCID: PMC3546370 DOI: 10.1111/j.1365-3148.2012.01164.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In 2006, the Canadian National Advisory Committee on Blood and Blood Products (NAC) developed a transfusion policy framework for the use of off-label recombinant factor VIIa (rFVIIa) in massive bleeding. Because the number of randomised controlled trials has doubled, the NAC undertook a review of the policy framework in 2011. On the basis of the review of 29 randomised controlled trials, there remains little evidence to support the routine use of rFVIIa in massive bleeding. Mortality benefits have not been demonstrated. Contrarily, an increase in arterial thromboembolic events has been observed with the use of off-label rFVIIa. Given the absence of evidence of benefit and with evidence of the risk of harm, the NAC recommends that recombinant VIIa no longer be used for the off-label indications of prevention and treatment of bleeding in patients without haemophilia.
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Affiliation(s)
- Y Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Ontario, Canada.
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130
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Easton JD, Lopes RD, Bahit MC, Wojdyla DM, Granger CB, Wallentin L, Alings M, Goto S, Lewis BS, Rosenqvist M, Hanna M, Mohan P, Alexander JH, Diener HC. Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial. Lancet Neurol 2012; 11:503-11. [PMID: 22572202 DOI: 10.1016/s1474-4422(12)70092-3] [Citation(s) in RCA: 200] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In the ARISTOTLE trial, the rate of stroke or systemic embolism was reduced by apixaban compared with warfarin in patients with atrial fibrillation (AF). Patients with AF and previous stroke or transient ischaemic attack (TIA) have a high risk of stroke. We therefore aimed to assess the efficacy and safety of apixaban compared with warfarin in prespecified subgroups of patients with and without previous stroke or TIA. METHODS Between Dec 19, 2006, and April 2, 2010, patients were enrolled in the ARISTOTLE trial at 1034 clinical sites in 39 countries. 18,201 patients with AF or atrial flutter were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalised ratio 2·0-3·0). The median duration of follow-up was 1·8 years (IQR 1·4-2·3). The primary efficacy outcome was stroke or systemic embolism, analysed by intention to treat. The primary safety outcome was major bleeding in the on-treatment population. All participants, investigators, and sponsors were masked to treatment assignments. In this subgroup analysis, we estimated event rates and used Cox models to compare outcomes in patients with and without previous stroke or TIA. The ARISTOTLE trial is registered with ClinicalTrials.gov, number NTC00412984. FINDINGS Of the trial population, 3436 (19%) had a previous stroke or TIA. In the subgroup of patients with previous stroke or TIA, the rate of stroke or systemic embolism was 2·46 per 100 patient-years of follow-up in the apixaban group and 3·24 in the warfarin group (hazard ratio [HR] 0·76, 95% CI 0·56 to 1·03); in the subgroup of patients without previous stroke or TIA, the rate of stroke or systemic embolism was 1·01 per 100 patient-years of follow-up with apixaban and 1·23 with warfarin (HR 0·82, 95% CI 0·65 to 1·03; p for interaction=0·71). The absolute reduction in the rate of stroke and systemic embolism with apixaban versus warfarin was 0·77 per 100 patient-years of follow-up (95% CI -0·08 to 1·63) in patients with and 0·22 (-0·03 to 0·47) in those without previous stroke or TIA. The difference in major bleeding with apixaban compared with warfarin was 1·07 per 100 patient-years (95% CI 0·09-2·04) in patients with and 0·93 (0·54-1·32) in those without previous stroke or TIA. INTERPRETATION The effects of apixaban versus warfarin were consistent in patients with AF with and without previous stroke or TIA. Owing to the higher risk of these outcomes in patients with previous stroke or TIA, the absolute benefits of apixaban might be greater in this population. FUNDING Bristol-Myers Squibb and Pfizer.
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Affiliation(s)
- J Donald Easton
- Department of Neurology, University of California-San Francisco, San Francisco, CA 94143-0114, USA.
