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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Transfusion Therapy in Specific Clinical Situations. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Transfusion interventions in critical bleeding requiring massive transfusion: a systematic review. Transfus Med Rev 2015; 29:127-37. [PMID: 25716645 DOI: 10.1016/j.tmrv.2015.01.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/28/2015] [Accepted: 01/30/2015] [Indexed: 01/08/2023]
Abstract
Critical bleeding (CB) requiring massive transfusion (MT) can occur in a variety of clinical contexts and is associated with substantial mortality and morbidity. In 2011, the Australian National Blood Authority (NBA) published patient blood management guidelines for CB and MT, which found limited high-quality evidence from which only 2 recommendations could be made. The aim of this systematic review (SR) was to update these guidelines and identify evidence gaps still to be addressed. A comprehensive search was performed for randomized controlled trials (RCTs) and SRs using MeSH index and free text terms in MEDLINE, the Cochrane Library (Issue 11, 2012), EMBASE, CINHAL, PUBMED, and the Transfusion Evidence Library up to July 15, 2014. The evidence was grouped according to 4 questions based on the original guideline relating to transfusion interventions: (1) effect of dose, timing, and ratio of red blood cells (RBCs) to component therapy on patient outcomes; (2) effect of RBC transfusion on patient outcomes; (3) effect of fresh frozen plasma, platelet, cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrate on patient outcomes; and (4) effect of recombinant activated factor VII (rFVIIa) on patient outcomes. From this search, 19 studies were identified: 6 RCTs and 13 SRs. Two of the RCTs were pilot/feasibility studies, 3 were investigating rFVIIa, and 1 compared restrictive versus liberal RBC transfusion in upper gastrointestinal hemorrhage. Overall, limited new evidence was identified and substantial evidence gaps remain, particularly with regard to the effect of component therapies, including ratio of RBC to component therapies, on patient outcomes. Clinical trials to address these questions are required.
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Emiru T, Bershad EM, Zantek ND, Datta YH, Rao GHR, Hartley EW, Divani AA. Intracerebral hemorrhage: a review of coagulation function. Clin Appl Thromb Hemost 2012; 19:652-62. [PMID: 22904112 DOI: 10.1177/1076029612454938] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is associated with a higher mortality rate among stroke subtypes. The amount of hematoma at baseline and subsequent expansion are considered strong independent markers for determining poor clinical outcome. Even though reduction in blood pressure to prevent and control the amount of bleeding in ICH has received considerable amount of attention, the impact of coagulopathy and platelet dysfunction, on the bleeding diathesis has not been extensively investigated. With the increasing use of antiplatelets and/or anticoagulants, given the aging population, a deeper understanding of the interactions between ICH and hemostatic mechanisms is essential to help minimize the risk of a catastrophic coagulopathy-related ICH. In this review article, etiology and risk factors associated with coagulopathy-related ICH are discussed. An overview of coagulation abnormalities, hemostatic agents, and blood biomarkers pertaining to ICH is included.
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Affiliation(s)
- Tenbit Emiru
- 1Department of Neurology, University of Minnesota, Minneapolis, MN, USA
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A review of current methods for assessing hemostasis in vivo and introduction to a potential alternative approach. Thromb Res 2012; 129 Suppl 2:S57-61. [PMID: 22405050 DOI: 10.1016/j.thromres.2012.02.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A validated method for assessing hemostasis in vivo is critical for testing the hemostatic efficacy of therapeutic agents in preclinical animal models and in patients with inherited bleeding disorders, such as von Willebrand disease (VWD) and hemophilia A, or with acquired bleeding disorders such as those resulting from medications or disease processes. In this review, we discuss current methods for assessing hemostasis in vivo and the associated challenges. We also present ARFI-Monitored Hemostatic Challenge; a new, potentially alternate method for in vivo hemostasis monitoring that is in development by our group.
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Transfusion Therapy in Specific Clinical Situations. Transfus Med 2011. [DOI: 10.1002/9781444398748.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011. [PMID: 21502651 DOI: 10.1059/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
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.
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011; 154:529-40. [PMID: 21502651 PMCID: PMC4102260 DOI: 10.7326/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
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.
