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Alhourani A, Stephenson TL, Bridwell EM, Danehower SE, Walek KW, Smith JW, Sieg E. Coagulopathy in Penetrating Ballistic Cranial Trauma: A 7-Year Experience. Neurosurgery 2024:00006123-990000000-01221. [PMID: 38899908 DOI: 10.1227/neu.0000000000002995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/25/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Penetrating ballistic cranial trauma (PBCT) carries significant mortality when compared with blunt trauma. The development of coagulopathy in PBCT is a strong predictor of mortality. The goal of the study was to describe the incidence and risk factors of coagulopathy in PBCT and to report the value of tranexamic acid administration in PBCT. METHODS We retrospectively analyzed 270 patients who presented with PBCT to a single, Level 1 trauma center between 2016 and 2023. RESULTS A total of 47% (127/270) of patients with PBCT developed coagulopathy at presentation. Fifty-seven patients received tranexamic acid at presentation, which did not affect the development of coagulopathy. Coagulopathic patients were more likely to have more serious injury patterns (bihemispheric [adjusted odds ratio, aOR: 2.6 CI: 1.4-4.9, P = .004] or transventricular trajectories [aOR: 4.9 CI: 1.9-19.6, P = .03]). In addition, they presented with a larger base deficit (aOR: 0.9 CI: 1.002-1.2 per mEq/L, P = .006) which negatively correlated with the international normalized ratio (ρ: -0.46, P < .0001, Spearman correlation). Using thromboelastography helped to identify an additional 20% of patients who presented with normal coagulation on conventional testing. CONCLUSION Coagulopathy is prevalent in approximately 50% of patients with PBCT and is persistent despite treatment in a substantial subset of patients. The addition of thromboelastography with its increased coagulopathy sensitivity can potentially guide treatment more efficiently than traditional coagulopathy laboratory tests and fibrinogen alone. Patients with a significant base deficit on arterial blood gas are at higher risk for coagulopathy.
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Affiliation(s)
- Ahmad Alhourani
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Tyler L Stephenson
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Sarah E Danehower
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Konrad W Walek
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Jason W Smith
- Department of General Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Emily Sieg
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
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Joseph B, Aziz H, Pandit V, Hays D, Kulvatunyou N, Tang A, Wynne J, Keeffe TO, Green DJ, Friese RS, Gruessner R, Rhee P. Prothrombin Complex Concentrate Use in Coagulopathy of Lethal Brain Injuries Increases Organ Donation. Am Surg 2020. [DOI: 10.1177/000313481408000413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration ( P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10) patients. Of these seven patients, consent for donation was obtained in six patients and resulted in 19 solid organs being procured. The cost of PCC per patient was $1022 ± 544. PCC effectively reveres coagulopathy associated with lethal traumatic brain injury and enabled patients to proceed to organ donation. Although various methodologies exist for the treatment of coagulopathy to facilitate organ donation, PCC provides a rapid and cost-effective therapy for reversal of coagulopathy in patients with lethal traumatic brain injuries.
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Affiliation(s)
- Bellal Joseph
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Hassan Aziz
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Viraj Pandit
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Daniel Hays
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Julie Wynne
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Terence O Keeffe
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Donald J. Green
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Randall S. Friese
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Rainer Gruessner
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona, Tucson, Arizona
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Neal CJ, Bell RS, Carmichael JJ, DuBose JJ, Grabo DJ, Oh JS, Remick KN, Bailey JA, Stockinger ZT. Catastrophic Non-Survivable Brain Injury Care-Role 2/3. Mil Med 2019; 183:73-77. [PMID: 30189063 DOI: 10.1093/milmed/usy083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Indexed: 11/13/2022] Open
Abstract
A catastrophic brain injury is defined as any brain injury that is expected to result in permanent loss of all brain function above the brain stem level. These clinical recommendations will help stabilize the patient so that they may be safely evacuated from theater. In addition to cardiovascular and hemodynamic goals, special attention must be paid to their endocrine dysfunction and its treatment-specifically steroid, insulin and thyroxin (t4) replacement while evaluating for and treating diabetes insipidus. Determining the futility of care coupled with resource management must also be made at each echelon. Logistical coordination and communication is paramount to expedite these patients to higher levels of care so that there is an increased probability of reuniting them with their family.