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131
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PALMASON R, VIDARSSON B, SIGVALDASON K, INGIMARSSON JP, GUDBJARTSSON T, SIGURDSSON GH, ONUNDARSON PT. Recombinant factor VIIa as last-resort treatment of desperate haemorrhage. Acta Anaesthesiol Scand 2012; 56:636-44. [PMID: 22489992 DOI: 10.1111/j.1399-6576.2012.02688.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Studies are inconclusive regarding clinical outcomes after administration of recombinant activated coagulation factor VII (rFVIIa) during severe haemorrhage. The circumstances encountered during desperate haemorrhage make it difficult to include the most critically ill patients that could possibly benefit the most from such treatment into randomized controlled trials. We report our experience with rFVIIa as last-resort treatment of desperate haemorrhage when all standard treatment has failed. MATERIALS AND METHODS Hospital charts of all consecutive patients treated with rFVIIa for desperate non-haemophilic bleeding over a 10-year period at the single institution administering rFVIIa were surveyed for treatment indications, clinical outcome, transfusion need and coagulation profiles. RESULTS Fifty-five rFVIIa treatment occasions of desperate bleeding were identified in 54 patients (median age 54 years). A single rFVIIa dose was used in 86%, and haemorrhage was considered effectively contained by immediate clinical response on 81% of occasions. Overall, 38 patients (71%) survived for over 30 days. Two thromboembolic events occurred (3.6%). The 24-h mortality in 45 rFVIIa immediate clinical responders and 10 non-responders was 2% and 50%, respectively (P = 0.0004), and the 30-day mortality was 25% and 60%, respectively (P = 0.05). Blood product use decreased with rFVIIa (P < 0.01) as did the prothrombin time (20.0-13.3 s, P < 0.0001). CONCLUSIONS The majority of unselected consecutive patients receiving rFVIIa as last-resort treatment for desperate haemorrhage were considered to have immediate clinical response as well as reduced transfusion requirements and correction of coagulation parameters. An immediate clinical response to rFVIIa may possibly be predictive of survival.
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Affiliation(s)
- R. PALMASON
- Division of Internal Medicine; Landspitali-University Hospital; Reykjavik; Iceland
| | | | - K. SIGVALDASON
- Department of Anesthesia and Intensive Care; Landspitali-University Hospital; Reykjavik; Iceland
| | - J. P. INGIMARSSON
- Department of Cardiothoracic Surgery; Landspitali-University Hospital; Reykjavik; Iceland
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132
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Goksedef D, Panagopoulos G, Nassiri N, Levine RL, Hountis PG, Plestis KA. Intraoperative use of recombinant activated factor VII during complex aortic surgery. J Thorac Cardiovasc Surg 2012; 143:1198-204. [DOI: 10.1016/j.jtcvs.2012.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 11/23/2011] [Accepted: 01/04/2012] [Indexed: 10/14/2022]
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133
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Andersen ND, Bhattacharya SD, Williams JB, Fosbol EL, Lockhart EL, Patel MB, Gaca JG, Welsby IJ, Hughes GC. Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations. Ann Thorac Surg 2012; 93:1921-8; discussion 1928-9. [PMID: 22551846 DOI: 10.1016/j.athoracsur.2012.02.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 02/07/2012] [Accepted: 02/08/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Numerous studies have supported the effectiveness of recombinant activated factor VII (rFVIIa) for the control of bleeding after cardiac procedures; however safety concerns persist. Here we report the novel use of intraoperative low-dose rFVIIa in thoracic aortic operations, a strategy intended to improve safety by minimizing rFVIIa exposure. METHODS Between July 2005 and December 2010, 425 consecutive patients at a single referral center underwent thoracic aortic operations with cardiopulmonary bypass (CPB); 77 of these patients received intraoperative low-dose rFVIIa (≤60 μg/kg) for severe coagulopathy after CPB. Propensity matching produced a cohort of 88 patients (44 received intraoperative low-dose rFVIIa and 44 controls) for comparison. RESULTS Matched patients receiving intraoperative low-dose rFVIIa got an initial median dose of 32 μg/kg (interquartile range [IQR], 16-43 μg/kg) rFVIIa given 51 minutes (42-67 minutes) after separation from CPB. Patients receiving intraoperative low-dose rFVIIa demonstrated improved postoperative coagulation measurements (partial thromboplastin time 28.6 versus 31.5 seconds; p=0.05; international normalized ratio, 0.8 versus 1.2; p<0.0001) and received 50% fewer postoperative blood product transfusions (2.5 versus 5.0 units; p=0.05) compared with control patients. No patient receiving intraoperative low-dose rFVIIa required postoperative rFVIIa administration or reexploration for bleeding. Rates of stroke, thromboembolism, myocardial infarction, and other adverse events were equivalent between groups. CONCLUSIONS Intraoperative low-dose rFVIIa led to improved postoperative hemostasis with no apparent increase in adverse events. Intraoperative rFVIIa administration in appropriately selected patients may correct coagulopathy early in the course of refractory blood loss and lead to improved safety through the use of smaller rFVIIa doses. Appropriately powered randomized studies are necessary to confirm the safety and efficacy of this approach.
