Recombinant activated factor VII for adjunctive hemorrhage control in trauma

Immobilization of blood coagulant factor VII on polycaprolactone membrane through polydopamine grafting

Postoperative bleeding following cardiac surgeries is still an issue that deranges the medical resources and cost. The oral and injection administrations of blood coagulation protein, Factor VII (FVII), is effective to stop the bleeding. However, its short half-life has limited the effectiveness of this treatment and frequent FVII intake may distress the patients. Instead, incorporating FVII into synthetic biodegradable polymers such as polycaprolactone (PCL) that is commonly used in drug delivery applications should provide a solution. Therefore, this study aimed to immobilize FVII on PCL membranes through a cross-linkage polydopamine (PDA) grafting as an intermediate layer. These membranes are intended to provide a solution for cardiac bleeding in coagulating blood and sealing the sutured region. The membranes were evaluated in terms of its physio-chemical properties, thermal behavior, FVII release profile and biocompatibility properties. The ATR-FTIR was used to analyze the chemical functionalities of the membranes. Further validation was done with XPS where the appearances of 0.45 ± 0.06% sulfur composition and C-S peak have confirmed the immobilization of FVII on the PCL membranes. The cross-linked FVIIs were viewed in spherical immobilization on the PCL membranes with a size range between 30 and 210 nm. The surface roughness and hydrophilicity of the membranes were enhanced with a slight shift of melting temperature. The PCL-PDA-FVII0.03 and PCL-PDA-FVII0.05 membranes, with wide area of FVII immobilization released approximately only 22% of FVII into the solution within 60 days period and, it is found that the PCL-PDA-FVIIx membranes projected the Higuchi release model with non-Fickian anomalous transport. While the cytotoxic and hemocompatibility analyses showed advance cell viability, identical coagulation time and low hemolysis ratio on the PCL-PDA-FVIIx membranes. The erythrocytes were viewed in polyhedrocyte coagulated structure under SEM visualization. These results validate the biocompatibility of the membranes and its ability to prolong blood coagulation, thus highlighting its potential application as cardiac bleeding sealant.

Four-Factor Prothrombin Complex Concentrate: An Indispensable Adjunct in Coagulopathy of Trauma Management - A Comparative Review of the Literature over 2 Decades

BACKGROUND

Damage control resuscitation forms the cornerstone of management in trauma surgery. Several blood products have been widely used for preoperative transfusions prior to emergency surgeries and for hemorrhage control in trauma. Prothrombin complex concentrate (PCC) is now being introduced as an essential component of damage control resuscitation.

SUMMARY

We did a comparative descriptive analysis of several single and multi-institutional clinical trials and retrospective cohort studies. The primary focus of these studies was a comparison between PCC and other transfusion modalities including recombinant factor VIIa, fresh-frozen plasma, and fibrinogen based on several vital parameters. The parameters included rapid international normalized ratio reversal, hospital length of stay, cost-effectiveness, mortality rate, and rate of thromboembolic complications.

KEY POINTS

Although still awaiting its approval from the FDA for use in traumatic coagulopathy, 4-factor PCC has shown far more convincing results in contrast to former transfusion modalities, even 3-factor PCC. However, more prospective extensive clinical trials on national levels are needed to compare its effectiveness to 3-factor PCC and gather promising recognition in the trauma care fraternity.

The impact of blood product ratio and procoagulant therapy on the development of thromboembolic events in severely injured hemorrhaging trauma patients

INTRODUCTION

Transfusion therapy in hemorrhaging trauma patients is associated with the development of thromboembolic events. It is unknown whether current resuscitation strategies, including large volumes of plasma and early administration of procoagulant therapy, increases this risk.

METHODS

A systematic search was conducted in MEDLINE, PubMed, and Embase. Studies were screened by two independent reviewers and included if they reported on thromboembolic events in patients with severe trauma (injury severity score ≥16) who received transfusion of at least 1 unit of red blood cells. The ratio by which blood products were transfused, as well as use of procoagulant or antifibrinolytic medication, was recorded.

RESULTS

A total of 40 studies with 11.074 bleeding trauma patients were included, in which 1.145 thromboembolic events were reported, yielding an incidence of 10% thromboembolic events. In studies performing routine screening for thromboembolic complications, the incidence ranged from 12% to 23%. The risk of thromboembolic events was increased after administration of tranexamic acid (TXA; odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7-4.1; p < 0.001) and fibrinogen concentrate (OR, 2.1; 95% CI, 1.0-4.2; p = 0.04). Blood product ratio, the use of prothrombin complex concentrate or recombinant factor VIIa were not associated with thromboembolic events.

CONCLUSION

This systematic review identified an incidence of thromboembolic events of 10% in severely injured bleeding trauma patients. The use of TXA and fibrinogen concentrate was associated with the development of thromboembolic complications.

Recombinant activated factor VII (rFVIIa) in refractory haemorrhage for non-haemophiliacs: an eleven-year single-centre experience

Background

Massive bleeding is one of the commonest salvageable causes of death. The search for an ideal haemostatic agent during massive bleeding is still ongoing. One of the novel haemostatic medications is recombinant activated factor VII (rFVIIa). To date, the usage of rFVIIa during massive haemorrhage among non-haemophiliac patients remains off-label. The aim of this study is to report our experience in using rFVIIa to treat refractory bleeding.

Methods

Medical records of all patients treated with rFVIIa for massive bleeding over an eleven-year period in a single institution were recorded. Treatment indications, 24-h and 30-day mortality, changes in transfusion needs and coagulation profiles after rFVIIa administration were analysed.

