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Carroll RB, Zaki H, McCracken C, Figueroa J, Guzzetta NA. Use of Factor VIIa and Anti-inhibitor Coagulant Complex in Pediatric Cardiac Surgery Patients. J Pediatr Pharmacol Ther 2020; 25:540-546. [PMID: 32839658 DOI: 10.5863/1551-6776-25.6.540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Postoperative bleeding is a common cause of morbidity and mortality in cardiac patients who undergo cardiopulmonary bypass (CPB). Pediatric patients are especially at risk for adverse effects of surgery and CPB on the coagulation system. This can result in bleeding, transfusions, and poor outcomes. Excessive bleeding unresponsive to blood products can warrant the off-label use of recombinant activated clotting factor VIIa (rFVIIa) and/or anti-inhibitor coagulant complex (FEIBA). Several studies have shown the utility in these agents off-label in patients who have undergone cardiac bypass surgery with acute bleeding episodes that are refractory to blood products. However, data regarding use of these agents in pediatrics are sparse. The purpose of this study is to report the use of rFVIIa and FEIBA in pediatric cardiac surgery patients in our institution. METHODS This was a retrospective chart review of pediatric cardiothoracic surgery patients who received rFVIIa or FEIBA at Children's Healthcare of Atlanta during the study period. RESULTS Thirty-three patients received rFVIIa and 9 patients received FEIBA either intraoperatively or postoperatively for bleeding related to the cardiac procedure. Approximately 13% of rFVIIa patients and 55% of FEIBA patients required repeat doses. There were decreases for all blood products administered after rFVIIa and FEIBA were given. However, the doses used did not correlate with either positive or negative outcomes. Seventeen percent (n = 7) of rFVIIa patients experienced a thrombus and 22% (n = 2) of FEIBA patients experienced a thrombus. CONCLUSIONS Both rFVIIa and FEIBA reduced blood product usage in pediatric patients following cardiac procedures.
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Scott JP. Recombinant activated factor seven in pediatric cardiac surgery-does thrombotic risk outweigh hemostatic benefit? Transl Pediatr 2019; 8:465-467. [PMID: 31993363 PMCID: PMC6970117 DOI: 10.21037/tp.2019.10.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- John P Scott
- Department of Anesthesiology and Pediatrics, Sections of Pediatric Anesthesiology and Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
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Christoff AS, Winlaw DS, Curtin J, Barnes EH, Egan JR. Recombinant activated factor VII in neonatal cardiac surgery. Eur J Cardiothorac Surg 2019; 55:817-822. [DOI: 10.1093/ejcts/ezy483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/10/2018] [Accepted: 12/21/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrea S Christoff
- Paediatric Intensive Care Unit, The Children’s Hospital at Westmead, Sydney, Australia
| | - David S Winlaw
- Cardiothoracic Surgery Department, The Children’s Hospital at Westmead, Sydney, Australia
- Heart Centre for Children, Sydney Children’s Hospitals Network, Sydney, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Julie Curtin
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
- Haematology Department, Sydney Children’s Hospitals Network, Sydney, Australia
| | - Elizabeth H Barnes
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Jonathan R Egan
- Paediatric Intensive Care Unit, The Children’s Hospital at Westmead, Sydney, Australia
- Heart Centre for Children, Sydney Children’s Hospitals Network, Sydney, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
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Validation of a definition of excessive postoperative bleeding in infants undergoing cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2017; 155:2112-2124.e2. [PMID: 29338867 DOI: 10.1016/j.jtcvs.2017.12.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/16/2017] [Accepted: 12/05/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To derive and validate an objective definition of postoperative bleeding in neonates and infants undergoing cardiac surgery with cardiopulmonary bypass. METHODS Using a retrospective cohort of 124 infants and neonates, we included published bleeding definitions and cumulative chest tube output over different postoperative periods (eg, 2, 12, or 24 hours after intensive care unit admission) in a classification and regression tree model to determine chest tube output volumes that were associated with red blood cell transfusions and surgical re-exploration for bleeding in the first 24 hours after intensive care unit admission. After the definition of excessive bleeding was determined, it was validated via a prospective cohort of 77 infants and neonates. RESULTS Excessive bleeding was defined as ≥7 mL/kg/h for ≥2 consecutive hours in the first 12 postoperative hours and/or ≥84 mL/kg total for the first 24 postoperative hours and/or surgical re-exploration for bleeding or cardiac tamponade physiology in the first 24 postoperative hours. Excessive bleeding was associated with longer length of hospital stay, increased 30-day readmission rate, and increased transfusions in the postoperative period. CONCLUSIONS The proposed standard definition of excessive bleeding is based on readily obtained objective data and relates to important early clinical outcomes. Application and validation by other institutions will help determine the extent to which our specialty should consider this definition for both clinical investigation and quality improvement initiatives.