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Affiliation(s)
- Chris J Neal
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Randy S Bell
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - J Jonas Carmichael
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Joseph J DuBose
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Daniel J Grabo
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - John S Oh
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Kyle N Remick
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jeffrey A Bailey
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt T Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Kozek-Langenecker S, Sørensen B, Hess JR, Spahn DR. Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R239. [PMID: 21999308 PMCID: PMC3334790 DOI: 10.1186/cc10488] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 08/23/2011] [Accepted: 10/14/2011] [Indexed: 12/14/2022]
Abstract
Introduction Haemostatic therapy in surgical and/or massive trauma patients typically involves transfusion of fresh frozen plasma (FFP). Purified human fibrinogen concentrate may offer an alternative to FFP in some instances. In this systematic review, we investigated the current evidence for the use of FFP and fibrinogen concentrate in the perioperative or massive trauma setting. Methods Studies reporting the outcome (blood loss, transfusion requirement, length of stay, survival and plasma fibrinogen level) of FFP or fibrinogen concentrate administration to patients in a perioperative or massive trauma setting were identified in electronic databases (1995 to 2010). Studies were included regardless of type, patient age, sample size or duration of patient follow-up. Studies of patients with congenital clotting factor deficiencies or other haematological disorders were excluded. Studies were assessed for eligibility, and data were extracted and tabulated. Results Ninety-one eligible studies (70 FFP and 21 fibrinogen concentrate) reported outcomes of interest. Few were high-quality prospective studies. Evidence for the efficacy of FFP was inconsistent across all assessed outcomes. Overall, FFP showed a positive effect for 28% of outcomes and a negative effect for 22% of outcomes. There was limited evidence that FFP reduced mortality: 50% of outcomes associated FFP with reduced mortality (typically trauma and/or massive bleeding), and 20% were associated with increased mortality (typically surgical and/or nonmassive bleeding). Five studies reported the outcome of fibrinogen concentrate versus a comparator. The evidence was consistently positive (70% of all outcomes), with no negative effects reported (0% of all outcomes). Fibrinogen concentrate was compared directly with FFP in three high-quality studies and was found to be superior for > 50% of outcomes in terms of reducing blood loss, allogeneic transfusion requirements, length of intensive care unit and hospital stay and increasing plasma fibrinogen levels. We found no fibrinogen concentrate comparator studies in patients with haemorrhage due to massive trauma, although efficacy across all assessed outcomes was reported in a number of noncomparator trauma studies. Conclusions The weight of evidence does not appear to support the clinical effectiveness of FFP for surgical and/or massive trauma patients and suggests it can be detrimental. Perioperatively, fibrinogen concentrate was generally associated with improved outcome measures, although more high-quality, prospective studies are required before any definitive conclusions can be drawn.
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Affiliation(s)
- Sibylle Kozek-Langenecker
- Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna, Hans-Sachs-Gasse 10-12, 1180-Vienna, Austria.
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Geeraerts T, Haïk W, Tremey B, Duranteau J, Vigué B. [Coagulation disorders after traumatic brain injury: pathophysiology and therapeutic implications]. ACTA ACUST UNITED AC 2010; 29:e177-81. [PMID: 20655167 DOI: 10.1016/j.annfar.2010.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Early activation of coagulation is common after traumatic brain injury. Its origin is probably mainly intracerebral, due to tissue factor release from the injured brain. Abnormalities in blood coagulation tests are associated with poor neurological prognosis. Coagulation activation may induce disseminated intravascular coagulation and fibrinolysis. Disseminated intravascular coagulation is linked to brain ischemia caused by intravascular microthrombosis. This review will focus on pathophysiology of coagulation disorders after traumatic brain injury, and on their implications for therapeutic approaches.
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Affiliation(s)
- T Geeraerts
- Département d'anesthésie-réanimation chirurgicale, hôpital de Bicêtre, AP-HP, faculté de médecine, université Paris Sud, 78 rue du Général-Leclerc, Le-Kremlin-Bicêtre, France.