Results

rFVIIa were administered in 76 patients. Of these, 41 (53.9%) were non-surgical bleeding, followed by 22 patients (28.9%) with trauma, other surgery bleedings in 9 patients (11.8%) and 4 patients (5.4%) with peripartum haemorrhage. Total survival rate was 78.9% within 24 h and 44.7% over 30 days. Among all these patients who had received rFVIIa due to life-threatening haemorrhage, blood and blood product requirements were significantly reduced (P < 0.001), and the coagulation profiles improved significantly (P < 0.05). Two patients with preexisting thromboembolism were given rFVIIa due to intractable bleeding, both survived. No thromboembolic events were reported after the administration of rFVIIa.

Conclusions

rFVIIa significantly improved coagulation parameters and reduced blood product requirements during refractory haemorrhage. Additionally, usage of rFVIIa in trauma and peripartum haemorrhage patients yield better outcomes than other groups of patients. However, the overall mortality rate remained high.

rFVIIa in trauma: a review and opinion-based guidelines

Recombinant activated factor seven (rFVIIa) is a novel and emerging therapy for the acquired coagulopathy associated with massive bleeding and hemorrhagic shock. The intent of this paper is to review the mechanism of action of rFVIIa, to discuss the current state of evidence regarding the safety and efficacy of rFVIIa, and to offer guidance regarding its use in severely traumatized patients. No study has demonstrated a survival benefit in humans. rFVIIa, is safe to use in the setting of severe trauma associated with ongoing bleeding and acquired coagulopathy. Doses of 80—200 μg/kg may be used after correction of thrombocytopenia and acidosis. Hypothermia should be corrected in any traumatized patient, but should not be a barrier to its administration. Definitive evidence supporting the use of rFVIIa is lacking, but ongoing studies will delineate survival benefits, dosing regimens, and adverse events associated with its use.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Interventional Algorithms for the Control of Coagulopathic Bleeding in Surgical, Trauma, and Postpartum Settings: Recommendations From the Share Network Group

Several clinical settings are associated with specific coagulopathies that predispose to uncontrolled bleeding. With the growing concern about the need for optimizing transfusion practices and improving treatment of the bleeding patient, a group of 9 Portuguese specialists (Share Network Group) was created to discuss and develop algorithms for the clinical evaluation and control of coagulopathic bleeding in the following perioperative clinical settings: surgery, trauma, and postpartum hemorrhage. The 3 algorithms developed by the group were presented at the VIII National Congress of the Associação Portuguesa de Imuno-hemoterapia in October 2013. They aim to provide a structured approach for clinicians to rapidly diagnose the status of coagulopathy in order to achieve an earlier and more effective bleeding control, reduce transfusion requirements, and improve patient outcomes. The group highlights the importance of communication between different specialties involved in the care of bleeding patients in order to achieve better results.

Uncontrolled haemorrhage in pelvic fracturesd---Can the inevitable be avoided?

Pelvic fractures carry a considerable risk for morbidity and mortality. Half or more of the early deaths in these patients have been attributed directly to haemorrhage. The transfusional requirements are four times higher for open pelvic fractures compared with a similar group of closed pelvic fractures. The loss of the tamponade effect by disruption of the pelvic soft tissues and the energy imparted play a central role in this potentially life threatening situation. We reported a case of open pelvic fracture in which persistent haemorrhage was stopped by giving recombinant activated coagulation factor VIIa as our last resort.

A Fibrin Cross-linking Polymer Enhances Clot Formation Similar to Factor Concentrates and Tranexamic Acid in an in vitro Model of Coagulopathy

Transfusion of blood components and factor concentrates is clinically used to replenish clotting factors and treat coagulopathy after injury when bleeding is severe. Alternatively, direct manipulation of fibrin polymerization via synthetic cross-linking agents may also improve clot formation during coagulopathic conditions as a novel way to treat coagulopathy. We recently developed a synthetic hemostatic polymer, PolySTAT, that promotes clot formation and stabilizes fibrin network structure by cross-linking fibrin monomers. In this study, we used rotational thromboelastometry (ROTEM) to monitor the effect of PolySTAT on the mechanical strength of clots during clot formation and breakdown in comparison to replacement clotting factors and antifibrinolytics under conditions of simulated trauma-induced coagulopathy (sTIC). Human recombinant activated Factor VII (rFVIIa) shortened clotting onset time and accelerated clotting rate, while tranexamic acid (TXA) eliminated clot lysis and restored maximal clot firmness.In contrast, fibrinogen and PolySTAT were both able to speed up clot formation, increase maximal firmness, and inhibit clot lysis. Furthermore, PolySTAT acted synergistically with TXA and fibrinogen, enhancing their individual effects on clot formation. Thus, manipulating fibrin clot structure by physical cross-linking with a synthetic polymer has beneficial effects on clot formation and may be a viable transfusion strategy for treatment of coagulopathy.

NovoSeven (recombinant factor VIIa) for the treatment of bleeding episodes and perioperative management in patients with Glanzmann's thrombasthenia

Glanzmann's thrombasthenia is a rare inherited autosomal recessive bleeding disorder caused by qualitative or quantitative defects of the platelet membrane glycoprotein IIb/IIIa. The ensuing lack of platelet aggregation is frequently associated with mucocutaneous bleeding that may be variable in both frequency and intensity, ranging from minimal bruising to severe and life-threatening hemorrhages. A number of treatment modalities have been proposed to manage the bleeding episodes, which include local measures, antifibrinolytic agents, platelet transfusions and recombinant activated factor VII. The role of this bypassing hemostatic agent for treatment or prevention of bleeding episodes in Glanzmann's thrombasthenia patients is critically analyzed in this review.

