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Use of recombinant activated factor VII for uncontrolled bleeding in a haematology/oncology paediatric ICU cohort. Blood Coagul Fibrinolysis 2021; 31:440-444. [PMID: 32833802 DOI: 10.1097/mbc.0000000000000942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
: Bleeding among critically ill paediatric haematology/oncology (CIPHO) patients leads to significant morbidity and mortality. Recombinant activated factor VII (rFVIIa) has shown some benefits in previous reported off-label use when conventional therapies have failed. However, data in CIPHO are lacking. We retrospectively studied (2006-2014) the efficacy and outcomes in CIPHO patients younger than 21 years who received at least one rFVIIa dose for bleeding in the ICU. Of 39 patients, the majority had leukaemia (59%), bone marrow transplantation (77%) and a life-threatening bleed (80%) with most common site being pulmonary haemorrhage (44%). Most needed invasive mechanical ventilation (87%) or vasopressor support (59%). After rFVIIa administration, 56% had cessation or decreased bleeding. Packed red blood cell transfusion requirements decreased significantly 48-72 h after rFVIIa administration. Lower baseline prothrombin time and more rFVIIa doses were related to bleeding control. A favourable response was associated with higher survival (55% in responders versus 18% in nonresponders, P = 0.019). Overall, bleeding-related mortality was 37.5%, highest in pulmonary haemorrhage. Two patients had thromboembolic events. Use of rFVIIa for CIPHO patients appears to be well tolerated with low adverse events. Despite half of the patients having a favourable response of cessation or decrease in bleeding after rFVIIa administration, mortality was high. These findings highlight the need for prospective studies to evaluate interventions to improve outcomes in this population.
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Park HJ, Choi EJ. Use of Recombinant Activated Factor VII for Pulmonary Hemorrhage in Premature Infants: A Single-Center Experience. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2016. [DOI: 10.15264/cpho.2016.23.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hye Jin Park
- Department of Pediatrics, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Eun Jin Choi
- Department of Pediatrics, Catholic University of Daegu School of Medicine, Daegu, Korea
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Bafaqih H, Chehab M, Almohaimeed S, Thabet F, Alhejaily A, AlShahrani M, Zolaly MA, Abdelmoneim AA, Abd ES. Pilot trial of a novel two-step therapy protocol using nebulized tranexamic acid and recombinant factor VIIa in children with intractable diffuse alveolar hemorrhage. Ann Saudi Med 2015; 35:231-9. [PMID: 26409798 PMCID: PMC6074453 DOI: 10.5144/0256-4947.2015.231] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Diffuse alveolar hemorrhage (DAH) is a life threatening condition with very limited, often unsuccessful, therapeutic options. This study aimed at exploring the feasibility and efficacy of nebulized tranexamic acid TXA (n-TXA) and nebulized recombinant factor VIIa (n-rFVIIa) when used in a two-step therapy protocol in children with intractable DAH in a pediatric intensive care unit. METHODS In a prospective trial, n-TXA (250 mg/dose for children < 25 kg and 500 mg/dose for children > 25 kg) was administered to 18 children (median age [interquartile range]; 24.0 months [11.3, 58.5]) with intractable DAH. N-rFVIIa (35 micro g/kg/dose for children < 25 kg, and 50 micro g/kg/dose for children > 25 kg) was added if no or minimal response was seen after 3 to 4 doses (18 to 24 hours) of n-TXA. RESULTS DAH was stopped in 10 (55.6%) children with n-TXA alone within 24 hours of therapy. Documented concomitant respiratory infection showed a significant negative association with response to n-TXA in a step.wise regression analysis (OR=0.06; 95% CI=0.01-0.74). In the other 8 (44.4%) children, n-rFVIIa was added due to n-TXA failure. Six (75.0%) showed complete cessation of DAH, while two children failed to respond with the addition of n-rFVIIa (25.0%). None of the children who responded to therapy showed recurrence of DAH after therapy termination. No complications related to therapy were recorded. CONCLUSIONS n-TXA and n-rFVIIa were effective and safe when used in a two-step-therapy protocol to control intractable DAH in pediatric patients in intensive care settings. This therapy modality warrants further exploration through larger multicenter clinical trials.