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Use of Recombinant Factor VIIa to Facilitate Organ Donation in Trauma Patients with Devastating Neurologic Injury. J Am Coll Surg 2009; 208:120-5. [DOI: 10.1016/j.jamcollsurg.2008.09.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 09/19/2008] [Accepted: 09/24/2008] [Indexed: 11/18/2022]
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Abstract
As of August 2007, 96 900 people are awaiting organ transplantation in the United States, while only 28 930 transplants were performed in 2006. With such a large gap between organ need and organ availability, it is inevitable that many will die while awaiting transplantation. This organ shortage has become a national public health crisis, and as a response, the United States Department of Health and Human Services launched the Organ Donation Breakthrough Collaborative, an ambitious campaign to dramatically increase the number of transplantable organs. One of the suggested strategies involves maximizing the number of organs obtained from the available cadaveric "brain dead'' donor pool by using donor management protocols that optimize and treat the profound physiological disturbances that are associated with brain death. The use of these standardized and aggressive donor management protocols has been shown to increase the number of transplanted organs and prevent the number of donors lost due to medical failures. A protocol-driven approach by a dedicated organ donor management team should be considered a key component of any program designed to bridge the gap between organ supply and demand.
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Affiliation(s)
- Joseph DuBose
- Division of Trauma and Critical Care at the Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
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8
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Abstract
Facial gunshot wounds pose a significant challenge for reconstructive surgeons, particularly when composed of significant soft and bone tissue defects. Often the result of assault, accident, or suicide attempt, facial defects must be thoroughly evaluated to devise an appropriate tissue repair and replacement with the likely prospect of secondary revision. In the acute setting after injury, the primary concern is patient stabilization centered on advanced trauma life support. Thorough examination along with appropriate imaging is critical for identifying any existing defects. As opposed to past surgical management that advocated delayed definitive treatment using serial debridement, today's management favors the use of more immediate reconstruction. Recent improvements in microsurgical technique have shifted favor from local tissue advancement to distant free-flap transfers, which improve cosmesis and function. This has reduced the number of surgeries necessary to achieve reconstruction. Given the diversity and complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is ultimately achieved.
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Zhang J, Groff RF, Chen XH, Browne KD, Huang J, Schwartz ED, Meaney DF, Johnson VE, Stein SC, Rojkjaer R, Smith DH. Hemostatic and neuroprotective effects of human recombinant activated factor VII therapy after traumatic brain injury in pigs. Exp Neurol 2008; 210:645-55. [PMID: 18291370 PMCID: PMC3979422 DOI: 10.1016/j.expneurol.2007.12.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 12/07/2007] [Accepted: 12/13/2007] [Indexed: 12/26/2022]
Abstract
Human recombinant activated factor-VII (rFVIIa) has been used successfully in the treatment of spontaneous intracerebral hemorrhage. In addition, there is increasing interest in its use to treat uncontrolled bleeding of other origins, including trauma. The aim of this study was to evaluate the safety and potential effectiveness of rFVIIa to mitigate bleeding using a clinically relevant model of traumatic brain injury (TBI) in the pig. A double injury model was chosen consisting of (1) an expanding cerebral contusion induced by the application of negative pressure to the exposed cortical surface and (2) a rapid rotational acceleration of the head to induce diffuse axonal injury (DAI). Injuries were performed on 10 anesthetized pigs. Five minutes after injury, 720 microg/kg rFVIIa (n=5) or vehicle control (n=5) was administered intravenously. Magnetic resonance imaging (MRI) studies were performed within 30 min and at 3 days post-TBI to determine the temporal expansion of the cerebral contusion. Euthanasia and histopathologic analysis were performed at day 3. This included observations for hippocampal neuronal degeneration, axonal pathology and microclot formation. The expansion of contusion volume over the 3 days post-injury period was reduced significantly in animals treated with rFVIIa compared to vehicle controls. Surprisingly, immunohistochemical analysis demonstrated that the number of dead/dying hippocampal neurons and axonal pathology was reduced substantially by rFVIIa treatment compared to vehicle. In addition, there was no difference in the extent of microthrombi between groups. rFVIIa treatment after TBI in the pig reduced expansion of hemorrhagic cerebral contusion volume without exacerbating the severity of microclot formation. Finally, rFVIIa treatment provided a surprising neuroprotective effect by reducing hippocampal neuron degeneration as well as the extent of DAI.