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Affiliation(s)
- Nicholas D Andersen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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134
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Vorobcsuk A, Aradi D, Farkasfalvi K, Horváth IG, Komócsi A. Outcomes of patients receiving clopidogrel prior to cardiac surgery. Int J Cardiol 2012; 156:34-40. [DOI: 10.1016/j.ijcard.2010.10.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 10/23/2010] [Indexed: 10/18/2022]
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135
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Lau P, Ong V, Tan WT, Koh PL, Hartman M. Use of Activated Recombinant Factor VII in Severe Bleeding - Evidence for Efficacy and Safety in Trauma, Postpartum Hemorrhage, Cardiac Surgery, and Gastrointestinal Bleeding. ACTA ACUST UNITED AC 2012; 39:139-150. [PMID: 22670132 DOI: 10.1159/000338034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 03/15/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND: Uncontrolled bleeding continues to be a major cause of mortality in trauma, cardiac surgery, postpartum hemorrhage and liver failure. The aim of this paper is to assess the evidence supporting the efficacy of activated recombinant factor VII (rFVIIa) administration in these settings. METHODS: Electronic literature search. RESULTS: Numerous retrospective trials have mostly shown a decrease in blood transfusion requirements with no increase in thromboembolic events (TEE), but major limitations in trial design make generalization difficult. In most retrospective reports rFVIIa has been administered as a last-ditch attempt to control bleeding, when acidosis, hypothermia and coagulation factor depletion may not allow optimal rFVIIa effect. Prospective randomized controlled trials have not shown any effect of rFVIIa on mortality or TEE, although some have shown a reduction in RBC requirement. CONCLUSION: Stipulated transfusion protocols in prospective trials have reduced anticipated mortality among controls and make future trials for mortality effect unlikely in view of large sample size requirements. Establishment of these protocols and rapid hemostasis are likely to have greater benefits than administration of a single agent.
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Affiliation(s)
- Philip Lau
- Department of Surgery, National University Hospital, Singapore, Republic of Singapore
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136
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Simpson E, Lin Y, Stanworth S, Birchall J, Doree C, Hyde C. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012:CD005011. [PMID: 22419303 DOI: 10.1002/14651858.cd005011.pub4] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies and for prophylaxis and treatment of patients with congenital factor VII deficiency. It is also used for off-license indications to prevent bleeding in operations where blood loss is likely to be high, and/or to stop bleeding that is proving difficult to control by other means. This is the third version of the 2007 Cochrane review on the use of recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia, and has been updated to incorporate recent trial data. OBJECTIVES To assess the effectiveness of rFVIIa when used therapeutically to control active bleeding or prophylactically to prevent (excessive) bleeding in patients without haemophilia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and other medical databases up to 23 March 2011. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing rFVIIa with placebo, or one dose of rFVIIa with another, in any patient population (except haemophilia). Outcomes were mortality, blood loss or control of bleeding, red cell transfusion requirements, number of patients transfused and thromboembolic adverse events. DATA COLLECTION AND ANALYSIS Two authors independently assessed potentially relevant studies for inclusion, extracted data and examined risk of bias. We considered prophylactic and therapeutic rFVIIa studies separately. MAIN RESULTS Twenty-nine RCTs were included: 28 were placebo-controlled, double-blind RCTs and one compared different doses of rFVIIa. In the 'Risk of bias' assessment, most studies were found to have some threats to validity although therapeutic RCTs