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Downey L, Brown ML, Faraoni D, Zurakowski D, DiNardo JA. Recombinant Factor VIIa Is Associated With Increased Thrombotic Complications in Pediatric Cardiac Surgery Patients. Anesth Analg 2017; 124:1431-1436. [PMID: 28319507 DOI: 10.1213/ane.0000000000001947] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is routinely used as an off-label hemostatic agent in children undergoing cardiac surgery. Despite evidence that rFVIIa use is associated with an increased incidence of thrombotic complications in adult cardiac surgery, the safety of rFVIIa as a rescue hemostatic agent in the pediatric cardiac surgical population is less definitively delineated. In this retrospective study, we used propensity score matching to compare the incidence of thrombotic complications between children treated with rFVIIa and their matched controls. METHODS We retrospectively reviewed medical records and pharmacy data from all neonates and children who underwent congenital cardiac surgery between May 1, 2011, and October 31, 2013, at Boston Children's Hospital, and identified those who received rFVIIa during the perioperative period. Using existing knowledge, we chose 10 factors associated with bleeding after cardiac surgery to be used in our propensity score: age, sex, body weight, neonates, prematurity, previous sternotomy, cardiopulmonary bypass time, deep hypothermic circulatory arrest time, aortic cross-clamp time, and the operative surgeon. We then used propensity-matched analysis to match children treated with rFVIIa with 2 controls. The primary outcome was thrombotic complications. Secondary outcomes included reexploration for bleeding, length of cardiac intensive care unit stay, length of hospital stay, and 30-day mortality. RESULTS One hundred forty-nine patients received perioperative rFVIIa during the study period. Propensity matching yielded 143 rFVIIa patients matched to 2 control patients each (n = 286). Three control patients were found to have received rFVIIa during the perioperative course and were removed from the analysis, for a total of 283 control patients. The administration of rFVIIa was associated with an increased incidence of thrombotic complications (20% vs 8%; odds ratio [OR]: 3.9 [95% confidence interval {CI}: 2.6-5.9], P < .001). Administration of rFVIIa was associated with a prolonged median length of cardiac intensive care unit stay (8 days [interquartile range {IQR}: 4-24] vs 5 days [IQR: 2-10], P < .001) and prolonged length of hospital stay (20 [IQR: 9-44] vs 11 days [IQR: 7-23], P < .001). No difference in reexploration for bleeding (rFVII = 14% vs controls = 9%; OR: 1.7 [95% CI, 0.92-3.1], P = .12) or 30-day mortality was observed (8% vs 6%; OR 1.3 [95% CI, 0.60-2.89], P = .51). CONCLUSIONS This retrospective analysis confirmed that perioperative administration of rFVIIa is associated with an increased incidence of postoperative thrombotic complications in neonates and children undergoing cardiac surgery, without increase in 30-day mortality. In conclusion, rFVIIa should be used with extreme caution in pediatric patients undergoing cardiac surgery.
