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Elevated International Normalized Ratio (INR) is Associated With an Increased Risk of Intraventricular Hemorrhage in Extremely Preterm Infants. J Pediatr Hematol Oncol 2019; 41:355-360. [PMID: 31135715 DOI: 10.1097/mph.0000000000001509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The international normalized ratio (INR), a standardized method of reporting the prothrombin time, can be a surrogate marker of the vitamin K-dependent coagulation pathways. OBJECTIVE To evaluate the relationship between INR measurements in the first 48 hours of life and subsequent development of intraventricular hemorrhage (IVH) in extremely preterm infants. MATERIALS AND METHODS A single-center retrospective, observational cohort study of infants born at <28 weeks gestation. The main outcome measure was defined as the degree of IVH seen on cranial ultrasound examinations at day 7 postnatal age. RESULTS Of 200 infants, 109 (mean gestational age, 25.2 wk [SD, 1.27]) had coagulation results available. Of 109, 26 developed IVH. Elevated INR was associated with increased risk of a severe IVH (odds ratio [OR] 6.50; 95% confidence interval [CI], 1.65-25.62; P=0.008) adjusted for gestation, birth weight, and sex. INR was significantly associated with severe IVH in infants who did not receive blood products (OR, 64.60; 95% CI, 1.35-3081.25; P=0.035), but not in those who did (OR, 2.93; 95% CI, 0.67-12.71; P=0.151) (Pinteraction=0.086). CONCLUSION An elevated INR in the first 48 hours of life may be useful to identify preterm infants at risk of severe IVH and may guide strategies to prevent the development, or limit the extension, of IVH.
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Haidl H, Pohl S, Leschnik B, Gallistl S, Muntean W, Schlagenhauf A. Neonatal thrombocytopenia: Thrombin generation in presence of reduced platelet counts and effects of rFVIIa in cord blood. Sci Rep 2019; 9:8014. [PMID: 31142810 PMCID: PMC6541708 DOI: 10.1038/s41598-019-44199-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 05/07/2019] [Indexed: 11/12/2022] Open
Abstract
Healthy neonates exhibit a well-functioning haemostatic system despite peculiarities regarding composition of clotting factors and inhibitors as well as impaired platelet aggregation. Thrombocytopenia and severe bleeding events are feared in sick infants. Recombinant factor VIIa (rFVIIa) is a haemostatic agent used as a last resort in neonates with refractory bleedings. Aim of this study was to investigate in-vitro (i) changes in thrombin generation with different platelet counts, (ii) effects of rFVIIa under conditions of thrombocytopenia and (iii) potentially differing dose-response of rFVIIa in cord blood as a surrogate for neonatal blood compared to adult blood. Thrombin generation parameters were observed in cord blood plasma and adult plasma with various platelet counts, with or without addition of rFVIIa, respectively. Low platelet counts did not influence thrombin generation in cord blood in contrast to adult blood. RFVIIa primarily affected lag time throughout all platelet concentrations. Interestingly, peak height was reduced exclusively in cord blood plasma after addition of rFVIIa. No significant differences regarding dose-response were observed between cord blood and adult blood. In contrast to adult blood, thrombocytopenia in cord blood does not significantly influence thrombin generation. Even at very low platelet counts there is enough negatively charged surface to support rFVIIa action in plasma from cord blood and adult blood in-vitro.
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Affiliation(s)
- Harald Haidl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Sina Pohl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bettina Leschnik
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Siegfried Gallistl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Wolfgang Muntean
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Axel Schlagenhauf
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
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Dunkley S, Curtin JA, Marren AJ, Heavener RP, McRae S, Curnow JL. Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy. Med J Aust 2019; 210:326-332. [PMID: 30924538 PMCID: PMC6850504 DOI: 10.5694/mja2.50123] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There have been significant advances in the understanding of the management of inherited bleeding disorders in pregnancy since the last Australian Haemophilia Centre Directors' Organisation (AHCDO) consensus statement was published in 2009. This updated consensus statement provides practical information for clinicians managing pregnant women who have, or carry a gene for, inherited bleeding disorders, and their potentially affected infants. It represents the consensus opinion of all AHCDO members; where evidence was lacking, recommendations have been based on clinical experience and consensus opinion. MAIN RECOMMENDATIONS During pregnancy and delivery, women with inherited bleeding disorders may be exposed to haemostatic challenges. Women with inherited bleeding disorders, and their potentially affected infants, need specialised care during pregnancy, delivery, and postpartum, and should be managed by a multidisciplinary team that includes at a minimum an obstetrician, anaesthetist, paediatrician or neonatologist, and haematologist. Recommendations on management of pregnancy, labour, delivery, obstetric anaesthesia and postpartum care, including reducing and treating postpartum haemorrhage, are included. The management of infants known to have or be at risk of an inherited bleeding disorder is also covered. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT Key changes in this update include the addition of a summary of the expected physiological changes in coagulation factors and phenotypic severity of bleeding disorders in pregnancy; a flow chart for the recommended clinical management during pregnancy and delivery; guidance for the use of regional anaesthetic; and prophylactic treatment recommendations including concomitant tranexamic acid.