Implementation of an off-label recombinant factor VIIa protocol for patients with critical bleeding at an academic medical center

To describe the development of a pharmacy driven off-label recombinant factor seven (rFVIIa) protocol by a multi-disciplinary team for critical bleeding. A multi-disciplinary team made up of members from several critical care and surgical departments within the hospital were formed and charged with developing a standardized approach to how rFVIIa would be used for critical bleeding in an academic medical center. Groups represented on the multi-disciplinary team included clinical pharmacy, emergency medicine, pulmonary, hematology, cardiothoracic surgery, trauma, neurosurgery, and vascular surgery physicians. A pharmacist driven off-label rFVIIa protocol was developed and implemented for the use in those patients with critical bleeding. The protocol was based on the available literature and local expert opinion. Through the use of this protocol a significantly smaller average dose of rFVIIa is now being used when compared to those patients treated prior to the new protocol (47.5 vs. 62.2 mcg/kg, p = 0.036) while all-cause mortality was not significantly altered (35 vs. 48.8%, p = 0.057). An effective and safe pharmacy driven protocol was implemented by a multi-disciplinary team for rFVIIa as seen by providing a significantly lower average dose of rFVIIa while not sacrificing for overall patient mortality.

Recombinant Activated Factor VII in Patients at High Risk of Bleeding

Currently, recombinant activated factor VII (rFVIIa) (NovoSeven) is indicated for the treatment of spontaneous and surgical bleeding in congenital haemophilia A and B patients with inhibitors to factors VIII (FVIII) and IX (FIX) >5 Bethesda units (BU) worldwide, and in patients with acquired haemophilia, congenital FVII deficiency and Glanzmann's thrombasthenia in Europe. Until April 2003, almost three-quarters of a milion doses of rFVIIa have been administered proving its efficacy and excellent safety record. According to results from initial clinical trials and a large number of case reports, the rFVIIa may be effective not only in treating haemophilia patients but also in treatment of bleeding in patients on oral anticoagulation or heparin, patients with liver diseases, von Willebrand disease (vWD), thrombocytopenia, various platelet defects, congenital or acquired deficiency of FVII, and in subjects without any pre-existing coagulopathy with diffuse life-threatening bleeding triggered by surgery or trauma. This review will briefly summarize rFVIIa mode of action in haemostasis, the current clinical experience with rFVIIa and focus on the alternative use of rFVIIa in patients at the high risk of bleeding in both spontaneous cases and clinical trials reports.

[Evolution of US military transfusion support for resuscitation of trauma and hemorrhagic shock]

Military conflicts create a dynamic medical environment in which the number of severe trauma cases is compressed in both time and space. In consequence, lessons are learned at a rapid pace. Because the military has an effective organizational structure at its disposal and the logistical capacity to rapidly disseminate new ideas, adoption of novel therapies and protective equipment occurs quickly. The recent conflicts in Iraq and Afghanistan are no exception: more than three dozen new clinical practice guidelines were implemented by the US Armed Forces, with attendant survival benefits, in response to observation and research by military physicians. Here we review the lessons learned by coalition medical personnel regarding resuscitation of severe trauma, integrating knowledge gained from massive transfusion, autopsies, and extensive review of medical records contained in the Joint Theater Trauma Registry. Changes in clinical care included the shift to resuscitation with 1:1:1 component therapy, use of fresh whole blood, and the application of both medical devices and pharmaceutical adjuncts to reduce bleeding. Future research will focus on emerging concepts regarding coagulopathy of trauma and evaluation of promising new blood products for far-forward resuscitation. New strategies aimed at reducing mortality on the battlefield will focus on resuscitation in the pre-hospital setting where hemorrhagic death continues to be a major challenge.

The early use of fibrinogen, prothrombin complex concentrate, and recombinant-activated factor VIIa in massive bleeding

BACKGROUND

Coagulopathy related to massive bleeding has a multifactorial aetiology. Coagulopathy is related to shock and blood loss including consumption of clotting factors and platelets and hemodilution. Additionally hyperfibrinolysis, hypothermia, acidosis, and metabolic changes affect the coagulation system. The aim of any hemostatic therapy is to control bleeding and minimize blood loss and transfusion requirements. Transfusion of allogeneic blood products as well as the presence of coagulopathy cause increased morbidity and mortality.

STUDY DESIGN AND METHODS

This paper presents a short review on new treatment strategies of coagulopathy, related to massive blood loss.

RESULTS

Paradigms are actively changing and there is still shortage of data. However, there is increasing experience and evidence that "target controlled algorithms" using point-of-care monitoring devices and coagulation factor concentrates are more effective compared to transfusion of fresh frozen plasma, independently of the individual clinical situation.

CONCLUSION

Future treatment of coagulopathy associated with massive bleeding can be based on an individualized point-of-care guided rational use of coagulation factor concentrates such as fibrinogen, prothrombin complex concentrate, and recombinant factor VIIa. The timely and rational use of coagulation factor concentrates may be more efficacious and safer than ratio-driven use of transfusion packages of allogeneic blood products.

Recombinant-activated factor VII in patients with uncontrolled bleeding: A retrospective observational analysis

Background:

Factor VIIa (recombinant) has an off-label use to control life-threatening bleeding that is refractory to other measures and was shown to decrease transfusion requirements.

