Use of recombinant factor VIIa in infants with severe coagulopathy

Predicting response to rFVIIa in neonates with intractable bleeding or severe coagulation disturbances

BACKGROUND

To date, clinical experience with recombinant factor VIIa (rFVIIa) in neonates is rather limited because of the lack of controlled studies. ΑIM: The objective of this study was to present further experience from our center with regard to the use of rFVIIa in newborns with severe bleeding or coagulopathy resistant to conventional therapy and to determine factors affecting the clinical outcome.

METHODOLOGY

We performed a retrospective data analysis of 29 neonates with intractable bleeding or severe coagulation disturbances. All patients received 100 μg/kg of rFVIIa per dose bolus intravenously (maximum of 23 doses), as rescue procedure after other interventions had failed to achieve hemostasis.

RESULTS

Fourteen neonates survived (group A), whereas 15 died (group B). There was no difference in birth weight, gestational age, and bleeding site and causes between the 2 groups. In the neonates who survived, rFVIIa had been administered earlier in the disease process (<24 h of beginning of bleeding) compared with those who died (P=0.009). In all 29 neonates, international normalized ratio was directly restored (from 2.99±1.4 before rFVIIa administration to 1.6±1.1 afterward, P<0.001) and prothrombin time and activated partial thromboplastin time were significantly decreased after administration of rFVIIa (from 28 to 16.4 and from 180 to 67, respectively; P=0.001 and 0.05, respectively). Blood products administered were significantly less in group A than in group B, as time from the beginning of bleeding to the administration of rFVIIa was significantly less in group A than in group B. Neither acute adverse events nor thromboembolic complications were observed.

CONCLUSIONS

In this neonatal group with intractable bleeding and/or severe coagulation disturbances, rFVIIa was more effective in early intervention as rescue therapy, without any adverse events in all neonates. Upon failure to achieve hemostasis with initial administration of blood products, fast intervention with rFVIIa could be considered in neonates with serious bleeding and coagulation disorders.

Thrombotic events in neonates receiving recombinant factor VIIa or fresh frozen plasma

BACKGROUND

Numerous recent reports have described the use of recombinant factor VIIa (rFVIIa) in non-hemophilia bleeding situations for achievement of hemostasis. However, its use in clinical situations other than hemophilia patients with inhibitors has been complicated by some reports of thrombotic events. rFVIIa has been used successfully to treat coagulopathic and/or bleeding neonates. The prevalence of thrombotic events in these neonates is completely unknown. This study was initiated to determine the risk of thrombotic events associated with rFVIIa use in neonates.

PROCEDURE

All published literature in non-hemophilic, non-congenital factor VII deficient neonates receiving rFVIIa was reviewed. In addition, all data submitted to the SeveN Bleep Registry, a web-based registry of rFVIIa uses in non-hemophilic children was analyzed. As the baseline risk of thrombotic events in bleeding and/or coagulopathic neonates is not known, we also reviewed the records of 100 consecutive neonates from a single institution who received fresh frozen plasma (FFP) alone to treat their coagulopathy and/or bleeding episode.

RESULTS

A total of 134 neonates received rFVIIa. Of these, 10 (7.5%) had a thrombotic event. The baseline risk of thrombotic events in neonates receiving FFP was 7%.

CONCLUSIONS

Overall the prevalence of thrombotic events in bleeding and/or coagulopathic neonates appears to be around 7%, whether or not they receive rFVIIa.

Fresh frozen plasma and recombinant factor VIIa use in neonates

BACKGROUND

Little recent data are available describing fresh frozen plasma (FFP) use in neonates. The purpose of this study was to determine the outcomes of FFP transfusions in neonates.

PATIENTS AND METHODS

A single institution, observational, and retrospective review of each transfusion of FFP given to neonates admitted to a neonatal intensive care unit over a 2-year period.

RESULTS

One hundred and seventy-three neonates were identified as having received FFP, giving a prevalence of FFP use at 12%. By far the most common determining factor for FFP use was an association with an abnormal activated partial thromboplastin time or prothrombin time (52%). Other factors included bleeding, invasive procedures, volume expansion, necrotizing enterocolitis, cardiopulmonary bypass, and hydrops fetalis. Of objectively accessible responses, FFP was able to correct abnormal coagulation tests into the normal range only 40% of the time. Twenty-four neonates received recombinant factor VIIa (rFVIIa) after first receiving FFP. The prevalence of thrombotic events was not higher in neonates receiving rFVIIa than those receiving FFP alone.