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Affiliation(s)
- Scott Dunkley
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW
| | - Julie A Curtin
- The Children's Hospital at Westmead, Sydney, NSW.,Australian Haemophilia Centres Directors' Organisation, Melbourne, VIC
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Leijser LM, de Vries LS. Preterm brain injury: Germinal matrix-intraventricular hemorrhage and post-hemorrhagic ventricular dilatation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:173-199. [PMID: 31324310 DOI: 10.1016/b978-0-444-64029-1.00008-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Germinal matrix hemorrhage and intraventricular hemorrhages (GMH-IVH) remain a common and clinically significant problem in preterm infants, particularly extremely preterm infants. A large GMH-IVH is often complicated by posthemorrhagic ventricular dilation (PHVD) or parenchymal hemorrhagic infarction and is associated with an increased risk of adverse neurologic sequelae. The widespread use of cranial ultrasonography since the early 1980s has shown a gradual decrease in the incidence of GMH-IVH and has helped with the identification of antenatal and perinatal risk factors and timing of the lesion. The increased use of magnetic resonance imaging (MRI) has contributed to more detailed visualization of the site and extent of the GMH-IVH. In addition, MRI has contributed to the awareness of associated white matter changes as well as associated cerebellar hemorrhages. Although GMH-IVH and PHVD still cannot be prevented, cerebrospinal fluid drainage initiated in the early stage of PHVD development seems to be associated with a better neurodevelopmental outcome. Further studies are underway to improve treatment strategies for PHVD and to potentially prevent and repair GMH-IVH and PHVD and associated brain injury. This chapter discusses the pathogenesis, incidence, risk factors, and management, including preventive measures, of GHM-IVH and PHVD.
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Affiliation(s)
- Lara M Leijser
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Gamaleldin I, Harding D, Siassakos D, Draycott T, Odd D. Significant intraventricular hemorrhage is more likely in very preterm infants born by vaginal delivery: a multi-centre retrospective cohort study. J Matern Fetal Neonatal Med 2017; 32:477-482. [DOI: 10.1080/14767058.2017.1383980] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - David Harding
- Women’s and Children’s Health, St. Michael’s Hospital, Bristol, UK
| | | | - Tim Draycott
- Women’s Health, Chilterns, Southmead Hospital, Bristol, UK
| | - David Odd
- Women’s and Children's Health, Southmead Hospital, Bristol, UK
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Cosar H, Isik H, Cakır SC, Yar N, Goksen B, Tokbay H, Kertmen H, Erdoğan N, Durak I. Recombinant Activated Factor VIIa (rFVIIa) Treatment in Very-Low-Birth-Weight (VLBW) Premature Infants with Acute Pulmonary Hemorrhage: A Single-Center, Retrospective Study. Paediatr Drugs 2017; 19:53-58. [PMID: 27826851 DOI: 10.1007/s40272-016-0203-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM We aimed to evaluate the efficacy of intravenous administration of recombinant activated factor VIIa (rFVIIa) for acute pulmonary hemorrhage treatment in very-low-birth-weight (VLBW) premature infants. PATIENTS AND METHODS This study was carried out retrospectively in premature infants with pulmonary hemorrhage that were ≤30 weeks gestational age or <1250 g birth weight. The data of all VLBW premature infants with pulmonary hemorrhage who were hospitalized in our neonatal intensive care unit between 01 January 2013 and 31 December 2015 were evaluated. Group 1 (n = 21) received rFVIIa support within the first 30 min of pulmonary hemorrhage plus conventional treatment, while Group 2 (n = 21) received conventional treatment only. RESULTS The number of patients whose pulmonary hemorrhage was stopped within the first 2 h was significantly higher in Group 1 than Group 2 (n = 14 vs n = 4; p = 0.002). After pulmonary hemorrhage, hemoglobin values of Group 1 were higher than Group 2 (11.12 ± 1.06 vs 10.14 ± 1.59 g/dL; p = 0.024). Erythrocyte suspension (1.43 ± 4.51 vs 5.71 ± 7.46 mL/kg; p = 0.030) and fresh frozen plasma use (5.71 ± 8.10 vs 19.52 ± 12.44 mL/kg; p < 0.001) in Group 1 were lower than those of Group 2. Prothrombin time, activated partial thromboplastin time, and international normalized ratio values in Group 1 were lower than those of Group 2 (p < 0.05). No statistically significant difference was identified in recurrence of pulmonary hemorrhage after 72 h, overall mortality, mortality from pulmonary hemorrhage, surfactant use, intubation time, hospitalization duration, intraventricular hemorrhage (IVH), severe IVH, patent ductus arteriosus rates, or short-term complication rates. CONCLUSION rFVIIa administration was observed to be effective in stopping pulmonary hemorrhage, reducing blood product requirement, and improving coagulation test parameters. Prospective studies are needed to evaluate the efficacy, reliability, and long-term results of rFVIIa in the prevention and treatment of pulmonary hemorrhage in premature infants.