Objective:

The primary objective of this study was to assess the safety and effectiveness of factor VIIa (recombinant) on blood transfusion requirements and coagulation parameters when used in patients whose bleeding was uncorrected by other means. The pharmacoeconomic impact for any discrepancy from our protocol was evaluated. Secondary outcomes included 4-hour and 28-day mortality, as well as safety of this agent in terms of thromboembolic complications.

Materials and Methods:

We retrospectively evaluated patients who received recombinant-activated factor VII (rFVIIa) for uncontrolled bleeding from June 2008 to April 2011. The medical records of 33 patients were evaluated. Coagulation parameters and blood products were determined 24 hours before and 24 hours after administration of rFVIIa, and the results compared. Patients were also screened for any thromboembolic complications.

Results:

Administration of rFVIIa reduced blood transfusion requirements and improved coagulation parameters significantly (P<0.05). No thromboembolic complications were reported. Most of the dosing was consistent with those recommended in our institutional protocol, with discrepancies resulting in an average cost of $56 058. Moreover, pH was reported in only 67% of patients. All patients treated with rFVIIa survived up to 4 hours after receiving this agent, while the 28-day mortality was 24% (8/33).

Conclusion:

The use of rFVIIa appears to be safe and effective in promoting hemostasis, as evident from reducing transfusion requirements and improving the coagulation variables.

Use of Activated Recombinant Factor VII in Severe Bleeding - Evidence for Efficacy and Safety in Trauma, Postpartum Hemorrhage, Cardiac Surgery, and Gastrointestinal Bleeding

BACKGROUND: Uncontrolled bleeding continues to be a major cause of mortality in trauma, cardiac surgery, postpartum hemorrhage and liver failure. The aim of this paper is to assess the evidence supporting the efficacy of activated recombinant factor VII (rFVIIa) administration in these settings. METHODS: Electronic literature search. RESULTS: Numerous retrospective trials have mostly shown a decrease in blood transfusion requirements with no increase in thromboembolic events (TEE), but major limitations in trial design make generalization difficult. In most retrospective reports rFVIIa has been administered as a last-ditch attempt to control bleeding, when acidosis, hypothermia and coagulation factor depletion may not allow optimal rFVIIa effect. Prospective randomized controlled trials have not shown any effect of rFVIIa on mortality or TEE, although some have shown a reduction in RBC requirement. CONCLUSION: Stipulated transfusion protocols in prospective trials have reduced anticipated mortality among controls and make future trials for mortality effect unlikely in view of large sample size requirements. Establishment of these protocols and rapid hemostasis are likely to have greater benefits than administration of a single agent.

Evaluation of recombinant factor VIIa treatment for massive hemorrhage in patients with multiple traumas

Background

Recent studies and case reports have shown that recombinant factor VIIa (rFVIIa) treatment is effective for reversing coagulopathy and reducing blood transfusion requirements in trauma patients with life-threatening hemorrhage. The purpose of this study is to evaluate the effect of rFVIIa treatment on clinical outcomes and cost effectiveness in trauma patients.

Methods

Between January 2007 and December 2010, we reviewed the medical records of patients who were treated with rFVIIa (N=18) or without rFVIIa (N=36) for life-threatening hemorrhage due to multiple traumas at the Emergency Department of Pusan National University Hospital in Busan, Korea. We reviewed patient demographics, baseline characteristics, initial vital signs, laboratory test results, and number of units transfused, and then analyzed clinical outcomes and 24-hr and 30-day mortality rates. Thromboembolic events were monitored in all patients. Transfusion costs and hospital stay costs were also calculated.

Results

In the rFVIIa-treated group, laboratory test results and clinical outcomes improved, and the 24-hr mortality rate decreased compared to that in the untreated group; however, 30-day mortality rate did not differ between the groups. Thromboembolic events did not occur in both groups. Transfusion and hospital stay costs in the rFVIIa-treated group were cost effective; however, total treatment costs, including the cost of rFVIIa, were not cost effective.

Conclusions

In our study, rFVIIa treatment was shown to be helpful as a supplementary drug to improve clinical outcomes and reduce the 24-hr mortality rate, transfusion and hospital stay costs, and transfusion requirements in trauma patients with life-threatening hemorrhage.

Massive bleeding: Are we doing our best?

Massive bleeding accounts for more than 50% of all trauma-related deaths within the first 48h following hospital admission and it can significantly raise the mortality rate of any kind of surgery. Despite this great clinical relevance, evidence on the management of massive bleeding is surprisingly scarce, and its treatment is often based on empirical grounds. Successful treatment of massive haemorrhage depends on better understanding of the associated physiological changes as well as on good team work among the different specialists involved in the management of such a complex condition.

[The "Seville" Consensus Document on Alternatives to Allogenic Blood Transfusion. Sociedades españolas de Anestesiología (SEDAR), Medicina Intensiva (SEMICYUC), Hematología y Hemoterapia (AEHH), Transfusión sanguínea (SETS) Trombosis y Hemostasia (SETH)]

The Consensus Document on Alternatives to Allogenic Blood Transfusion (AABT) has been drawn up by a panel of experts from 5 scientific societies. The Spanish Societies of Anesthesiology (SEDAR), Critical Care Medicine and Coronary Units (SEMICYUC), Hematology and Hemotherapy (AEHH), Blood Transfusion (SETS) and Thrombosis and Hemostasis (SETH) have sponsored and participated in this Consensus Document. Alternatives to blood transfusion have been divided into pharmacological and non-pharmacological, with 4 modules and 12 topics. The main objective variable was the reduction of allogenic blood transfusions and/or the number of transfused patients. The extent to which this objective was achieved by each AABT was evaluated using the Delphi method, which classifies the grade of recommendation from A (supported by controlled studies) to E (non-controlled studies and expert opinion). The experts concluded that most of the indications for AABT were based on middle or low grades of recommendation, "C", "D", or "E", thus indicating the need for further controlled studies.