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Affiliation(s)
- Jun Zhang
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Robert F. Groff
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Xiao-Han Chen
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Kevin D. Browne
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Jason Huang
- Department of Neurological Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, NY 14642, USA
| | - Eric D. Schwartz
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David F. Meaney
- Department of Bioengineering, The University of Pennsylvania, Philadelphia PA19104, USA
| | - Victoria E. Johnson
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Sherman C. Stein
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | | | - Douglas H. Smith
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Harhangi BS, Kompanje EJO, Leebeek FWG, Maas AIR. Coagulation disorders after traumatic brain injury. Acta Neurochir (Wien) 2008; 150:165-75; discussion 175. [PMID: 18166989 DOI: 10.1007/s00701-007-1475-8] [Citation(s) in RCA: 229] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 10/01/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Over the past decade new insights in our understanding of coagulation have identified the prominent role of tissue factor. The brain is rich in tissue factor, and injury to the brain may initiate disturbances in local and systemic coagulation. We aimed to review the current knowledge on the pathophysiology, incidence, nature, prognosis and treatment of coagulation disorders following traumatic brain injury (TBI). METHODS We performed a MEDLINE search from 1966 to April 2007 with various MESH headings, focusing on head trauma and coagulopathy. We identified 441 eligible English language studies. These were reviewed for relevance by two independent investigators. A meta-analysis was performed to calculate the frequencies of coagulopathy after TBI and to determine the association of coagulopathy and outcome, expressed as odds ratios. RESULTS Eighty-two studies were relevant for the purpose of this review. Meta-analysis of 34 studies reporting the frequencies of coagulopathy after TBI, showed an overall prevalence of 32.7%. The presence of coagulopathy after TBI was related both to mortality (OR 9.0; 95%CI: 7.3-11.6) and unfavourable outcome (OR 36.3; 95%CI: 18.7-70.5). CONCLUSIONS We conclude that coagulopathy following traumatic brain injury is an important independent risk factor related to prognosis. Routine determination of the coagulation status should therefore be performed in all patients with traumatic brain injury. These data may have important implications in patient management. Well-performed prospective clinical trials should be undertaken as a priority to determine the beneficial effects of early treatment of coagulopathy.
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In vitro effect of activated recombinant factor VII (rFVIIa) on coagulation properties of human blood at hypothermic temperatures. ACTA ACUST UNITED AC 2008; 63:1079-86. [PMID: 17993954 DOI: 10.1097/ta.0b013e31815885f1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) is currently administered off-label to control diffuse coagulopathic bleeding of patients with traumatic injuries. These patients are often cold, acidotic, and coagulopathic upon arrival and each responds differently to rFVIIa therapy. This study investigated the effects of hypothermia on clotting and the potential benefit of rFVIIa administration on blood coagulation at different hypothermic temperatures. METHOD Citrated blood samples were collected from eight healthy volunteers (20-45 years old) and incubated at 37 degrees C, 34 degrees C, 31 degrees C, and 28 degrees C for 30 minutes. rFVIIa (1.26 microg/mL equivalent to 90 microg/kg in vivo dose) or vehicle solution (saline) was added to each blood sample, incubated (10 minutes), and analyzed at the respective temperatures by standard coagulation tests and thrombelastography. RESULTS The clot reaction time of blood samples, measured as prothrombin time, activated partial thromboplastin time, and R time (thrombelastography analysis), was significantly prolonged at 31 degrees C or below compared with at 37 degrees C. The clot formation rate ([alpha] angle, maximum clotting velocity [Vmax]) was decreased at all cold temperatures. Maximum clot strength (maximum amplitude) was only affected (reduced) at 28 degrees C. Addition of rFVIIa shortened the prothrombin time, activated partial thromboplastin time, and R times at every temperature, surpassing the normal (37 degrees C) temperature values in 31 degrees C and 34 degrees C cold samples. Similarly, clot formation rate parameters (clotting time, [alpha] angle, Vmax) were also improved by rFVIIa addition and normothermic values were restored in 31 degrees C and 34 degrees C cold blood samples. rFVIIa did not affect maximum amplitude at any temperature. CONCLUSIONS Mild to moderate hypothermia delayed the initial clot reaction and reduced clot formation rate without affecting ultimate clot strength. FVIIa effectively compensated for the adverse effects of hypothermia except in severe cases. These results suggest that administration of FVIIa should be beneficial in enhancing hemostasis in hypothermic trauma patients without the need for prior correction of the patient's body temperature.