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Affiliation(s)
- Hese Cosar
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey.
| | - Halil Isik
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
| | - Salih Cagrı Cakır
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
| | - Nese Yar
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
| | - Bulent Goksen
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
| | - Hakan Tokbay
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
| | - Hasan Kertmen
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
| | - Nihal Erdoğan
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
| | - Ikbal Durak
- Neonatal Intensive Care Unit, Private Egepol Hospital, 507 Street, No: 3, 35270, Konak, Izmir, Turkey
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Neary E, Ni Ainle F, El-Khuffash A, Cotter M, Kirkham C, McCallion N. Plasma transfusion to prevent intraventricular haemorrhage in very preterm infants. Hippokratia 2016. [DOI: 10.1002/14651858.cd012341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Elaine Neary
- Rotunda Hospital; Department of Paediatrics; Dublin Ireland
| | | | | | - Melanie Cotter
- Rotunda Hospital; Department of Haematology; Dublin Ireland
| | - Colin Kirkham
- Rotunda Hospital; Department of Statistics; Dublin Ireland
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Punzalan RC, Gottschall JL. Use and Future Investigations of Recombinant and Plasma-Derived Coagulation and Anticoagulant Products in the Neonate. Transfus Med Rev 2016; 30:189-96. [PMID: 27576087 DOI: 10.1016/j.tmrv.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
Although congenital bleeding disorders can manifest in the newborn period, the most common causes of bleeding and thrombosis in neonates are acquired conditions. Factor concentrates are used for specific diagnoses (hemophilia with inhibitors, specific factor deficiency, von Willebrand disease) and approved indications, and increasingly for off-label indications (bleeding in surgery cardiopulmonary bypass, extracorporeal membrane oxygenation). We will review the approved indications for factor products in the neonate and discuss the evidence and rationale for off-label use of factor products in management of bleeding and thrombosis in the neonate.
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Affiliation(s)
- Rowena C Punzalan
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Jerome L Gottschall
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
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9
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Abstract
Both coagulopathy and abnormal thrombosis can complicate the anesthetic and surgical management of neonatal patients; however, the patterns of bleeding and thrombosis in neonates differ from those in adults or older children. Severe coagulopathic bleeding most commonly occurs during heart surgery and almost certainly contributes to morbidity and mortality in this population. Such severe bleeding is rare during other surgery; the exception is babies presenting to the operating room with established coagulopathy secondary to severe sepsis. Alternatively, pathological thrombosis will mainly occur in association with indwelling vascular access devices or surgically created vascular shunts. There are important differences between the coagulation system in neonates and older patients. The implication of this is that therapies established in other patient groups will not be optimal for neonates without adaptation. While evidence from high-quality clinical trials is rarely available, an understanding of how coagulation in neonates differs can help to guide practice. This review will discuss important differences between the coagulation system of neonates and older patients and how these relate to newer models of coagulation. The emphasis will be on issues likely to impact on perioperative care. In particular, the management of severe bleeding, the manipulation of coagulation during heart surgery, and the management of coagulopathy in septic neonates will be discussed in detail.