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Affiliation(s)
- Hind Bafaqih
- Hind Bafaqih, Consultant Pediatric Intensive Care Medicine, Pediatric Intensive Care Unit, Prince Sultan Military Hospital, Riyadh, Saudi Arabia, M: 966555558218,
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Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or autoimmune disorders, and it has a high mortality rate. The current treatment options of corticosteroids, transfusions, and immunosuppressants have been limited and largely unsuccessful, and they can be accompanied by multiple complications. Intrapulmonary administration of recombinant activated factor VII (rFVIIa) has been reported in adults, but there are scarce data on its use in children. The present article reviews our institutional experience with intrapulmonary rFVIIa for the treatment of DAH in children. The study included 6 pediatric patients with acute, bronchoscopically confirmed DAH treated between 2011 and 2013. The median age was 11 years, and patient diagnoses were as follows: acute myeloid leukemia (2 patients), myelodysplastic syndrome (1 patient), hemophagocytic lymphohistiocytosis (1 patient), T-cell lymphoblastic lymphoma (1 patient), and idiopathic pulmonary hemosiderosis (1 patient). These patients were treated with intrapulmonary rFVIIa concurrent with methylprednisolone, fresh-frozen plasma, and maintenance of the platelet count >50 000/mm(3). Complete and sustained hemostasis after rFVIIa treatment and an absence of adverse events were observed in all patients. The PaO2/fraction of inspired oxygen ratio increased significantly, and rapid clinical improvements were observed. Two patients who received hematopoietic stem cell transplantation died of subsequent respiratory syncytial virus and Acinetobacter baumannii infections, but the other 4 patients exhibited rapid improvement, were successfully weaned from ventilators, and experienced long-term survival. Our findings indicate that intrapulmonary administration of rFVIIa is an effective and safe treatment option for children with DAH; however, further clinical studies are needed.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Haeundae-Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Byoung-Ju Kim
- Department of Pediatrics, Haeundae-Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
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Abstract
PURPOSE OF REVIEW To summarize our current understanding of the pathophysiology, diagnosis, and management of acute traumatic coagulopathy in children. RECENT FINDINGS Traumatic coagulopathy is a complex process that leads to global dysfunction of the endogenous coagulation system and results in worse outcomes and increased mortality. Although the cause is multifactorial, it is common in severely injured patients and is driven by significant tissue injury and hypoperfusion. Viscoelastic coagulation tests have been established as a rapid and reliable method to assess traumatic coagulopathy. Additionally, massive transfusion protocols have improved outcomes in adults, but limited studies in pediatrics have not shown any difference in mortality. SUMMARY Prospective studies are needed to determine how to best diagnose and manage acute traumatic coagulopathy in children.
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Recombinant activated factor VII usage in life threatening hemorrhage: a pediatric experience. Indian J Pediatr 2011; 78:961-8. [PMID: 21328080 DOI: 10.1007/s12098-011-0364-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 01/07/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine the safety and efficacy of off label usage of Recombinant activated factor VII (rFVIIa) in children with severe bleeding in non-hemophiliac children with diverse etiologies like leukemia, post hematopoietic stem cell transplantation, dengue shock syndrome and Glanzmann thrombasthenia. METHOD Medical records of 16 non-hemophiliac children with 20 bleeding episodes where rFVIIa was administered only after failure of standard measures to control bleeding were retrospectively reviewed and data collected regarding patient demographics, diagnosis and location of bleeding. Blood counts, coagulation and other lab parameters, both pre and post rFVIIa, were also noted. Severity of bleeding was assessed using a scoring system used previously by Nevo S et al. A record of usage of the amount of blood components (red blood cells, platelets, fresh frozen plasma, and cryoprecipitate) 24 h pre and post rFVIIa was also made. The dose of rFVIIa and any adverse side effects were recorded. RESULTS Bleeding sites were gastrointestinal (13/20), pulmonary hemorrhage (6/20) and intracranial hemorrhage (1/20). Thrombocytopenia (platelet count <50,000/cumm) was present in 50% episodes and five had refractory low platelets. Usage of packed red cells and platelets was significantly less after usage of rFVIIa (p value 0.001 and 0.006, respectively). Mean dosage of rFVIIa was 77 μgm/kg/dose (range 60 to 90 μgm/kg/dose). The bleeding stopped completely in 11(55%), decreased to minimal in 2 (10%), reduced but transfusions needed in 4 (20%) and did not stop in 3 (15%) episodes. Five patients (31%) did not survive the bleeding episode. None of the patients developed thrombosis. CONCLUSIONS rFVIIa appears to be safe and effective in controlling life-threatening bleed in non-hemophiliac children.