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Webert KE, Arnold DM, Carruthers J, Molnar L, Almonte T, Decker K, Seroski W, Reed J, Chan AK, Pai M, Walker IR. Utilization of recombinant activated factor VII in southern Ontario in 85 patients with and without haemophilia. Haemophilia 2007; 13:518-26. [PMID: 17880438 DOI: 10.1111/j.1365-2516.2007.01490.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Recombinant activated factor VII (rFVIIa) is licensed for the treatment of bleeding in individuals with haemophilia and inhibitors. The use of rFVIIa appears to be increasing, and an increase in unlicensed use is suspected. There are currently few data about the specific indications for its use. The aim of this study was to describe the patterns of utilization of rFVIIa. We performed a retrospective cohort study using rFVIIa infusion data collected prospectively and clinical data collected retrospectively. Patients were identified using a tracking system designed to account for use of all coagulation factor concentrates issued in southern Ontario. Between 1 January 2001 and 31 December 2005, 85 patients received rFVIIa. 1164 infusions were given (8246.4 mg). Haemophilia patients with inhibitors accounted for 82.9% of rFVIIa infused and represented 8.2% of patients. The total amount of rFVIIa used increased each year from 2001 to 2004 and then decreased in 2005. The total number of infusions of rFVIIa administered annually increased. Both on-label and off-label use of rFVIIa increased. The number of patients with haemophilia receiving rFVIIa remained small and constant. The number of patients receiving rFVIIa for off-label indications increased markedly. Most rFVIIa infusions were given for licensed indications; however, these infusions represented <10% of patients treated. Overall, the utilization of rFVIIa is increasing, mostly for approved indications; however, the number of patients being prescribed rFVIIa for off-label indications has increased. The tracking system used in this study is a valuable tool to describe ongoing utilization patterns of rFVIIa.
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Affiliation(s)
- K E Webert
- Division of Hematology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada.
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Pang G, Donaldson A. Probable right atrial thrombus immediately after recombinant activated factor VII administration. Br J Anaesth 2007; 99:221-5. [PMID: 17522107 DOI: 10.1093/bja/aem099] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
We report the finding of a probable right atrial thrombus in a 33-yr-old male patient with severe head, chest, and abdominal trauma. Refractory coagulopathy and gross haemodynamic instability ensued, which was only partially controlled with massive blood product transfusion and high-dose inotropic support during laparotomy. Continuous transoesophageal echocardiography revealed a probable atrial thrombus partially occluding the right ventricular inflow tract, which appeared immediately after the patient received 100 microg kg(-1) of recombinant activated factor VII (rFVIIa) via a left internal jugular central line. This is the first report documenting an immediate temporal relationship between rFVIIa administration and a space-occupying lesion compatible with localized thrombosis, despite ongoing severe systemic coagulopathy. We review the clinical use of rFVIIa and discuss possible factors contributing to this event.
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Affiliation(s)
- G Pang
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, Queensland 4006, Australia.
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15
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Aiyagari V, Diringer MN. Response to discussion by Dr Philip Hébert. J Crit Care 2006; 21:115-6; author reply 116. [PMID: 16616637 DOI: 10.1016/j.jcrc.2005.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Accepted: 11/08/2005] [Indexed: 10/24/2022]
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