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Affiliation(s)
- Philip D Arnold
- Jackson Rees Department of Paediatric Anaesthesia, Alder Hey Children's Hospital NHS Trust, Liverpool, UK; University of Liverpool, Liverpool, UK
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10
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Kuperman AA, Brenner B, Kenet G. Intraventricular haemorrhage in preterm infants – Can we improve outcome by addressing coagulation? J Matern Fetal Neonatal Med 2013; 28 Suppl 1:2265-7. [DOI: 10.3109/14767058.2013.796165] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Winch PD, Naguib AN, Bradshaw JR, Galantowicz M, Tobias JD. Decreasing the need for transfusion: infant cardiac surgery using hemodilution and recombinant factor VIIa. Pediatr Cardiol 2013; 34:119-24. [PMID: 22760694 DOI: 10.1007/s00246-012-0398-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 05/17/2012] [Indexed: 11/28/2022]
Abstract
Many strategies, including intraoperative acute normovolemic hemodilution (ANH) and pharmacologic agents, exist to minimize the use of allogeneic blood products in pediatric congenital heart surgery. Recombinant activated factor VIIa (rFVIIa) is a hemostatic agent approved for the treatment of bleeding episodes and prevention of bleeding in surgical interventions in patients with hemophilia A or B with inhibitors, acquired hemophilia, or congenital factor VII deficiency. Off-label use in nonhemophilic patients for uncontrolled hemorrhage is increasing although still under investigation. We present our experience with ANH and rFVIIa in nine patients. All were <16 months of age and underwent complex cardiac surgery with the end point of achieving hemostasis while decreasing or eliminating the need for allogeneic blood products. Clinically, we have observed rapid hemostasis in patients who underwent ANH and then had autologous blood reinfused after cardiopulmonary bypass, along with rFVIIa, without any time delay. The patients required no allogeneic blood products and therefore results suggested the potential utility of this practice. The study group consisted of nine patients <16 months of age who received rFVIIa in the operating room after open-heart surgery. Amount of autologous blood removed preoperatively, blood product use, time from protamine to rFVIIa administration, platelet count, INR, and fibrinogen level were retrospectively obtained. Of the nine patients, the three who underwent the most aggressive hemodilution received rFVIIa most rapidly and required no allogeneic blood products to achieve hemostasis although they had an average lower fibrinogen level on admission to the cardiothoracic intensive care unit. These preliminary data suggest that hemodilution before surgical stimulation and the rapid administration of rFVIIa, along with the reintroduction of autologous blood, may decrease or potentially eliminate the need for allogeneic blood products. Prospective trials are warranted to further explore this technique.
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Affiliation(s)
- Peter D Winch
- Department of Anesthesiology and Pain Medicine and The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
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12
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Kuperman AA, Brenner B, Kenet G. Intraventricular hemorrhage in preterm infants and coagulation – Ambivalent perspectives? Thromb Res 2013; 131 Suppl 1:S35-8. [DOI: 10.1016/s0049-3848(13)70018-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Does risk-based coagulation screening predict intraventricular haemorrhage in extreme premature infants? Blood Coagul Fibrinolysis 2012; 23:532-6. [DOI: 10.1097/mbc.0b013e3283551145] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Poralla C, Hertfelder HJ, Oldenburg J, Müller A, Bartmann P, Heep A. Elevated interleukin-6 concentration and alterations of the coagulation system are associated with the development of intraventricular hemorrhage in extremely preterm infants. Neonatology 2012; 102:270-5. [PMID: 22906886 DOI: 10.1159/000341266] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 06/24/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pathogenesis of intraventricular hemorrhage (IVH) in premature infants is multifactorial. Little is known about the influence of pro-inflammatory cytokine activation on the coagulation system in extremely preterm infants and its impact on the development of IVH. OBJECTIVE To determine the interaction between serum interleukin-6 (IL-6) and the coagulation system in preterm infants predisposed to the development of IVH. METHODS Vitamin K-dependent coagulation factors were examined retrospectively in 132 extremely preterm infants prior to vitamin K administration at the first day of life. Patients were grouped according to the occurrence of IVH and serum concentration of IL-6 >/<100 pg/ml. RESULTS Occurrence of IVH was associated with clinical diagnosis of chorioamnionitis, low gestational age, high CRIB score, air leak, catecholamine treatment, low initial hematocrit and increased serum concentration of IL-6. Infants developing IVH showed a diminished coagulation profile. Multivariable logistic regression analysis revealed decreased activity of coagulation factor VII, development of pneumothorax and low hematocrit as independent risk factors for the development of IVH. An increased IL-6 serum concentration was associated with a significantly decreased activity of coagulation factor VII and increased levels of fibrinogen. CONCLUSIONS The association of elevated IL-6 levels with alterations of the coagulation profile and development of IVH found in our study supports the assumption of a close pathophysiological relation between inflammation and IVH.