were found to be less prone to bias than prophylactic RCTs.Sixteen trials involving 1361 participants examined the prophylactic use of rFVIIa; 729 received rFVIIa. There was no evidence of mortality benefit (risk ratio (RR) 1.04; 95% confidence interval (CI) 0.55 to 1.97). There was decreased blood loss (mean difference (MD) -297 mL; 95% CI -416 to -178) and decreased red cell transfusion requirements (MD -261 mL; 95% CI -367 to -154) with rFVIIa treatment; however, these values were likely overestimated due to the inability to incorporate data from trials (four RCTs in the outcome of blood loss and three RCTs in the outcome of transfusion requirements) showing no difference of rFVIIa treatment compared to placebo. There was a trend in favour of rFVIIa in the number of participants transfused (RR 0.85; 95% CI 0.72 to 1.01). However, there was a trend against rFVIIa with respect to thromboembolic adverse events (RR 1.35; 95% CI 0.82 to 2.25).Thirteen trials involving 2929 participants examined the therapeutic use of rFVIIa; 1878 received rFVIIa. There were no outcomes where any observed advantage or disadvantage of rFVIIa over placebo could not have been observed by chance alone. There was a trend in favour of rFVIIa for reducing mortality (RR 0.91; 95% CI 0.78 to 1.06). However, there was a trend against rFVIIa for increased thromboembolic adverse events (RR 1.14; 95% CI 0.89 to 1.47).When all trials were pooled together to examine the risk of thromboembolic events, a significant increase in total arterial events was observed (RR 1.45; 95% CI 1.02 to 2.05). AUTHORS' CONCLUSIONS The effectiveness of rFVIIa as a more general haemostatic drug, either prophylactically or therapeutically, remains unproven. The results indicate increased risk of arterial events in patients receiving rFVIIa. The use of rFVIIa outside its current licensed indications should be restricted to clinical trials.
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Affiliation(s)
- Ewurabena Simpson
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.
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137
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Görlinger K, Fries D, Dirkmann D, Weber CF, Hanke AA, Schöchl H. Reduction of Fresh Frozen Plasma Requirements by Perioperative Point-of-Care Coagulation Management with Early Calculated Goal-Directed Therapy. ACTA ACUST UNITED AC 2012; 39:104-113. [PMID: 22670128 DOI: 10.1159/000337186] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 08/02/2011] [Indexed: 01/28/2023]
Abstract
BACKGROUND: Massive bleeding and transfusion of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets are associated with increased morbidity, mortality and costs. PATIENTS AND METHODS: We analysed the transfusion requirements after implementation of point-of-care (POC) coagulation management algorithms based on early, calculated, goal-directed therapy with fibrinogen concentrate and prothrombin complex concentrate (PCC) in different perioperative settings (trauma surgery, visceral and transplant surgery (VTS), cardiovascular surgery (CVS) and general and surgical intensive care medicine) at 3 different hospitals (AUVA Trauma Centre Salzburg, University Hospital Innsbruck and University Hospital Essen) in 2 different countries (Austria and Germany). RESULTS: In all institutions, the implementation of POC coagulation management algorithms was associated with a reduction in the transfusion requirements for FFP by about 90% (Salzburg 94%, Innsbruck 88% and Essen 93%). Furthermore, PRBC transfusion was reduced by 8.4-62%. The incidence of intraoperative massive transfusion (≥10 U PRBC) could be more than halved in VTS and CVS (2.56 vs. 0.88%; p < 0.0001 and 2.50 vs. 1.06%; p = 0.0007, respectively). Platelet transfusion could be reduced by 21-72%, except in CVS where it increased by 115% due to a 5-fold increase in patients with dual antiplatelet therapy (2.7 vs. 13.7%; p < 0.0001). CONCLUSIONS: The implementation of perioperative POC coagulation management algorithms based on early, calculated, goal-directed therapy with fibrinogen concentrate and PCC is associated with a reduction in the transfusion requirements for FFP, PRBC and platelets as well as with a reduced incidence of massive transfusion. Thus, the limited blood resources can be used more efficiently.