Pre-hospital resuscitation with HBOC-201 and rFVIIa compared to HBOC-201 alone in uncontrolled hemorrhagic shock in swine

In a previous dose escalation study our group found that combining 90μg/kg rFVIIa with HBOC-201 reduced blood loss and improved physiologic parameters compared to HBOC alone. In this follow-up study in a swine liver injury model, we found that while there were no adverse hematology effects and trends observed in the previous study were confirmed, statistical significance could not be reached. Additional pre-clinical studies are indicated to identify optimal components of a multifunctional blood substitute for clinical use in trauma.

Recombinant activated factor VII usage in life threatening hemorrhage: a pediatric experience

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.

Update and new developments in the management of the exsanguinating patient

Definitive management of the exsanguinating patient continues to challenge providers in multiple specialties. Significant hemorrhage may be encountered in a variety of patient care circumstances. Over the past two decades, the vast majority of data and evidence regarding transfusion in the exsanguinating patient has been based upon the trauma literature, and a large amount of recent research has investigated this subject area. In addition to the care of trauma patients, the data which have emerged can also be extrapolated to the treatment of nontrauma patients undergoing transfusion for major hemorrhage. The concept of massive transfusion is an evolving paradigm, and numerous investigations have challenged old principles while creating new controversies. The current review will examine the latest developments in the management of patients with profound hemorrhage. The challenges of dealing with the "lethal triad" will be discussed, as will the various aspects of damage control and hemostatic resuscitation. The latest literature and controversy regarding massive transfusions and massive transfusion protocols will be elucidated with inclusion of data from recent military experiences. Finally, adjuncts including the most recent advances in hemorrhage control, identification of early predictors for massive transfusion, and utilization of pharmacologic and complementary factor agent therapy will be discussed.

Creation, implementation, and maturation of a massive transfusion protocol for the exsanguinating trauma patient

The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. With this combination of massive blood loss and coagulopathy, it has become increasingly more common to transfuse early the trauma patients and with a combination of PRBC, plasma, and platelets. Given the inherent uncertainties common early in the care of patients with severe injuries, the efficient administration of massive amounts of PRBC and clotting factors tends to work best in a predefined, protocol driven system. Our purpose here is to (1) define the problem of massive hemorrhage and coagulopathy in the trauma patient, (2) identify which group of patients this type of protocol should be applied, (3) describe the extensive coordination required to implement this multispecialty MT protocol, (4) explain in detail how the MT was developed and implemented, and (5) emphasize the need for a robust performance improvement or quality improvement process to monitor the implementation of such a protocol and to help identify problems and deliver feedback in a "real-time" fashion. The successful implementation of such a complex process can only be accomplished in a multispecialty setting. Input and representation from departments of Trauma, Critical Care, Anesthesiology, Transfusion Medicine, and Emergency Medicine are necessary to successfully formulate (and implement) such a protocol. Once a protocol has been agreed upon, education of the entire nursing and physician staff is equally essential to the success of this effort. Once implemented, this process may lead to improved clinical outcomes and decreased overall blood utilization with extremely small wastage of vital blood products.

Intravenous hemostat: nanotechnology to halt bleeding

Blood loss is the major cause of death in both civilian and battlefield traumas. Methods to staunch bleeding include pressure dressings and absorbent materials. For example, QuikClot effectively halts bleeding by absorbing large quantities of fluid and concentrating platelets to augment clotting, but these treatments are limited to compressible and exposed wounds. An ideal treatment would halt bleeding only at the injury site, be stable at room temperature, be administered easily, and work effectively for internal injuries. We have developed synthetic platelets based on Arg-Gly-Asp functionalized nanoparticles, which halve bleeding time after intravenous administration in a rat model of major trauma. The effects of these synthetic platelets surpass other treatments, including recombinant factor VIIa, which is used clinically for uncontrolled bleeding. Synthetic platelets were cleared within 24 hours at a dose of 20 mg/ml, and no complications were seen out to 7 days after infusion, the longest time point studied. These synthetic platelets may be useful for early intervention in trauma and demonstrate the role that nanotechnology can have in addressing unmet medical needs.

Surgical innovations arising from the Iraq and Afghanistan wars

The delivery of combat casualty care poses numerous challenges including austere conditions, limited supplies and medical personnel, and multiple simultaneous patients. However, the exigent circumstances of the battlefield compel the development of research and the advancement of adaptive, practical medical technologies to support and sustain military health. In Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), modern changes in medical management, coupled with improved protective gear and evacuation capabilities, have facilitated the highest survival rate in combat history.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Transfusion therapy in hemorrhagic shock

PURPOSE OF REVIEW

Bleeding and death from hemorrhage remain a leading cause of morbidity and mortality in the trauma population. Early resuscitation of these gravely injured patients has changed significantly over the past several years. The concept of damage control resuscitation has expanded significantly with the experience of the US military in southwest Asia. This review will focus on this resuscitation strategy of transfusing blood products (red cells, plasma, and platelets) early and often in the exsanguinating patient.

RECENT FINDINGS

In trauma there are no randomized controlled trials comparing the current damage control hematology concept to more traditional resuscitation methods. But the overwhelming conclusion of the data available support the administration of a high ratio of plasma and platelets to packed red blood cells. Several large retrospective studies have shown ratios close to 1: 1 will result in higher survival.