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Martin JB. Prevention of Intraventricular Hemorrhages and Periventricular Leukomalacia in the Extremely Low Birth Weight Infant. ACTA ACUST UNITED AC 2011. [DOI: 10.1053/j.nainr.2011.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Intra-ventricular hemorrhage (IVH) occurs predominantly in very low birth weight premature infants. Survivors of severe IVH frequently experience long-term consequences including major neurological deficits. Advances in neonatal and obstetric care in the last decades, have led to a steady decline in mortality and in the incidence of IVH. However, significant improvements in the survival rates small premature infants have led to an increase in the population of newborns prone to IVH. The pathogenesis of IVH is multifactorial. Prematurity of the germinal matrix, fluctuations in cerebral blood flow, hypoxic ischemic cerebral injury and developmental hemostatic abnormalities of newborns are important risk factors. The following manuscript will address the epidemiology and pathogenesis of IVH and review studies regarding potential pro-coagulant therapy.
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Affiliation(s)
- Gili Kenet
- Thrombosis Unit, National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.
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17
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Malhotra A, Veldman A. Recombinant activated Factor VII for prevention and treatment of intraventricular haemorrhage in neonates. Hippokratia 2011. [DOI: 10.1002/14651858.cd009032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Atul Malhotra
- Monash Medical Centre; Monash Newborn; 246 Clayton Road Clayton Victoria Australia 3168
| | - Alex Veldman
- Monash Medical Centre; Monash Newborn; 246 Clayton Road Clayton Victoria Australia 3168
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18
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Rama-Maceiras P, Ingelmo-Ingelmo I, Fàbregas-Julià N, Hernández-Palazón J. Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neurocríticos. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70016-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Piotrowski A, Dabrowska-Wojciak I, Mikinka M, Fendler W, Walas W, Sobala W, Kuczkowski KM. Coagulation abnormalities and severe intraventricular hemorrhage in extremely low birth weight infants. J Matern Fetal Neonatal Med 2010. [DOI: 10.3109/14767050903229614] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Poralla C, Hertfelder HJ, Oldenburg J, Müller A, Bartmann P, Heep A. Treatment of acute pulmonary haemorrhage in extremely preterm infants with recombinant activated factor VII. Acta Paediatr 2010; 99:298-300. [PMID: 19839953 DOI: 10.1111/j.1651-2227.2009.01551.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Dunkley SM, Russell SJ, Rowell JA, Barnes CD, Baker RI, Sarson MI, Street AM. A consensus statement on the management of pregnancy and delivery in women who are carriers of or have bleeding disorders. Med J Aust 2009; 191:460-3. [PMID: 19835544 DOI: 10.5694/j.1326-5377.2009.tb02887.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Accepted: 08/05/2009] [Indexed: 11/17/2022]
Abstract
Pregnancy and delivery are critical times for women with bleeding disorders, with mothers, and possibly their affected infants, being exposed to a variety of haemostatic challenges. Management of women with bleeding disorders during pregnancy involves a multidisciplinary team including, but not limited to, an obstetrician, an anaesthetist and a haematologist. This consensus document from the Australian Haemophilia Centre Directors' Organisation (AHCDO) provides practical information for clinicians managing women with bleeding disorders during pregnancy. Included are: the expected physiological response in pregnancy in such women; management of pregnancy, labour and delivery, as well as obstetric anaesthesia issues, postpartum care, and reducing and treating postpartum haemorrhage; and management of infants at risk of a bleeding disorder and of bleeding in neonates. The guidelines were developed after extensive consultation, face-to-face meetings and revisions. The final document represents a consensus opinion of all AHCDO members. Where evidence is lacking, recommendations are based on clinical experience and consensus opinion.