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Affiliation(s)
- Klaus Görlinger
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany
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138
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Fernández-Hinojosa E, Murillo-Cabezas F, Puppo-Moreno A, Leal-Noval SR. [Treatment alternatives in massive hemorrhage]. Med Intensiva 2012; 36:496-503. [PMID: 22321860 DOI: 10.1016/j.medin.2011.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 11/07/2011] [Accepted: 11/14/2011] [Indexed: 10/14/2022]
Abstract
Massive hemorrhage is the main cause of mortality and morbidity in trauma patients, and is one of the most important causes in any patient following major surgery. Conventional treatment consists of volume replacement, including the transfusion of blood products, so that tissue perfusion and oxygenation may be maintained. Associated hypothermia, acidosis and coagulopathy is a lethal triad. This review focuses on the latest therapeutic management of massive hemorrhage. The authors advocate the use of crystalloids as per protocol (controlled volumes) in order to achieve a systolic blood pressure of 85mmHg. The administration of the three blood products (red cells, plasma, and platelets) should be on a 1:1:1 basis. Where possible, this in turn should be guided by thromboelastography performed at point of care near the patient. Coagulopathy can occur early and late. With the exception of tranexamic acid, the cost-benefit relationships of the hemostatic agents, such as fibrinogen, prothrombin complex, and recombinant F VII, are subject to discussion.
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Affiliation(s)
- E Fernández-Hinojosa
- Servicio de Cuidados Críticos, Hospital Universitario Virgen del Rocío, Sevilla, España
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139
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Christensen MC, Dziewior F, Kempel A, von Heymann C. Increased Chest Tube Drainage Is Independently Associated With Adverse Outcome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2012; 26:46-51. [DOI: 10.1053/j.jvca.2011.09.021] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Indexed: 11/11/2022]
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140
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141
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Alström U, Levin LÅ, Ståhle E, Svedjeholm R, Friberg Ö. Cost analysis of re-exploration for bleeding after coronary artery bypass graft surgery. Br J Anaesth 2012; 108:216-22. [DOI: 10.1093/bja/aer391] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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142
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Tarzia V, Bottio T, Buratto E, Spiezia L, Simioni P, Gerosa G. The hazard of comparing apples and oranges: the proper indication for the use of recombinant activated clotting factor VII in cardiac surgery. J Thorac Cardiovasc Surg 2012; 142:1588-9; author reply 1589. [PMID: 22093717 DOI: 10.1016/j.jtcvs.2011.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 08/10/2011] [Indexed: 01/17/2023]
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143
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Lee AI, Campigotto F, Rawn JD, Neuberg D, Kaufman RM, Berliner N. Clinical significance of coagulation studies in predicting response to activated recombinant Factor VII in cardiac surgery patients. Br J Haematol 2012; 157:397-400. [PMID: 22224596 DOI: 10.1111/j.1365-2141.2011.08992.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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144
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Pychyńska-Pokorska M, Pągowska-Klimek I, Krajewski W, Moll JJ. Use of Recombinant Activated Factor VII for Controlling Refractory Postoperative Bleeding in Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2011; 25:987-94. [DOI: 10.1053/j.jvca.2011.05.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Indexed: 02/03/2023]
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145
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Dunne B, Xiao P, Andrews D. Successful use of factor VIIa to control life-threatening post-operative haemorrhage in a patient on extra-corporeal membrane oxygenation. Heart Lung Circ 2011; 21:229-30. [PMID: 22036715 DOI: 10.1016/j.hlc.2011.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 08/30/2011] [Accepted: 09/10/2011] [Indexed: 11/16/2022]
Abstract
Recombinant Factor VII (Novoseven) is gaining recognition as an established treatment option for post-cardiac surgery bleeding. However, little information is available on its use in patients being maintained on Extra-Corporeal Membrane Oxygenation (ECMO) support, particularly in the adult population. We present the first case of the successful use of Factor VIIa to control bleeding in an adult patient on ECMO post cardiac surgery.