SUMMARY

The current evidence supports that the acute coagulopathy of trauma is present in a high percentage of trauma patients. Patients who will require a massive transfusion will have improved outcomes the earlier that this is identified and the earlier that damage control hematology is instituted. Current evidence does not describe the best ratio but the preponderance of the data suggests it should be greater than 2: 3 plasma-to-packed red blood cells.

Complications of recombinant activated human coagulation factor VII

BACKGROUND

Recombinant factor VIIa (rFVIIa) frequently is used for treatment of life-threatening hemorrhage in trauma.

METHODS

A retrospective review of injured patients receiving rFVIIa at an American College of Surgeons-verified Level 1 trauma center was performed. Controls were matched for age, sex, Injury Severity Score, and traumatic brain injury. Thrombotic complications in patients administered rFVIIa, including deep venous thrombosis (DVT), pulmonary embolus, acute myocardial infarction, ischemic stroke, mesenteric ischemia, arterial thromboembolism, and death, were determined.

RESULTS

Thirty-six patients were given rFVIIa, of whom 5 (13.8%) had thrombotic complications. Indications for rFVIIa were life-threatening intracranial bleeding in the presence of pre-injury anticoagulation or hemorrhage. The incidences of DVT (n = 4) and acute myocardial infarction (n = 1) were noted. In the control group, there were fewer thrombotic complications (DVT, 1; pulmonary embolus, 1). The mortality rate (52.8%) was higher in patients receiving rFVIIa compared with the control group (22.2%; P = .014). Pre-injury anticoagulation was common in the treatment group.

CONCLUSIONS

Pre-injury anticoagulation is frequently the indication for rFVIIa administration. Thrombotic complications occur with rFVIIa administration. The mortality rate of injured patients who receive rFVIIa is high.

[Haemostatic disorders in orthopaedic surgery: laboratory diagnosis]

Coagulative disorders may result from a breakdown in the balance between coagulation and fibrinolysis. It is important to assess relative physiological states of coagulation and fibrinolysis related to operation. An ideal outcome in orthopaedic surgical procedures is the achievement of adequate haemostasis without excessive bleeding despite transection of numerous blood vessels, a necessary part of any surgical procedure. Meticulous attention to secure intraoperative haemostasis is a surgeon's responsibility. The postoperative haemostatic response to injury must also lead to a hypercoagulable state and thrombosis because it is also accompanied by stasis and vessel injury, fulfilling Virchow's triad. For discussion of prophylaxis and treatment of venous thromboembolic disease and orthopaedic surgical bleeding, the reader is referred to other articles. This paper discusses selected conditions leading to postoperative bleeding and thrombosis after orthopaedic surgery as well as laboratory diagnosis.

The role of recombinant activated Factor VII in major obstetric haemorrhage: the Farnborough experience

Major obstetric haemorrhage is one of the commonest causes of maternal mortality and morbidity worldwide. It may result in coagulopathy and diffuse pelvic or vaginal bleeding. Correction of coagulopathy when administering Factor VII may be crucial to the management of selected cases. We report the use of recombinant activated factor in three cases of massive obstetric haemorrhage. Prolonged international normalised ratio, activated partial thromboplastin time, and reduced fibrinogen were the trigger to use rFVIIa. It was effective to halt the process of coagulopathy, secure haemostasis and improve laboratory parameters in all three patients. We review the relevant literature and discuss its indications, the potential benefits and possible complications. Recombinant activated Factor VII is a potential haemostatic agent in massive obstetric haemorrhage. Its successful use has been reported in post-surgical bleeding and consumptive coagulopathy. It may abolish the need for hysterectomy, which has a devastating effect on the patient future fertility and psychological well-being.

Recombinant factor VIIa: use in fatal post partum hemorrhage - Indian experience case series and review of literature

Postpartum hemorrhage is leading cause of maternal mortality and still remains a challenging condition to treat and hysterectomy may be required to control the bleeding once medical interventions fail. These strategies are not always successful and a direct approach in activating the coagulation system can be more effective and life saving. We describe here the mechanism of action of rFVIIa, review of literature and its use in 10 cases with different causes for PPH with good response.

Use of recombinant factor VIIa in the treatment of massive retroperitoneal bleeding due to severe necrotizing pancreatitis

Background. Recently, a growing number of case reports and case series have suggested that the use of recombinant activated factor VII (rFVIIa) may be effective in treatment of patients with non-hemophilic acquired coagulopathy not responding to conventional treatment such as major surgery, major trauma, sepsis, necrotizing pancreatitis and bleeding due to cerebral arteriovenous malformations. Case report. We presented a septic patient with massive, lifethreatening bleeding caused by retroperitoneal necrosis, due to severe acute necrotizing pancreatitis. As conservative treatment (blood, plasma, cryoprecipitates and platelet transfusions) failed to induce cessation of bleeding, the patient was urgently operated on. In spite of usual procedures of surgical hemostasis (ligation, suture, thermocauterisation, fibrin glue, temporary tamponade), hemorrhage could not be stopped. The patient manifested the signs of hypothermia and metabolic acidosis and, therefore, the decision was made to use recombinant activated factor VII (Novo Seven?). The application of rFVIIa resulted in significant discontinuation of hemorrhage, restoration to normal blood count as well as other relevant coagulation parameters. Conclusion. Although application of rFVIIa is still in the initial clinical phase, and the experience is based mainly on uncontrolled series as well as on individual observations, it seems that this drug can be promising, potent and attractive adjunctive prohemostatic agent. This drug may play a beneficial role in the treatment of serious and unresponsive, 'nonsurgical', life-threatening bleeding due to severe acute necrotizing pancreatitis.