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Affiliation(s)
- Scott M Dunkley
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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22
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Bassan H. Intracranial hemorrhage in the preterm infant: understanding it, preventing it. Clin Perinatol 2009; 36:737-62, v. [PMID: 19944833 DOI: 10.1016/j.clp.2009.07.014] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
New discoveries in neonatal imaging, cerebral monitoring, and hemodynamics, and greater understanding of inflammatory and genetic mechanisms involved in intracranial hemorrhage (ICH) in the preterm infant are creating opportunities for innovative early detection and prevention approaches. This article covers the spectrum of ICH in the preterm infant, including germinal matrix intraventricular hemorrhage, its complications, and associated phenomena, such as the emerging role of cerebellar hemorrhage. The overall aim of this article is to review the current knowledge of the mechanisms, diagnosis, outcome, and management of preterm ICH; to revisit the origins from which they develop; and to discuss future expectations.
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Affiliation(s)
- Haim Bassan
- Pediatric Neurology Unit, Neonatal Neurology Service, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, Tel Aviv 64239, Israel.
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Puetz J, Darling G, Brabec P, Blatny J, Mathew P. Thrombotic events in neonates receiving recombinant factor VIIa or fresh frozen plasma. Pediatr Blood Cancer 2009; 53:1074-8. [PMID: 19621430 DOI: 10.1002/pbc.22160] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- John Puetz
- Division of Hematology/Oncology, Department of Pediatrics, Saint Louis University, SSM Cardinal Glennon Children's Medical Center, St. Louis, Missouri 63104, USA.
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Abstract
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.
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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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Dani C, Poggi C, Ceciarini F, Bertini G, Pratesi S, Rubaltelli FF. Coagulopathy screening and early plasma treatment for the prevention of intraventricular hemorrhage in preterm infants. Transfusion 2009; 49:2637-44. [PMID: 19682341 DOI: 10.1111/j.1537-2995.2009.02328.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite the improvement in the assistance and treatment of preterm infants, intraventricular hemorrhage (IVH) remains a frequent complication in these patients. Our aim was to demonstrate the hypothesis that a coagulopathy screening and the early treatment with fresh-frozen plasma (FFP) of proven coagulopathy may contribute to decrease the occurrence of IVH in infants with gestational age of less than 29 weeks. STUDY DESIGN AND METHODS This study compared two cohorts of infants who received FFP (10 mL/kg) after the evidence of pathologic coagulation tests performed within 2 hours after birth (screening group, n = 127) or after the development of bleedings and evidence of pathologic coagulation tests (no-screening group, n = 91). RESULTS The screening strategy decreased the relative risk (RR) of developing IVH (RR = 0.65; 95% confidence interval, 0.44-0.98) compared to no-screening strategy, but the effect was limited to infants born at 23 to 26 weeks of gestation in whom screening strategy lowered IVH occurrence (34.5% vs. 61.1%, p = 0.008). CONCLUSIONS A coagulopathy screening strategy decreases the risk of developing IVH in preterm infants but this effect is limited to infants born at 23 to 26 weeks of gestation.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital of Florence, Florence, Italy.