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Abstract
OBJECTIVE Report clinical response to recombinant factor VIIa in a cohort of critically ill infants. STUDY DESIGN We identified all infants who received factor VIIa in the Duke Neonatal Intensive Care Unit between January 2005 and July 2008. Hematological data and volume of blood transfusions before and after factor VIIa treatment were compared. The precipitating diagnosis for each factor VIIa use, and the ensuing clinical outcomes of bleeding, thrombosis and mortality were noted. RESULT We identified 18 infants with median birth weight of 880 g and median gestational age of 26 weeks. One to six doses of factor VIIa (90 mcg kg(-1) per dose) were administered, with 13 (72%) infants receiving a single dose. Hemostasis was achieved in 13 (72%) of the infants. Prothrombin time and activated partial thromboplastin time significantly decreased following treatment with factor VIIa. Volume of plasma transfusions significantly decreased following treatment with factor VIIa (P=0.02). Thrombosis occurred in one (11%) infant. Six (33%) infants died within 72 h of treatment, and overall mortality was 10/18 (56%). CONCLUSION Treatment with factor VIIa at doses of 90 mcg kg(-1) improved coagulation studies and decreased the need for plasma transfusions in a group of critically ill infants without significant risk. Factor VIIa may be an effective addition to current treatment modalities for refractory hemorrhage in infants.
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Hong I, Stachnik J. Unlabeled uses of factor VIIa (recombinant) in pediatric patients. Am J Health Syst Pharm 2010; 67:1909-19. [DOI: 10.2146/ajhp090667] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Irene Hong
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, NY; when this article was written, she was Postgraduate Year 2 Drug Information Resident, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Joan Stachnik
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago
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Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg 2010; 19:286-91. [PMID: 20889085 DOI: 10.1053/j.sempedsurg.2010.07.002] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hemorrhagic shock in the pediatric trauma patient is an uncommon but fundamental problem for the treating clinician. Current management of hemorrhagic shock involves initial resuscitation with crystalloid fluids followed by infusion of blood components as necessary. In management of the adult trauma patient, many institutions have implemented massive transfusion protocols to guide transfusion in situations requiring or anticipating the use of greater than 10 U of packed red blood cells. In the pediatric population, guidelines for massive transfusion are vague or nonexistent. Adult trauma transfusion protocols can be applied to children until a pediatric protocol is validated. Here, we attempt to identify certain principles of transfusion therapy specific to pediatric trauma and outline a sample pediatric massive transfusion protocol that may be used to guide resuscitation. Also, adjuncts to transfusion, such as colloid fluids, other plasma expanders or hemoglobin substitutes, and recombinant activated factor VII, are discussed.
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Affiliation(s)
- Jeffrey J Dehmer
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA
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Recombinant-activated factor VII for control and prevention of hemorrhage in nonhemophilic pediatric patients. Blood Coagul Fibrinolysis 2010; 21:354-62. [PMID: 20449890 DOI: 10.1097/mbc.0b013e3283389500] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A total of 108 episodes among 103 nonhemophilic pediatric patients (nine newborns, 16 infants and 78 children) treated with recombinant factor-activated VII (rFVIIa) were evaluated retrospectively. These episodes were divided into two groups: group 1 included 86 occurrences for hemorrhagic control of ongoing massive bleeding due to thrombocytopenia and coagulopathy unresponsive to blood component therapy in patients with dengue hemorrhagic fever, life-threatening, intraoperative and postoperative bleeding; group 2 included 22 episodes for prevention of hemorrhage with invasive procedures in patients with chronic liver disease and associated coagulopathy, and patients without preexisting hemostatic disorder but at high risk due to their underlying diagnosis and required surgical intervention. The effective control of hemostasis response rate in group 1 was significantly lower than in group 2. The median total dose per kilogram of rFVIIa group 1 was twice that of group 2. The overall case-fatality rate related to bleeding or underlying conditions was 31.1% (32/103). Adverse events were observed in three patients (2.9%) receiving rFVIIa for control of intraoperative and postoperative bleeding in the setting of corrective cardiac surgery. These results support the safety and potential benefit of rFVIIa for control and prevention of hemorrhage in pediatric patients without congenital hemophilia.
