The use of recombinant activated coagulation factor VII for spine surgery

Perioperative hyperfibrinolysis - physiology and pathophysiology

Introduction and objectives

The role of the anesthesiologist in the perioperative management of hemostasis has attracted increasing attention. The fibrinolytic system participates in hemostasis, removing clots after repair of the vascular injury. Over the past two decades, several studies have assessed the efficacy and safety of antifibrinolytic agents in reducing perioperative bleeding and transfusion requirements. Some of the conditions that seem to benefit from antifibrinolytic drugs involve trauma, postpartum hemorrhage, cardiac surgery, spine surgery, knee or hip arthroplasty, urological and gynecological surgery, among others. However, there are currently few publications focusing on the perioperative features of fibrinolytic system, which will be the subject of the present review.

Content and conclusions

Fibrinolytic physiology, its relationship with the clot structure and its perioperative behavior are described. Pathophysiological mechanisms related to anesthesiology clinical practice and their possible perioperative scenarios are addressed according to a suggested classification. This article aims to provide anesthesiologists with a broader understanding of the normal functioning of fibrinolysis, the mechanisms of possible deviations from normality in the perioperative period, the pathophysiological rationale supporting the current indications of antifibrinolytics, and some recent outcomes obtained with their use.

A case report on the surgical treatment of the huge inflammatory pseudotumor in the AIDS patient with hemophilic

An HIV infected hemophilia patient with huge inflammatory pseudotumor was in severe ill condition. The operation of right hip joint amputation was performed on the patient with perioperative infusion of coagulation factor VIII and highly active antiretroviral therapy (HAART). The pathological found that Inflammatory cell infiltration, formation of folliculus lymphaticus, muscular fiber breakage, and fibrous tissue hyperplasy, necrosis in both soft tissue and bone were seen in inflammatory pseudotumour. The vital signs remained stable during the operation and patient's overall health condition improved significantly ten months after operation. With the infusion of coagulation factor VIII and HAART, HIV infected hemophilia patient can be safety operation and may get effective result.

Influence of cardiopulmonary bypass on the interaction of recombinant factor VIIa with activated platelets

Recombinant factor VIIa (rFVIIa) interacts preferentially with coated platelets characterized by a high exposure of phosphatidyl serine (PS), FV, FVIII, FIX, and FX binding, and fibrinogen. Cardiopulmonary bypass (CPB) is known to impair platelet function. In this study, the influence of CPB on formation of coated platelets and the interaction of rFVIIa with the platelets were studied. Blood was either exposed to a closed CPB circuit or obtained from patients undergoing CPB-assisted cardiac surgery, and platelets were analyzed by flow cytometry with and without dual agonist stimulation with thrombin and a GPVI collagen receptor agonist known to induce coated platelet formation. Platelets circulated within a closed CPB circuit did not spontaneously form coated platelets. Dual agonists stimulation caused formation of coated platelets at a reduced level compared to pre-CPB level (51 +/- 21% vs. 80 +/- 17% before CPB, p < .001). The rFVIIa interaction with the coated platelets was not impaired after CPB. Platelets isolated from patients undergoing CPB-assisted cardiac surgery also formed coated platelets only after dual agonist stimulation but to the same level as before surgery (76 +/- 8% vs. 83 +/- 14% before surgery, p = .17, n = 10). rFVIIa interaction with the coated platelets was not impaired after surgery. No spontaneous rFVIIa-binding platelets were found. The data indicate that CPB exposure in vivo does not compromise the platelet-dependent effects of rFVIIa either by spontaneous formation of coated platelets, thereby limiting the risk of systemic coagulation, or by impairing rFVIIa interaction with the agonist-induced coated platelets, thereby retaining the hemostatic potential of rFVIIa after CPB.

Effects of the hormones of the thyroid axis on the vitamin K-dependent plasma factors of blood coagulation (II, VII, IX, and X)

The hormonal regulation of haemostasis is a problem which has not received much attention. The data concerning the influence of hormones from the hypothalamic-pituitary-thyroid axis are scarce, contradictory and based mainly on clinical observations. The objective of the current research is to study the influence of the Thyrotropin releasing hormone (TRH), Thyroid stimulating hormone (TSH), Triiodothyronine (T3) and Thyroxin (T4) on the activity level of the vitamin K-dependent plasma factors of blood coagulation--factor II (F II), factor VII (F VII), factor IX (F IX) and factor X (F X). This study was carried out on 40 male Wistar rats. The necessary quantity of blood was obtained by cardiac puncture under ether narcosis. The indicators studied were activated partial thromboplastin time (aPTT), protothrombin time (PT), F II, F VII, F IX and F X, and were determined by means of Diagnostica Stago tests and with the help of an automatic coagulometer. The hormones studied were: TRH (0.06 mg/kg b.w.), TSH (1 MU/kg b.w.), T3 (0.08 mg/kg b.w.) T4 (0.08 mg/kg b.w.) prolonged aPTT (p<0.001) and PT (p<0.001). TRH and T3 significantly reduced the activity level of factors II, VII, IX and X; T4 only reduced the level of F II (p<0.05), and TSH did not induce significant changes in the haemocoagulation factors studied. The TRH, TSH, T3 and T4 hormones, although elements of one and the same axis, have an ambiguous effect on the vitamin K-dependent factors of blood coagulation. The results obtained show that the determined changes in the activity levels of the vitamin K-dependent plasma factors of blood coagulation are undoubtedly related to the hypocoagulation observed in the intrinsic and extrinsic pathways under the influence of the hormones of the thyroid axis.

Recombinant-activated coagulation factor VIIa (NovoSeven®): current development

Recombinant activated coagulation factor VII (rFVIIa) was developed initially for treatment of patients with hemophilia and neutralizing antibodies ("inhibitors") to coagulation factors VIII or IX. Owing to the unique and selective mechanism of action of rFVIIa and encouraged by clinical experience with other circumstances of inadequate hemostasis, a broad development program has been pursued to test potential efficacy and evaluate safety of this biologic for indications other than hemophilia. This review summarizes the current development of rFVIIa, focusing on results of prospective, randomized clinical trials.

Medical complications of surgical treatment of adult spinal deformity and how to avoid them

STUDY DESIGN

Review article of medical complications related to adult spinal deformity surgery.

OBJECTIVE

To identify medical complications related to surgery for adult spinal deformity and suggest ways to minimize their occurrence and to avoid them.

SUMMARY OF BACKGROUND DATA

Medical complications are a major consideration in adult spinal deformity surgery. Few studies have been done to identify the medical complication rate in relation to these procedures.

METHODS

We review the literature pertaining to medical complications regarding spinal deformity surgery.

RESULTS

Urinary tract infections are the most frequently seen complication. Additionally, pulmonary complications are the most common life-threatening complication. Medical complications are a frequent occurrence with adult deformity spinal surgery.

CONCLUSIONS

Awareness of the presentation, treatment, and prevention of medical complications of deformity surgery may allow minimization of their occurrence and optimize treatment should they occur.