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Alten JA, Benner K, Green K, Toole B, Tofil NM, Winkler MK. Pediatric off-label use of recombinant factor VIIa. Pediatrics 2009; 123:1066-72. [PMID: 19255041 DOI: 10.1542/peds.2008-1685] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our goal was to report our institutional experience with recombinant factor VIIa for the treatment and/or prevention of bleeding in nonhemophiliac children. METHODS This was a retrospective case series in a tertiary pediatric referral hospital. RESULTS During 1999-2006, 135 patients received recombinant factor VIIa for off-label use. The median number of doses was 2; the median dose was 88 mug/kg. The most common diagnoses among patients receiving recombinant factor VIIa were disseminated intravascular coagulation/sepsis (28), surgical bleeding (19), procedural prophylaxis (16), and trauma (15). The median volume of blood products administered 24 hours before recombinant factor VIIa treatment was 29.7 vs 11.7 mL/kg 24 hours after treatment. Only 1 high-risk patient had significant bleeding after receiving prophylactic recombinant factor VIIa before an invasive procedure. Nonsurvivors had significantly increased incidence of multiple organ dysfunction syndrome (75%) compared with survivors (23%). The largest group of patients (n = 28) received recombinant factor VIIa for bleeding and/or coagulopathy because of disseminated intravascular coagulation; the mortality in this group was 26 (93%) of 28. Eleven patients received multiple doses of recombinant factor VIIa to treat bleeding complications after hematopoietic stem cell transplant, without improvement in blood use. Mortality in medical patients was 58% vs 16% in surgical patients. Three patients had significant thrombotic adverse events after receiving recombinant factor VIIa, resulting in 2 deaths and 1 leg amputation. CONCLUSIONS Off-label use of recombinant factor VIIa significantly decreases blood-product administration; surgical patients had control of life-threatening bleeding with low associated mortality. Prophylactic recombinant factor VIIa may be effective in preventing bleeding if given before invasive procedures in children at high risk. Prolonged use of recombinant factor VIIa for bleeding complications after hematopoietic stem cell transplant is not effective in preventing packed red blood cell transfusion. Presence of disseminated intravascular coagulation and mulitorgan dysfunction syndrome may help predict futility of recombinant factor VIIa treatment. Off-label use of recombinant factor VIIa is associated with thromboembolic events in children.
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Affiliation(s)
- Jeffrey A Alten
- University of Alabama at Birmingham, 1600 7th Ave South, ACC 504, Birmingham, AL 35233, USA.
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Abstract
Neonatal hemostatic abnormalities can present diagnostic and therapeutic challenges to the physician. Developmental deficiencies and/or increases of certain coagulation proteins, coupled with acquired or genetic risk factors, can result in a hemorrhagic or thromboembolic emergency. The timely diagnosis of a congenital hemorrhagic or thrombotic disorder can avoid significant long-term sequelae. However, due to the lack of randomized clinical trials addressing the management of neonatal coagulation disorders, treatment strategies are usually empiric and not evidence-based. In this chapter, we will review the neonatal hemostatic system and will discuss the most common types of hemorrhagic and thrombotic disorders. Congenital and acquired risk factors for hemorrhagic and thromboembolic disorders will be presented, as well as current treatment options. Finally, suggested evaluations for neonates with either hemorrhagic or thromboembolic problems will be reviewed.
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Affiliation(s)
- Matthew A Saxonhouse
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL 32610, USA.
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Recombinant activated Factor VII as a hemostatic agent in very low birth weight preterms with gastrointestinal hemorrhage and disseminated intravascular coagulation. J Pediatr Hematol Oncol 2008; 30:337-42. [PMID: 18458565 DOI: 10.1097/mph.0b013e3181639b28] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Acute hemorrhage in preterm infants leads immediately to a life-threatening event because of the small circulating blood volume. The beneficial use of recombinant activated Factor VII (rFVIIa; NovoSeven, NovoNordisk, Gentofte, Denmark) as hemostatic treatment in neonates with hemorrhagic shock has been described. Necrotizing enterocolitis is a challenge in neonatology as the disease represents one of the leading causes of mortality in preterm infants. We report on the use of rFVIIa in very low birth weight (<1500 g), preterms with intestinal hemorrhage, and disseminated intravascular coagulation (DIC). DESIGN Retrospective analysis of 5 cases. PATIENTS Five preterm infants <or=28 weeks gestational age with DIC and hemorrhagic shock due to severe diffuse gastrointestinal bleeding. INTERVENTION Intravenous bolus administration of 100 to 180-microg/kg rFVIIa (total of 9 doses) as rescue procedure after other interventions (substitution of platelets, fresh frozen plasma, red packed cells, surgery) failed to achieve hemostasis. RESULTS Two patients with severe acidosis, hypothermia, and thrombopenia died in hemorrhagic shock, treatment with rFVIIa was unsuccessful. In 3 patients, rFVIIa was effective and gastrointestinal bleeding could be stopped. No acute adverse event, increasing bowel necrosis, increasing platelet consumption, or thromboembolic complications were observed. CONCLUSIONS In this small group of preterms with DIC, intestinal hemorrhage, and persistent hemorrhagic shock, rFVIIa was effective as a rescue therapy but failed in patients with severe acidosis, hypothermia, and thrombopenia.