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Curry N, Stanworth S, Hopewell S, Dorée C, Brohi K, Hyde C. Trauma-induced coagulopathy--a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice? Transfus Med Rev 2011; 25:217-231.e2. [PMID: 21377318 DOI: 10.1016/j.tmrv.2011.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systematic reviews are accepted as a robust and less biased means of appraising and synthesizing results from high-quality studies. This report collated and summarized all the systematic review evidence relating to the diagnosis and management of trauma-related coagulopathy and transfusion, thereby covering the widest possible body of literature. We defined 4 key clinical questions: (1) What are the best methods of predicting and diagnosing trauma-related coagulopathy? (2) Which methods of clinical management correct coagulopathy? (3) Which methods of clinical management correct bleeding? and (4) What are the outcomes of transfusion in trauma? Thirty-seven systematic reviews were identified through searches of MEDLINE (1950-July 2010), EMBASE (1980-July 2010), The Cochrane Library (Issue 7, 2010), National Guidelines Clearing House, National Library for Health Guidelines Finder, and UKBTS SRI Transfusion Evidence Library (www.transfusionevidencelibrary.com). The evidence from the systematic review literature was scanty with many gaps, and we were not able to conclusively answer any of our 4 questions. Much more needs to be understood about how coagulopathy and bleeding in trauma are altered by transfusion practices and, most importantly, whether this translates into improved survival. There is a need for randomized controlled trials to answer these questions. The approach described in this report provides a framework for incorporating new evidence.
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Affiliation(s)
- Nicola Curry
- NHS Blood and Transplant, Oxford Radcliffe Hospitals NHS Trust and University of Oxford, UK.
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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 2011:CD005011. [PMID: 21328270 DOI: 10.1002/14651858.cd005011.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies. It is also increasingly being 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. 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 STRATEGY We searched the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE, EMBASE and other specialised databases up to 25 February 2009. 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-five RCTs were included: 24 were placebo-controlled double-blind RCTs and one compared different doses of rFVIIa.Fourteen trials involving 1137 participants examined the prophylactic use of rFVIIa; 713 received rFVIIa. There was no evidence of mortality benefit (RR 1.06; 95% CI 0.50 to 2.24). There was decreased blood loss (WMD -272 mL; 95% CI -399 to -146) and decreased red cell transfusion requirements (WMD -243 mL; 95% CI -393 to -92) with rFVIIa treatment; however these values were likely overestimated due to the inability to incorporate data from trials showing no difference of rFVIIa treatment compared to placebo. There was a trend in favour of rFVIIa in the number of participants transfused (RR 0.91; 95% CI 0.82 to 1.02). But there was a trend against rFVIIa with respect to thromboembolic adverse events (RR 1.32; 95% CI 0.84 to 2.06).Eleven trials involving 2366 participants examined the therapeutic use of rFVIIa; 1507 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 0.89; 95% CI 0.77 to 1.03). However, there was a trend against rFVIIa for increased thromboembolic adverse events (RR 1.21; 95% CI 0.93 to 1.58). AUTHORS' CONCLUSIONS The effectiveness of rFVIIa as a more general haemostatic drug, either prophylactically or therapeutically, remains unproven. The use of rFVIIa outside its current licensed indications should be restricted to clinical trials.
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Affiliation(s)
- Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre and Canadian Blood Services, 2075 Bayview Avenue, Room B204, Toronto, Ontario, Canada, M4N 3M5
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Wicklund BM. Bleeding and clotting disorders in pediatric liver disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:170-177. [PMID: 22160030 DOI: 10.1182/asheducation-2011.1.170] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The coagulopathy of liver disease in pediatric patients presents an unusual set of challenges. Little pediatric data have been published, so this review is based largely on adult studies. There is a precarious balance between deficiencies of clotting factors and anticoagulation factors in liver disease that result in abnormal prothrombin time (PT) and activated partial thromboplastin time (aPTT) tests that would suggest a bleeding tendency, yet the patients can form a clot and are at risk of thromboembolic disease. Attention has centered on thromboelastography and thrombin-generation assays to clarify the patient's ability to control bleeding, but these tests are not routinely available to many treating physicians.
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Affiliation(s)
- Brian M Wicklund
- Department of Hematology/Oncology, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Recombinant Factor VIIa: An Assessment of Evidence Regarding Its Efficacy and Safety in the Off-Label Setting. Hematology 2010; 2010:153-9. [DOI: 10.1182/asheducation-2010.1.153] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Recombinant human factor VIIa (rFVIIa) is approved by the US Food and Drug Administration for use in the setting of hemorrhage associated with factor VIII or factor IX inhibitors in patients with congenital or acquired hemophilia. This indication represents only a small number of bleeding conditions. Since it became available, rFVIIa has been increasingly used in the management of off-label indications, ranging from emergent hemostasis in traumatic hemorrhage to prophylactic hemostasis in patients undergoing major surgery. Prominent off-label indications include the management of patients with coagulopathies, such as occurs in trauma patients experiencing massive and uncontrolled hemorrhage, and in patients undergoing cardiovascular surgery with cardiopulmonary bypass. Other occasions for use occur in patients with intact coagulation systems, with nontraumatic intracranial hemorrhage being the most common in this group. Uncertainties regarding the efficacy and safety associated with use of rFVIIa in these off-label scenarios have led to evidence-based assessments of patient outcomes, including mortality, the rate of thromboembolic adverse events, and posttreatment functional status. We review the evidence regarding the efficacy and safety of this important, but controversial, hemostatic agent in the off-label setting.