Understanding the therapeutic action of recombinant factor VIIa in platelet disorders

Recombinant factor VIIa (rFVIIa) is a pro-haemostatic agent that is effective in the treatment of bleeding in haemophilia complicated by inhibitors and some other haemorrhagic disorders. The rFVIIa product promotes haemostasis in these settings by enabling the rapid generation of thrombin on the surface of activated platelets which increases fibrin deposition. rFVIIa also has therapeutic activity in bleeding in platelet function disorders such as Glanzmann's thrombasthenia and thrombocytopenia. This suggests that rFVIIa also has a pro-haemostatic effect on platelets and this may contribute to the overall therapeutic action of this agent. The effects of high-concentration FVIIa on platelets have been studied in detail in experiments using ex vivo model systems of haemostasis under static and flow conditions. These experiments show that FVIIa potentiates multiple functional markers of platelet activation and this effect requires direct binding of FVIIa to the activated platelet membrane and the generation of thrombin. The mechanism of this potentiating effect of FVIIa on platelet activation is complex and is likely to require multiple platelet activation receptors and signalling pathways. These include the GPIb-IX-V glycoprotein complex and the thrombin protease activated receptors. The proposed mechanism of action of high-concentration FVIIa has important implications for the therapeutic activity of rFVIIa in vivo. This review summarizes the clinical and experimental evidence supporting a potentiating effect of FVIIa on platelet activation and discusses the likely mechanism of action.

Successful use of recombinant activated factor VII for postoperative associated haemorrhage: a case report

Background

Coagulopathy is a major contributing factor to bleeding related mortality even after achieving adequate surgical control of the haemorrhage in trauma and surgical patients.

Case presentation

A 65 years old Greek man was admitted in our ICU with critical haemorrhage following renal biopsy. Despite surgical exploration the patient continued to bleed resulting in a vicious cycle of transfusion, coagulopathy and re-bleeding. After all standard management options were exhausted, the patient was given rFVIIa (total dose 4,8 mg). Clinical improvement was noted without adverse thrombotic complications. One month later the same patient was operated on for a suspected retroperitoneal infected collection that it was assumed to be the cause of persistent pyrexia. After abdominal washout, he suffered haemorrhagic shock with postoperative coagulopathy. Standard transfusion therapy was again unsuccessful. The patient was given rFVIIa again resulting in an immediate reduction in coagulopathic haemorrhage accompanied by a significant improvement in laboratory measurements and reduction in blood products requirements.

Conclusion

Published clinical experiences for the use of rFVIIa in trauma patients are limited to small series and case reports. However, in trauma patients, administration of rFVIIa appears to be effective in addition to prompt surgical intervention as an adjunctive haemostatic measure to control life threatening bleeding in appropriately selected patients.

Low-dose recombinant factor VIIa for trauma patients with coagulopathy

INTRODUCTION

Coagulopathy in injured patients is common and is generally treated with fresh frozen plasma (FFP). Response can be variable, thus complete correction may take hours and require large volumes of fluids. High-dose recombinant factor VIIa (FVIIa, Novoseven, Novo Nordisk, Bagsvaerd, Denmark) has been used off-label to treat severe coagulopathy following trauma. Expense has limited use. Recently, we began administering low dose FVIIa (1.2mg) to patients with mild to moderate coagulopathy after trauma, hypothetising that it would be effective and safe.

PATIENTS AND METHODS

We retrospectively reviewed consecutive patients who received a low dose of 1.2mg of FVIIa over a 2-year period. Factor VIIa is administered after approval by a gatekeeper at the discretion of the treating physician. Demographics, injury and laboratory data were abstracted as were indications for use, source of coagulopathy, effectiveness, and complications. A two-tailed paired t-test was used to determine significant changes in coagulation parameters and blood product utilisation.

RESULTS

Eighty-one patients received 84 low doses of FVIIa. The mean age of the patients was 51 (+/-22) with a mean ISS of 29 (+/-11). Seventy-three per cent were male and 67% had a traumatic brain injury (TBI) as their primary injury. The aetiology of the coagulopathy in the study population included; TBI (40%), warfarin use (22%), and cirrhosis (13%). Mean prothrombin time (PT) fell from 17.0 s (+/-3.2) to 10.6s (+/-1.4) (p<0.0001). All patients had a good clinical response with no bleeding complications. Utilisation of packed red blood cells and fresh frozen plasma were significantly less in the 24h after FVIIa administration as compared to the 24h prior. Subsequent thromboembolic events were observed in 12 of the 81 patients (15%) and included; cerebrovascular accident (CVA) (6), mesenteric thrombosis (2), myocardial infarction (MI) (1), pulmonary embolism/deep venous thrombosis (PE/DVT) (2), and atrial thrombus (1). Only four of these events were thought to be related to the FVIIa administration, with two of the four contributing to a lethal outcome.

CONCLUSIONS

Low dose FVIIa rapidly and effectively treats mild to moderate coagulopathy following injury. This low dose (1.2mg) FVIIa is the smallest available unit dose. It costs approximately the same as 8 units of plasma and may be cost-effective in patients who require high volume factor administration. Low dose FVIIa may be effective in coagulopathic trauma patients who are not in shock but require rapid normalisation of clotting function.