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Affiliation(s)
- Laura Downey
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital, Stanford University, Stanford, California; †Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and ‡Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Singh SP, Chauhan S, Choudhury M, Malik V, Choudhary SK. Recombinant activated factor VII in cardiac surgery: single-center experience. Asian Cardiovasc Thorac Ann 2013; 22:148-54. [DOI: 10.1177/0218492312471672] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background the widespread off-label use of recombinant activated factor VII for the control of refractory postoperative hemorrhage continues despite a warning from the Food and Drug Administration. Although effective in reducing the need for transfusion of blood and blood products, safety concerns still prevail. Objective to compare the dosing and efficacy of recombinant activated factor VII between pediatric and adult patients, and in the operating room and intensive care unit. Methods the records of 69 patients (33 children and 36 adults) who underwent cardiovascular surgery and received recombinant activated factor VII were reviewed retrospectively. The dose of recombinant activated factor VII, mediastinal drainage, use of blood and blood products, incidence of thrombosis, and 28-day mortality were studied. Results the efficacy of recombinant activated factor VII was comparable in adults and children, despite the lower dose in adults. Prophylactic use of recombinant activated factor VII decreased the incidence of mediastinal exploration and the duration of intensive care unit stay. A 4.3% incidence of thrombotic complications was observed in this study. Conclusion the efficacious dose of recombinant activated factor VII is much less in adults compared to children. Prophylactic use of recombinant activated factor VII decreases the dose required, the incidence of mediastinal exploration, and intensive care unit stay, with no survival benefit.
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Affiliation(s)
- Sarvesh Pal Singh
- Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Chauhan
- Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Minati Choudhury
- Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwas Malik
- Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Choudhary
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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Martínez López MC, Alcaraz Romero AJ, Martínez López AB, Fernández-Llamazares CM, Ramos Navarro C. [Risk assessment of thrombotic events after the use of activated factor VII]. An Pediatr (Barc) 2012; 79:177-81. [PMID: 23265723 DOI: 10.1016/j.anpedi.2012.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/05/2012] [Accepted: 11/07/2012] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The objective of this study was to analyze the incidence of thrombotic complications related to recombinant human factor viia (rFVIIa) therapy for severe postoperative bleeding in cardiac surgery. MATERIAL AND METHODS A retrospective matched case-control study was conducted over two years, including 72 children admitted to intensive care unit and treated with rFVIIa because of a severe bleeding during or after cardiac surgery. A control group of 63 patients was chosen, who were statistically comparable in sex, weight, diagnosis, surgical risk according RASCH-1 score, and surgical characteristics, was chosen. RESULTS There were no significant differences between cases and controls either in the rate of thrombosis (20% vs 28%, P=.540), or in the mortality rate (16% vs 9.5%, P=.208). CONCLUSIONS In our study, the rFVIIa therapy was shown to be useful in controlling severe operative bleeding in pediatric cardiac surgery, but does not seem to increase the risk of thrombotic complications or mortality rate in the postoperative period.
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Affiliation(s)
- M C Martínez López
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España.
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Benkwitz C, Hammer GB. Thrombotic endotracheal tube occlusion after administration of recombinant factor VIIa. J Cardiothorac Vasc Anesth 2012; 27:1330-3. [PMID: 22959153 DOI: 10.1053/j.jvca.2012.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Claudia Benkwitz
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA.