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DeLoughery TG. Management of acquired bleeding problems in cancer patients. Hematol Oncol Clin North Am 2010; 24:603-24. [PMID: 20488357 DOI: 10.1016/j.hoc.2010.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cancer patients can have acquired bleeding problems for many reasons. In this review, an approach to the evaluation and management of the bleeding patient is discussed. Specific issues including coagulation defects, thrombocytopenia, platelet dysfunction, and bleeding complications of specific hematological malignancies due to anticoagulation, are discussed.
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Affiliation(s)
- Thomas G DeLoughery
- Divisions of Hematology and Medical Oncology, Department of Medicine, L586, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA.
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Abstract
Cancer patients can have acquired bleeding problems for many reasons. In this review, an approach to the bleeding patient in the Emergency Department is discussed. Specific issue including coagulation defects, thrombocytopenia, platelet dysfunction, bleeding complications of specific hematological malignancies and due to anticoagulation, are discussed.
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Affiliation(s)
- Thomas G DeLoughery
- Division of Hematology, Department of Medicine, L586, Oregon Health & Science University, Portland, OR 97201-3098, USA.
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Abstract
Disorders of hemostasis and thrombosis are frequently encountered in the ICU setting. Understanding the relevance of laboratory findings is essential in providing appropriate therapy. Various blood products and hemostatic agents are available to assist in the control of bleeding, and several different classes of anticoagulants are now available for use. Appropriate use of these agents maximizes therapeutic effect while minimizing complications. Use of fresh frozen plasma, cryoprecipitate, and other hemostatic agents should generally be reserved for those who have active bleeding, those undergoing invasive procedures, and those at high risk for bleeding because of their underlying diagnoses or because of associated hematologic derangements.
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Affiliation(s)
- Peter W Marks
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
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Stanworth SJ, Birchall J, Doree CJ, Hyde C. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2007:CD005011. [PMID: 17443565 DOI: 10.1002/14651858.cd005011.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies. It is also increasingly being 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. 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 STRATEGY We searched the Cochrane Injuries Group's Specialised Register, CENTRAL, MEDLINE, EMBASE and other specialised databases up to March 2006. We also searched reference lists of articles and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing rFVIIa with placebo, or one dose of rFVIIa with another, in any patient population with the exception of those with haemophilia. There was no restriction by outcomes examined, but this review focuses on 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. Data were extracted and methodological quality was examined. Studies using rFVIIa prophylactically and those using rFVIIa therapeutically have been considered separately. Data were pooled using fixed and random effects models, but random effects models were preferred because of the variability in clinical features of the included studies. MAIN RESULTS Thirteen trials met the inclusion criteria; all were placebo-controlled double-blind RCTs. Six trials involving 724 participants examined the prophylactic use of rFVIIa; 379 received rFVIIa. There were no outcomes by which any observed advantage, or disadvantage, of rFVIIa over placebo could not have been observed by chance alone. There were trends in favour of rFVIIa for a number of outcomes, particularly the number of participants transfused, pooled RR 0.85 (95% CI 0.72 to 1.01) but this was balanced by a trend against rFVIIa with respect to thromboembolic adverse events, pooled RR 1.25 (95% CI 0.76 to 2.07). Seven trials involving 1214 participants examined the therapeutic use of rFVIIa; 687 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 0.82 (95% CI 0.64 to 1.04), although no other clear trends in favour of rFVIIa were noted for other desired outcomes. Interpretation of these results must take into account one study which could not be included in the quantitative summary but which showed results strongly in favour of rFVIIa for the treatment of intra-cerebral haemorrhage. There was a trend against rFVIIa with respect to thromboembolic adverse events; the RR 1.50 (95% CI 0.86 to 2.62). AUTHORS' CONCLUSIONS Although rFVIIa has a role in the management of patients with haemophilia, its effectiveness as a more general haemostatic drug, either prophylactically or therapeutically, remains uncertain. Its effectiveness as a therapeutic agent, particularly for intra-cerebral haemorrhage, looks more encouraging than prophylactic use. The use of rFVIIa outside its current licensed indications should be very limited and its wider use await the results of ongoing and possibly newly commissioned RCTs. In the interim, rFVIIa use should be restricted to clinical trials.
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Affiliation(s)
- S J Stanworth
- National Blood Service, Haematology, Level 2, John Radcliffe Hospital, Headington, Oxford, UK OX3 9BQ.
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