Recombinant activated factor VII as an adjunctive therapy for bleeding control in severe trauma patients with coagulopathy: subgroup analysis from two randomized trials

Severe Trauma-Induced Coagulopathy: Molecular Mechanisms Underlying Critical Illness

Trauma remains one of the leading causes of death in adults despite the implementation of preventive measures and innovations in trauma systems. The etiology of coagulopathy in trauma patients is multifactorial and related to the kind of injury and nature of resuscitation. Trauma-induced coagulopathy (TIC) is a biochemical response involving dysregulated coagulation, altered fibrinolysis, systemic endothelial dysfunction, platelet dysfunction, and inflammatory responses due to trauma. The aim of this review is to report the pathophysiology, early diagnosis and treatment of TIC. A literature search was performed using different databases to identify relevant studies in indexed scientific journals. We reviewed the main pathophysiological mechanisms involved in the early development of TIC. Diagnostic methods have also been reported which allow early targeted therapy with pharmaceutical hemostatic agents such as TEG-based goal-directed resuscitation and fibrinolysis management. TIC is a result of a complex interaction between different pathophysiological processes. New evidence in the field of trauma immunology can, in part, help explain the intricacy of the processes that occur after trauma. However, although our knowledge of TIC has grown, improving outcomes for trauma patients, many questions still need to be answered by ongoing studies.

Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis

BACKGROUND

Recombinant factor VIIa (rFVIIa) has been used off-label as an adjunct in the reversal of warfarin therapy and management of hemorrhage after trauma. Only a handful of these reports are rigorous studies, from which results regarding safety and effectiveness have been mixed. There remains no clear consensus as to the role of rFVIIa in traumatic brain injury (TBI).

METHODS

Eleven level 1 trauma centers provided clinical data and head CT scans of patients with a Glasgow Coma Scale (GCS) score of ≤13 and radiographic evidence of TBI. A propensity score (PS) to receive rFVIIa in those surviving ≥2 days was calculated for each patient based on patient demographics, comorbidities, physiology, Injury Severity Score, admission GCS score, and treatment center. Patients receiving rFVIIa within 24 hours of admission were matched to patients who did not receive rFVIIa for outcomes assessment. Subgroup analysis evaluated patients with primary head injury with PS matching.

RESULTS

There were 4284 patient observations; 129 received rFVIIa. Groups were comparable after matching. No differences in mortality or morbidity were found. Improvement in GCS score from admission to discharge was less among those receiving rFVIIa (5.5 vs. 2.4; P value 0.001); however, there was no difference in average GCS score at discharge. No significant differences in outcomes were identified in patients with isolated TBI receiving rFVIIa.

DISCUSSION

rFVIIa in early management of TBI is not associated with a decreased risk of mortality or morbidity, and may negatively impact recovery and functional status at discharge in the severely injured patient with polytrauma.

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Therapeutic/care management.

Hemostasis and nanotechnology

Hemorrhage accounts for significant morbidity and mortality. Various techniques have been employed to augment hemostasis from simple tourniquets to self-assembling nanoparticles. A growing understanding of the natural clotting cascade has allowed agents to become more targeted for potential use in different clinical scenarios. This review discusses current and developing hemostatic techniques, including matrix agents, external agents, biologically inspired agents, and synthetic and cell-derived nanoparticles.

Investigation of the status quo of massive blood transfusion in China and a synopsis of the proposed guidelines for massive blood transfusion

The aim of this study was to provide an overview of massive transfusion in Chinese hospitals, identify the important indications for massive transfusion and corrective therapies based on clinical evidence and supporting experimental studies, and propose guidelines for the management of massive transfusion. This multiregion, multicenter retrospective study involved a Massive Blood Transfusion Coordination Group composed of 50 clinical experts specializing in blood transfusion, cardiac surgery, anesthesiology, obstetrics, general surgery, and medical statistics from 20 tertiary general hospitals across 5 regions in China. Data were collected for all patients who received ≥10 U red blood cell transfusion within 24 hours in the participating hospitals from January 1 2009 to December 31 2010, including patient demographics, pre-, peri-, and post-operative clinical characteristics, laboratory test results before, during, and after transfusion, and patient mortality at post-transfusion and discharge. We also designed an in vitro hemodilution model to investigate the changes of blood coagulation indices during massive transfusion and the correction of coagulopathy through supplement blood components under different hemodilutions. The experimental data in combination with the clinical evidence were used to determine the optimal proportion and timing for blood component supplementation during massive transfusion. Based on the findings from the present study, together with an extensive review of domestic and international transfusion-related literature and consensus feedback from the 50 experts, we drafted the guidelines on massive blood transfusion that will help Chinese hospitals to develop standardized protocols for massive blood transfusion.