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Okonta KE, Kesieme EB, Agarwal V. eComment. The vraisemblance of haemostatic therapy for excessive bleeding after cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:389. [PMID: 22908177 DOI: 10.1093/icvts/ivs307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Kelechi E Okonta
- Cardiovascular and Thoracic Surgery, University College Hospital, PMB 5116, Ibadan, Nigeria
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Guzzetta NA, Russell IA, Williams GD. Review of the Off-Label Use of Recombinant Activated Factor VII in Pediatric Cardiac Surgery Patients. Anesth Analg 2012; 115:364-78. [DOI: 10.1213/ane.0b013e31825aff10] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Okonta KE, Edwin F, Falase B. Is recombinant activated factor VII effective in the treatment of excessive bleeding after paediatric cardiac surgery? Interact Cardiovasc Thorac Surg 2012; 15:690-4. [PMID: 22811512 DOI: 10.1093/icvts/ivs309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in paediatric cardiac surgery was written according to a structured protocol. The question addressed was whether recombinant activated factor VII was effective for the treatment of excessive bleeding after paediatric cardiac surgery. Altogether 150 papers were found using the reported search; 13 papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. A total of 311 children experienced excessive bleeding following cardiac surgery that was refractory to the conventional methods of achieving haemostasis. One hundred and ninety-two patients received the rFVIIa while 116 were in control arm from five studies. The primary end-point was on chest tube drainage, the plasma prothrombin time, the activated partial thromboplastin time after the administration of rFVIIa and the secondary end-point was reduction of blood products transfusion. Thrombosis was a complication in 8 patients (4.2%); three deaths (1.6%) but not attributable to thromboembolic events following the use of rFVIIa. Most of the studies failed to clearly state the doses but the extracted doses ranged between 30 and 180 µg/kg/dose, the interval between doses ranged between 15 and 120 min with a maximum of four doses. However, most of the patients had 180 µg/kg/dose with interval between dose of 2 h and maximum of two doses with dosage moderated with respect to weight, prior coagulopathy and responsiveness. There were two randomized studies with good sample size. One showed no significant differences in the secondary end points between the two arms and noted no adverse complications. However, the rFVIIa was used prophylactically. The other observed that there were no increase in thromboembolic events rather rFVIIa was effective in decreasing excessive bleeding that may complicate cardiac surgery in children. In conclusion, the studies were in support of the notion that the use of rFVIIa was effective in decreasing excessive bleeding which may complicate paediatric cardiac surgery, and care should be exercised when using it in the children on ECMO circuit.
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Affiliation(s)
- Kelechi E Okonta
- Division of Cardiothoracic Surgery, Department of Surgery, University College Hospital, Ibadan, Nigeria.
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Tsai TC, Rosing JH, Norton JA. Role of factor VII in correcting dilutional coagulopathy and reducing re-operations for bleeding following non-traumatic major gastrointestinal and abdominal surgery. J Gastrointest Surg 2010; 14:1311-8. [PMID: 20517651 PMCID: PMC2909430 DOI: 10.1007/s11605-010-1227-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Accepted: 05/11/2010] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the effectiveness of rfVIIa in reducing blood product requirements and re-operation for postoperative bleeding after major abdominal surgery. BACKGROUND Hemorrhage is a significant complication after major gastrointestinal and abdominal surgery. Clinically significant bleeding can lead to shock, transfusion of blood products, and re-operation. Recent reports suggest that activated rfVIIa may be effective in correcting coagulopathy and decreasing the need for re-operation. METHODS This study was a retrospective review over a 4-year period of 17 consecutive bleeding postoperative patients who received rfVIIa to control hemorrhage and avoid re-operation. Outcome measures were blood and clotting factor transfusions, deaths, thromboembolic complications, and number of re-operations for bleeding. RESULTS Seventeen patients with postoperative hemorrhage following major abdominal gastrointestinal surgery (nine pancreas, four sarcoma, two gastric, one carcinoid, and one fistula) were treated with rfVIIa. In these 17 patients, rfVIIa was administered for 18 episodes of bleeding (dose 2,400-9,600 mcg, 29.8-100.8 mcg/kg). Transfusion requirement of pRBC and FFP were each significantly less than pre-rfVIIa. Out of the 18 episodes, bleeding was controlled in 17 (94%) without surgery, and only one patient returned to the operating room for hemorrhage. There were no deaths and two thrombotic complications. Coagulopathy was corrected by rfVIIa from 1.37 to 0.96 (p < 0.0001). CONCLUSION Use of rfVIIa in resuscitation for hemorrhage after non-traumatic major abdominal and gastrointestinal surgery can correct dilutional coagulopathy, reducing blood product requirements and need for re-operation.
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Affiliation(s)
- Thomas C. Tsai
- Department of Surgery, Stanford University School of Medicine, Stanford, CA USA
| | - James H. Rosing
- Department of Surgery, Stanford University School of Medicine, Stanford, CA USA
| | - Jeffrey A. Norton
- Department of Surgery, Stanford University School of Medicine, Stanford, CA USA
- 300 Pasteur Drive H3591, Stanford, CA 94305-5641 USA
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