CONCLUSIONS

FFP was widely used in this neonatal unit. As data showing the predictive value of coagulation tests in neonates are discrepant, it is unclear if FFP was being appropriately used. Prospective, controlled data are required.

Use of recombinant factor VIIa in a preterm infant with coagulopathy and subdural hematoma

Activated recombinant factor VIIa was administered to a preterm infant with bleeding diasthesis and a huge subdural hematoma that could not be controlled by the blood products. The coagulation tests were normalized the following day. Recombinant factor VIIa can be a choice in selected cases with intractable bleedings unesponsive to conventional replacement therapy.

Traumatic bleeding at birth treated with Factor VII

We report 36 week gestation twins born following a traumatic delivery. Twin 2 had profuse haemorrhage where haemostasis was achieved with recombinant Factor VIIa (rFVIIa - NovoSeven;Novo Nordisk A/S, Bagsvaerd, Denmark).

Recombinant activated factor seven in acute life-threatening bleeding in neonates: report on three cases and review of literature

INTRODUCTION

Acute bleeding of different genesis can be a severe, life-threatening problem in neonatology. Recombinant factor seven (rFVIIa) is known to have unique hemostatic properties in adults and older children.

CASE PRESENTATION

Three cases of acute life-threatening peri- and postnatal hemorrhage were successfully controlled after the application of fFVIIa. All infants were first treated with vitamin K, fresh-frozen plasma and platelet transfusion.

CONCLUSION

The cases substantiate other reports that rFVIIa is an effective treatment for acute, refractory and life-threatening bleeding in neonates and premature infants.

Recombinant factor VIIa for treatment of massive liver fracture in a premature infant

Recombinant factor VIIa (rFVIIa) is a highly efficacious therapy initially used to treat the bleeding diathesis of hemophiliac patients that has recently gained a wider role in the treatment of liver disease, thrombocytopenia, and intracerebral and traumatic hemorrhage. Data with regard to the use of rFVIIa within the pediatric population for the treatment of liver injury, however, are limited. We present a case report of successful treatment using rFVIIa of an iatrogenic liver injury in a 1200-g infant who was undergoing resection of a large sacrococcygeal teratoma. In addition, we review the issues of surgical relevance to the pediatric surgeon relating to rFVIIa's mechanism of action and dosages for clinical application.

Prevention of intraventricular haemorrhage: a role for recombinant activated factor VII?

As the survival from extreme prematurity continues to improve, focus on the quality of this survival becomes increasingly important. Prevention of intraventricular haemorrhage (IVH) and its potential long-term sequelae remains one of the major challenges in the early management of these infants. Recombinant activated factor VII (rVIIa), a novel haemostatic agent with an ever-expanding list of potential applications, warrants consideration for use in this setting. This review examines the pathogenesis and prevention of IVH, current concepts of haemostasis both in adults and neonates, and the postulated mechanism of action and various uses of rVIIa. Published data specifically relating to use of rVIIa in neonates is summarised. The hypothesis that early (prophylactic) administration of rVIIa to extremely preterm infants (<28 weeks) would reduce the incidence of severe IVH is explored.

An evaluation of the procoagulant action of recombinant activated factor VII in cord whole blood versus adult whole blood using thromboelastography

Recombinant activated factor VII (rFVIIa) has been reported to be effective in adult patients in various clinical situations and might be beneficial in neonates with bleeding tendency. In the present study we compared the procoagulant action of increasing amounts of rFVIIa in both cord whole blood and adult whole blood with respect to changes in the values of the clotting time, clot formation time, and maximum clot firmness by means of thromboelastography. Thromboelastography allows evaluation of the effects of rFVIIa on haemostasis in whole blood. When increasing amounts of rFVIIa were added in vitro to whole blood samples, significant decreases in the values of the clotting time and clot formation time and a significant increase in the maximum clot firmness were observed. Cord whole blood was significantly more sensitive to rFVIIa addition than adult whole blood, an effect probably attributable to the low anticoagulant capacity of the neonatal plasma. Maximum clot firmness values were significantly lower in cord whole blood than in adult whole blood, an effect mainly attributable to the hypofunctional state of neonatal platelets. Since cord whole blood exerted a significantly higher sensitivity to addition of rFVIIa, we speculate that lower doses of rFVIIa might be required to treat neonates with bleeding tendency compared with the adult rFVIIa administration strategy.