Perioperative Use of Recombinant Factor VII to Prevent Intraoperative Aneurysm Rupture in High Risk Patients: A Preliminary Safety Evaluation

Intraoperative rupture in the surgical treatment of patients with intracranial aneurysms

Intraoperative rerupture (IOR) during clipping of cerebral aneurysms is a difficult complication of microneurosurgery. The aim of this study was to evaluate the incidence of IOR and analyze the strategies for controlling profound hemorrhage. A total of 165 patients with unruptured intracranial aneurysms and 46 patients with subarachnoid hemorrhage (SAH) treated surgically between April 2010 and March 2011, were reviewed. The data were collected with regard to age, sex, presence of symptoms, confounding factors and strategy for controlling intraoperative hemorrhage was analyzed in terms of location of aneurysms, timing of rupture and severity of IOR. 211 patients with 228 aneurysms were treated in this series. There were a total of six IORs which represented an IOR rate of 2.84% per patient and 2.63% per aneurysm. The highest ruptures rates occurred in patients with internal carotid artery aneurysms (25%). Surgeries in the group with ruptured aneurysms had a much higher rate of IOR compared with surgeries in the group with unruptured aneurysms. Of the six IOR aneurysms, one occurred during predissection, four during microdissection and one during clipping. One was major IOR, three were moderate and two were minor. Intraoperative rupture of an intracranial aneurysm can be potentially devastating in vascular neurosurgery. Aneurysm location, presence of SAH and surgical experience of the operating surgeon seem to be important factors affecting the incidence of IOR.

Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm

Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.

Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications

BACKGROUND

Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications.

PURPOSE

To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy.

DATA SOURCES

Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed.

STUDY SELECTION

Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review.

DATA EXTRACTION

Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence.

DATA SYNTHESIS

16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs.

LIMITATIONS

The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded.

CONCLUSION

Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.

Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications

BACKGROUND

Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications.

PURPOSE

To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy.

DATA SOURCES

Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed.

STUDY SELECTION

Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review.

DATA EXTRACTION

Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence.

DATA SYNTHESIS

16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs.

LIMITATIONS

The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded.

CONCLUSION

Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.

Recombinant factor VIIa and the patient with neurologic bleeding: separating fact from fiction

Notwithstanding its limited Food and Drug Administration-approved indications, rFVIIa has rapidly gained widespread use for the treatment of a variety of hemorrhagic conditions, including intracranial bleeding from spontaneous, traumatic, surgical, and coagulopathic causes. Although it appears that the drug only minimally increases the risk of thromboembolic events, its efficacy remains in question. The idea of finding a universal cure for hemorrhage in a medication bottle remains highly appealing, but enthusiasm for the concept is no replacement for evidence. Neuroscience nurses, who are the interface between patients and rFVIIa, need to balance hope and hype until the facts are all in.