Successful use of factor VIIa to control life-threatening post-operative haemorrhage in a patient on extra-corporeal membrane oxygenation

Venoarterial Extracorporeal Membrane Oxygenation in Adults With Cardiac Arrest

Cardiac arrest (CA) is a major cause of morbidity and mortality worldwide. Despite the use of conventional cardiopulmonary resuscitation (CPR), rates of return of spontaneous circulation and survival with minimal neurologic impairment remain low. Utilization of venoarterial extracorporeal membrane oxygenation (ECMO) for CA in adults is steadily increasing. Propensity-matched cohort studies have reported outcomes associated with ECMO use to be superior to that of conventional CPR alone in in-hospital patients with CA. In this review, we discuss the mechanism, indications, complications, and evidence for ECMO in CA in adults.

Safety and efficacy of recombinant activated factor VII for refractory hemorrhage in pediatric patients on extracorporeal membrane oxygenation: a single center review

Background:

Medically refractory hemorrhage in patients on ECMO (extracorporeal membrane oxygenation) support can have catastrophic complications. Recombinant-Activated Factor VII (rFVIIa; NovoSeven®) may provide lifesaving hemostasis; however, there are reports of catastrophic thrombosis related to its administration.

Objective:

This review attempts to add safety and efficacy data to existing literature regarding the use of rFVIIa for refractory hemorrhage in pediatric patients on ECMO support.

Design/Methods:

A retrospective chart review was performed for all pediatric patients on ECMO who received rFVIIa for refractory hemorrhage from 2004 to 2009. Data was extracted for each refractory bleeding event, including patient blood loss and transfused blood products in the 6 hours before the first dose, between rFVIIa doses and in the 6 hours after the final dose. For purposes of data collection, a hemorrhagic event was defined as new onset hemorrhage or a hemorrhage occurring at least 12 hours after the most recent dose of rFVIIa.

Results:

In total, seven patients aged 1 month to 15 years received rFVIIa for 14 different hemorrhagic events. There was no significant difference in blood loss or blood product transfusion associated with rFVIIa administration. There was one patient-related and one ECMO-related complication temporally associated with rFVIIa administration: decreased ECMO circuit oxygenator efficiency and the development of an intra-gastric clot requiring surgical evacuation.

Conclusion:

These data suggest limited efficacy for rFVIIa use for refractory hemorrhage in pediatric patients on ECMO support. There were two non-catastrophic complications temporally associated with its administration.

Recombinant factor VIIa for uncontrollable bleeding in patients with extracorporeal membrane oxygenation: report on 15 cases and literature review

Introduction

Bleeding is the most frequent complication in patients receiving venoarterial or venovenous extracorporeal membrane oxygenation (ECMO). Recombinant activated factor VII (rFVIIa) has been used in these patients with conflicting results. We describe our experience with rFVIIa for refractory bleeding in this setting and review the cases reported in the literature.

Methods

Clinical characteristics, demographics, bleeding, thrombotic complications, mortality, and rFVIIa administration were retrospectively collected for analysis from the electronic charts of the 15 patients in our intensive care unit who received rFVIIa while being given ECMO from January 2006 to March 2011.

Results

Fifteen patients received rFVIIa for persistent bleeding under venoarterial (n = 11) or venovenous (n = 4) ECMO. Bleeding dramatically decreased in 14 patients, without a major thrombotic event, except in one patient in whom a major stroke could not be ruled out. Two circuits were changed within the 48 hours after rFVIIa administration for clots in the membrane and decreased oxygenation but without massive clotting. The mortality rate was 60%.

Conclusions

rFVIIa use for intractable hemorrhaging in patients receiving ECMO controlled bleeding, without major thrombotic events, and with 60% dying. Hence, its use warrants discussion, and clinicians should be aware of the possibility of potentially life-threatening systemic thrombosis, emboli, or circuit clotting. Whether rFVIIa can save the lives of such patients remains to be determined.

Mechanical circulatory support for cardiogenic shock

Cardiogenic shock (CS) is a syndrome of progressive depression of myocardial function with systemic hypoperfusion. It occurs due to various aetiologies such as acute myocardial infarction, myocarditis, acute decompensated heart failure and postcardiotomy. Cardiogenic shock carries poor prognosis, and medical therapy alone is not effective. Mechanical circulatory support is required to unload the ventricles, decrease the myocardial demand, prevent further injury, improve the coronary perfusion, stabilise the haemodynamics and maintain the end-organ perfusion before definitive interventions such as coronary reperfusion can take place. Currently, there are several methods of mechanical circulatory support. These include extracorporeal life support, paracorporeal or extracorporeal ventricular-assist devices, percutaneous ventricular assist devices, intra-aortic balloon counterpulsation and total artificial heart. In this review, we discuss the role of each of these circulatory support devices in the management of acute cardiac failure.