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Altman R, Scazziota A, de Lourdes Herrera M, Gonzalez CD. The hemostatic profile of recombinant activated factor VII. Can low concentrations stop bleeding in off-label indications? Thromb J 2010; 8:8. [PMID: 20444280 PMCID: PMC2885319 DOI: 10.1186/1477-9560-8-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 05/05/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High concentrations of recombinant activated factor VII (rFVIIa) can stop bleeding in hemophilic patients. However the rFVIIa dose needed for stopping haemhorrage in off-label indications is unknown. Since thrombin is the main hemostatic agent, this study investigated the effect of rFVIIa and tissue factor (TF) on thrombin generation (TG) in vitro. METHODS Lag time (LT), time to peak (TTP), peak TG (PTG), and area under the curve after 35 min (AUCo-35 min) with the calibrated automated thrombography was used to evaluate TG. TG was assayed in platelet-rich plasma (PRP) samples from 29 healthy volunteers under basal conditions and after platelet stimulation with 5.0 mug/ml, 2.6 mug/ml, 0.5 mug/ml, 0.25 mug/ml, and 0.125 mug/ml rFVIIa alone and in normal platelet-poor plasma (PPP) samples from 22 healthy volunteers, rFVIIa in combination with various concentrations of TF (5.0, 2.5, 1.25 and 0.5 pM). RESULTS In PRP activated by rFVIIa, there was a statistically significant increase in TG compared to basal values. A significant TF dose-dependent shortening of LT and increased PTG and AUCo-->35 min were obtained in PPP. The addition of rFVIIa increased the effect of TF in shorting the LT and increasing the AUCo-->35 min with no effect on PTG but were independent of rFVIIa concentration. CONCLUSION Low concentrations of rFVIIa were sufficient to form enough thrombin in normal PRP or in PPP when combined with TF, and suggest low concentrations for normalizing hemostasis in off-label indications.
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Affiliation(s)
- Raul Altman
- Centro de Trombosis de Buenos Aires, Viamonte 2008, 1056 Buenos Aires, Argentina.
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Successful use of recombinant factor VIIa in a preterm infant with life-threatening haematuria. Blood Coagul Fibrinolysis 2009; 20:601-4. [DOI: 10.1097/mbc.0b013e32832f6c40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVES Abdominal trauma is relatively uncommon in children but can be the source of significant morbidity and mortality. The diagnosis and treatment of blunt abdominal injury to the solid organs were examined, and the differences between children and adults were highlighted. METHODS The PubMed database was used to identify the relevant literature. Additional source material was identified through referenced articles. RESULTS Identification of injury to the solid organs in children depends on a high index of suspicion, abnormal physical examination findings, and the judicious use of laboratory and imaging studies. Although abdominal and pelvic computed tomography with intravenous contrast remains the gold standard for imaging, it does expose children to a significant dose of radiation. Currently, more than 90% of solid organ injuries in children are treated nonoperatively. Abnormal hemodynamics, however, suggests active bleeding and requires operative intervention. Accurate diagnosis of the organ injured and degree of injury are important considerations for "return to play" decisions. The management of pancreatic ductal injuries is somewhat controversial, although the distal spleen preserving pancreatectomy is frequently the technique of choice. CONCLUSIONS Pediatric intra-abdominal solid organ injury is relatively uncommon, but a potential source of significant morbidity. Non-operative management is the standard of care for the majority of these injuries, although continued hemodynamic instability mandates operative intervention.
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Kitchens CS. Thrombocytopenia and thrombosis in disseminated intravascular coagulation (DIC). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2009; 2009:240-246. [PMID: 20008204 DOI: 10.1182/asheducation-2009.1.240] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Disseminated intravascular coagulation (DIC) is the physiologic result of pathologic overstimulation of the coagulation system. Despite multiple triggers, a myriad of laboratory abnormalities, and a clinical presentation ranging from gross hemostatic failure to life-threatening thrombosis, or even both simultaneously, a simplified clinical approach augmented by a few readily available tests allows prompt identification of the process and elucidation of treatment opportunities. Platelet counts in DIC may be low, especially in acute sepsis-associated DIC, yet increased in malignancy-associated chronic DIC. Thrombotic risk is not a function of the platelet count, and thrombocytopenia does not protect the patient from thrombosis. The stratification of both thrombotic risk and hemorrhagic risk will be addressed.
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