[Medical-surgical management of traumatic cardiac rupture: Relevance of recombinant activated factor VII]

The mortality rate from cardiac rupture by blunt chest injury is high. In multiple trauma patient, haemorrhage is a major cause of death. Regardless of aetiology, the management of massive bleeding requires immediate surgery with simultaneous stabilization of haemostasis and maintenance of normovolaemia. A pharmacological approach to reduce blood transfusion consists on the use of recombinant activated factor VII (rFVIIa). We report our experience with rFVIIa to control the haemorrhage in a blunt heart trauma with coagulopathy. The surgical exploration found a right haemothorax related to a pericardium rupture with two open wounds of the heart. The atrial and ventricular ruptures were repaired without cardiopulmonary bypass. The use of two consecutive doses (100 microg/kg) of rFVIIa during, and after surgery, reduced the need of transfusion. After this episode, the patient developed a transient cardiac dysfunction, and then was discharged from hospital. The use of rFVIIa reduced probably the need of blood transfusion in this case of blunt heart trauma. This treatment should be envisaged in similar cases after the failure of standard therapy to control the bleeding.

Effect of haemodilution, acidosis, and hypothermia on the activity of recombinant factor VIIa (NovoSeven)

Background

A range of plasma volume expanders is used clinically, often in settings where haemostasis may already be impaired. The haemostatic agent, recombinant activated factor VII (rFVIIa, NovoSeven^®), may be used to improve haemostasis but potential interactions with different volume expanders are poorly understood.

Methods

Clot formation was measured by thromboelastography (TEG) using blood from healthy volunteers. In vitro effects of rFVIIa with haemodilution, acidosis, and hypothermia were examined. Conditions were induced by dilution with NaCl (0.9%), lactated Ringer's solution, albumin 5%, or hydroxyethyl starch (HES) solutions [MW (molecular weight) 130–670 kDa]; by adjusting pH to 6.8 with 1 M HEPES (N-2-hydroxyethylpiperazine-N′-2-ethanesulphonic acid) buffer; or by reducing temperature to 32°C. We also studied the effect of low vs high MW HES (MW 200 vs 600 kDa) and rFVIIa on in vivo bleeding time (BT) in rabbits.

Results

Haemodilution progressively altered TEG parameters. rFVIIa improved TEG parameters in the presence of acidosis, hypothermia or 20% haemodilution (P<0.05). At 40% haemodilution, the rFVIIa effect was diminished particularly with high MW HES. In vivo, rFVIIa shortened the BT (P<0.05) with low but not high MW HES.

Conclusions

Efficacy of rFVIIa was affected by the degree of haemodilution and type of volume expander, but not by acidosis or hypothermia.

Single-center experience: use of recombinant factor VIIa for acute life-threatening bleeding in children without congenital hemorrhagic disorder

Coagulopathy is an important cause of mortality in critically ill children. Traditional therapies to correct coagulopathy lead to great time delays and cause fluid overload in patients. The authors report the effectiveness and safety of the activated recombinant factor VII (rFVIIa) administration in a series of 13 nonhemophiliac children with acute, life-threatening bleeding. In this retrospective study, the records of the patients who were not diagnosed with congenital hemorrhagic disorder and were administered rFVIIa due to any other reason in Ege University Faculty of Medicine, Department of Pediatrics, between February 2002 and February 2007 were reviewed retrospectively. Thirteen nonhemophiliac patients with acute life-threatening bleeding and ages ranging from 2 days to 15 years received rFVIIa over a 5-year period. Three patients were diagnosed with hemaphagocytic lymphohistiocytosis, 4 with prematurity, sepsis, and disseminated intravascular coagulation (DIC), 5 with sepsis, multiple organ dysfunction syndrome, and DIC, and 1 with acute liver failure. Severe bleeding resulted from pulmonary (n = 3), lower gastrointestinal system (n = 2), esophagus varices (n = 1), pulmonary and gastrointestinal system (n = 4), pulmonary, gastrointestinal system, and intracranial hemorrhage (n = 1), and gastrointestinal system and intracranial hemorrhage (n = 2). Median frequency of rFVIIa administration was 3 per patient (range 2-15) and median dose of rFVIIa was 90 microg/kg, ranging from 60 to 135 microg/kg each administration. All of the patients were given fresh frozen plasma and if necessary platelet transfusion (n = 10) or fibrinogen concentrate (n = 3) before administration of rFVIIa. In 6 patients, lack of success to control bleeding by conventional methods was the only cause to start rFVIIa. In 7 patients, the need for volume restriction was also a significant contributing factor in deciding to start rFVIIa. Median PT was 32.9 s (range: 19-65) before rFVIIa administration and it was decreased to 11.6 s (range: 10.7-12.8), 2-3 h after rFVIIa infusion. Bleeding was stopped completely in 10 patients at least for 24 h and decreased in 3 patients 30-45 min after rFVIIa administration. Two patients had thrombotic complications attributed to rFVIIa administration. No other complication was observed in the other patients. In this retrospective study, rFVIIa was found to be effective at controlling severe hemorrhagic symptoms of different etiologies in children without congenital hemorrhagic disorder. In addition to the rapid control of bleeding, administration of this agent improved fluid balance and led to a reduction in blood product requirements in critically ill children. However, survival was still poor (23%), and 2/13 (15.4%) patients developed venous and arterial thrombosis within 3 h of treatment. The authors emphasize that in acquired, acute life-threatening bleeding, simultaneous administration of rFVIIa with conventional treatment may contribute to patient survival. However, the risk of thromboembolism should be considered before this treatment is given.