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Affiliation(s)
- Ben Dunne
- Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, WA 6000, Australia.
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146
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Nalla BP, Freedman J, Hare GMT, Mazer CD. Update on blood conservation for cardiac surgery. J Cardiothorac Vasc Anesth 2011; 26:117-33. [PMID: 22000983 DOI: 10.1053/j.jvca.2011.07.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Bhanu P Nalla
- Department of Anesthesia, Keenan Research Center in the Li Ka Shing Knowledge Translation Institute of St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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147
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Ponschab M, Landoni G, Biondi-Zoccai G, Bignami E, Frati E, Nicolotti D, Monaco F, Pappalardo F, Zangrillo A. Recombinant Activated Factor VII Increases Stroke in Cardiac Surgery: A Meta-analysis. J Cardiothorac Vasc Anesth 2011; 25:804-10. [PMID: 21596585 DOI: 10.1053/j.jvca.2011.03.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Indexed: 02/08/2023]
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148
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Barua A, Rao VP, Ramesh B, Barua B, El-Shafei H. Salvage use of activated recombinant factor VII in the management of refractory bleeding following cardiac surgery. J Blood Med 2011; 2:131-4. [PMID: 22287872 PMCID: PMC3262339 DOI: 10.2147/jbm.s21609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Refractory post cardiopulmonary bypass (CPB) bleeding continues to cause concern for cardiac surgeons and intensivists. Massive postoperative hemorrhage following CPB is multifactorial and not fully understood, and it is also associated with increased mortality and morbidity. Activated recombinant factor VII (rFVIIa) has emerged as possible salvage medication in refractory post cardiac surgical bleeding. This observational study sought to identify the pattern of use of rFVIIa in cardiac surgery, its effectiveness, and risk. METHODS This study involved a retrospective case review of medical records of ten patients undergoing a variety of cardiac surgery procedures and who developed life-threatening bleeding during surgery or after surgery despite conventional medical therapy, including transfusion of blood and blood products, and received rFVIIa at a regional center between August 2007 and April 2009. RESULTS All ten patients received two consecutive doses of rFVIIa (average dose 65 μg/kg) at a 2-hour interval. Eight patients were re-explored due to massive postoperative bleeding or cardiac tamponade before receiving rFVIIa. Surgical sources of bleeding were not identified in any cases. A second re-exploration was carried out in two cases. Two patients (20%) died in ITU from problems not related to bleeding and thromboembolism. Blood loss was significantly reduced after administration of rFVIIa. Blood loss 6 hours prior to treatment was 1758.5 ± 163.9 mL and blood loss in the 6-hour period post treatment was 405.6 ± 50.5 mL (P < 0.05). Blood and blood products used in the 6-hour period before and after administration of rFVIIa were 19.6 ± 1.5U and 4.4 ± 0.6U, respectively (P < 0.05). No adverse reactions or thrombotic complications related to rFVIIa were noted. CONCLUSION In our limited study, use of rFVIIa in refractory post surgical bleeding was significantly reduced blood loss and use of blood and blood products. We concluded that rFVIIa can be used satisfactorily and safely as a rescue therapy in the management of post cardiac surgical bleeding.
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Affiliation(s)
- Anupama Barua
- Cardiothoracic Department, Nottingham City Hospital, Nottingham, UK
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149
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Fibrin formation is more impaired than thrombin generation and platelets immediately following cardiac surgery. Thromb Res 2011; 128:277-82. [PMID: 21429567 DOI: 10.1016/j.thromres.2011.02.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 02/13/2011] [Accepted: 02/23/2011] [Indexed: 11/22/2022]
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150
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Ranucci M, Aronson S, Dietrich W, Dyke CM, Hofmann A, Karkouti K, Levi M, Murphy GJ, Sellke FW, Shore-Lesserson L, von Heymann C. Patient blood management during cardiac surgery: Do we have enough evidence for clinical practice? J Thorac Cardiovasc Surg 2011; 142:249.e1-32. [DOI: 10.1016/j.jtcvs.2011.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 02/09/2011] [Accepted: 04/08/2011] [Indexed: 12/13/2022]
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