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Mitsiakos G, Papaioannou G, Giougi E, Karagianni P, Garipidou V, Nikolaidis N. Is the use of rFVIIa safe and effective in bleeding neonates? A retrospective series of 8 cases. J Pediatr Hematol Oncol 2007; 29:145-50. [PMID: 17356391 DOI: 10.1097/mph.0b013e3180335bcb] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa), originally developed for the treatment of life-threatening bleeding in hemophilic patients with inhibitors to factors VIII or IX, has been increasingly used to control hemorrhage unresponsive to conventional treatment, in the absence of a defined coagulopathy or thrombocytopathy. To date, clinical experience of rFVIIa administration in neonates, especially preterms, is rather limited, because of the lack of controlled studies and based solely on some published case reports and 1 prospective pilot study. The objective of this study was to retrospectively evaluate the clinical outcome of newborns treated with recombinant activated factor VII for intractable bleeding or severe coagulation disturbances, resistant to conventional hemostatic therapy. METHODS The medical records of 8 neonates treated with rFVIIa (100 micro g/kg) were retrospectively reviewed for the course of hemorrhage and the hemostatic interventions performed before and up to 24 hours after the administration rFVIIa. Coagulation parameters of 3 different time-points were assessed and compared: before administration of any blood product (time-point 1), before administration of the first dose of rFVIIa (time-point 2), and 4 hours after the administration of the last dose of rFVIIa (time-point 3). The safety and tolerability profile of rFVIIa in bleeding neonates was also evaluated. RESULTS Six preterm and 2 term patients were included in the study. Seven patients presented with refractory bleeding and 1 was diagnosed with severe coagulopathy unresponsive to the conventional treatment. Prompt hemostasis was achieved in half of the patients with their coagulation profile being restored within 4 hours after the administration of the first dose of rFVIIa. Improvement in prothrombin time, activated partial thromboplastin time, and fibrinogen after rFVIIa administration was statistically significant, as compared with that observed after conventional treatment. No major safety issues were observed during the study. All 8 patients survived and had their hemorrhage or coagulopathy controlled within 4 hours after transfusion of the last dose of rFVIIa. CONCLUSIONS In this study, the hemostatic agent rFVIIa was well-tolerated and behaved in a safe and efficacious manner in all infants treated for life-threatening bleeding and coagulation disorders. Future prospective controlled trials are needed to determine the efficacy, safety, tolerability, and possibly the optimal dose and timing of rFVIIa administration.
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Affiliation(s)
- George Mitsiakos
- B' NICU and Neonatology Department of Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Mathew P, Simon TL, Hunt KE, Crookston KP. How we manage requests for recombinant factor VIIa (NovoSeven). Transfusion 2007; 47:8-14. [PMID: 17207224 DOI: 10.1111/j.1537-2995.2007.01058.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Prasad Mathew
- Department of Pathology, University of New Mexico, New Mexico, USA
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Abstract
Recombinant factor VIIa (rFVIIa) has been used in haemophilia bleeding since its introduction in 1996. It has been found to be safe and effective in the majority of patients with haemophilia who have developed inhibitors. There is increasing use of rFVIIa in many off-label bleeding conditions, but there is a paucity of randomized studies regarding the use of rFVIIa in children. This review will attempt to address and summarize the studies focusing on the role of rFVIIa in both haemophilia and non-haemophilia bleeding conditions in children. rFVIIa has been administered as both bolus and continuous infusions, and at varying doses. Furthermore, adverse events have not reportedly increased in children despite growing experience with its use in the paediatric population.
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Affiliation(s)
- P Mathew
- Department of Pediatrics, University of New Mexico, Albuquerque, NM 87131-0001, and Children's Hospital of Orange County, Orange, CA, USA.
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Hansen TWR. Prophylaxis of intraventricular hemorrhage in premature infants: new potential tools, new potential challenges. Pediatr Crit Care Med 2006; 7:90-2. [PMID: 16395085 DOI: 10.1097/01.pcc.0000194000.12155.79] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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