Damage Control and the Open Abdomen: Challenges for the Nonsurgical Intensivist

BACKGROUND

As strategies in acute care surgery focus on damage control to restore physiology, intensivists spanning all disciplines care for an increasing number of patients requiring massive transfusion, temporary abdominal closures, and their sequelae.

OBJECTIVE

To equip the nonsurgical intensivist with evidence-based management principles for patients with an open abdomen after damage control surgery.

DATA SOURCE

Search of PubMed database and manual review of bibliographies from selected articles.

DATA SYNTHESIS AND CONCLUSIONS

Temporary abdominal closure improves outcomes in patients with abdominal compartment syndrome, hemorrhagic shock, and intra-abdominal sepsis but creates new challenges with electrolyte derangement, hypovolemia, malnutrition, enteric fistulas, and loss of abdominal wall domain. Intensive care of such patients mandates attention to resuscitation, sepsis control, and expedient abdominal closure.

Successful Treatment of Intracranial Hemorrhage with Recombinant Activated Factor VII in a Patient with Newly Diagnosed Acute Myeloid Leukemia: A Case Report and Review of the Literature

Intracranial hemorrhage (ICH) is a common complication in acute myeloid leukemia (AML) patients with an incidence rate of 6.3% (1). Bleeding disorders related to disseminated intravascular coagulation (DIC) are common complications in AML cases (2). Recombinant activated Factor VII [rFVIIa (NovoSeven(®))] is approved for the treatment of bleeding complications with FVIII or FIX inhibitors in patients with congenital FVII deficiency. Use of rFVIIa for the treatment of acute hemorrhage in patients without hemophilia has been successful (3, 4). Herein, we describe the successful use of rFVIIa in a patient with acute ICH in the setting of newly diagnosed AML.

Successful use of N-acetyl cysteine and activated recombinant factor VII in fulminant hepatic failure and massive bleeding secondary to dengue hemorrhagic fever

Consensus on management of complicated cases of dengue infection is evolving. Dengue hemorrhagic fever (DHF) occasionally progress to fulminant liver failure with high fatality rate. Inadvertent use of blood products to control massive bleeding in dengue shock syndrome may worsen fluid overload and subsequently the multi-organ dysfunction. We report a case of 37-years-old Sri Lankan man who developed fulminant liver failure and massive bleeding associated with DHF, subsequently recovered completely with supportive measures including administration of N-acetyl cysteine and activated recombinant factor VII. In conclusion, prevention of ischemic injury to liver and adoption of early aggressive supportive measures in complicated cases of dengue hemorrhagic fever is crucial for a favorable outcome. Indications for rFVIIa to arrest uncontrolled internal bleeding and use of NAC in non-acetaminophen-induced acute liver failure in complicated DHF are a platform for discussion.

[Off-label use of recombinant factor VII (rFVIIa) in teaching hospitals in Paris in 2010]

INTRODUCTION

Recombinant activated factor VII (rFVIIa) (Novoseven(®)) was initially developed as a substitutive treatment in haemophiliacs but has then been used in situations of major haemorrhage in non-haemophiliacs (off-label use). The goal of the present study was to assess the practice patterns when rFVIIa is used in off-label indications in major teaching hospitals of Paris in 2010.

METHODS

We retrospectively identified files of patients in whom rFVIIa had been used. Physicians in charge of these patients (or the most proxy physician available) were contacted and files analysed with one of the authors. Quality of rFVIIa used in these off-label situations was determined based on either French or European guidelines or the available literature when no guidelines could be found. Three categories were defined for indication, dosage, timing, associated biological factors and overall use: adequate, acceptable (mainly adequate but lacking some characteristics of an "ideal" prescription) and inadequate (lacking most of the necessary characteristics of an "ideal" prescription).

RESULTS

Among 59 patients who had an off-label prescription of rFVIIa, 49 prescriptions could be analysed. Indication for use and timing of administration were adequate in 100% of multiple trauma cases and 83% of obstetrical cases. Biological criteria associated with an improved efficacy were found in two thirds of prescriptions analysed. Overall, prescriptions were adequate or acceptable in 82% of cases.

CONCLUSION

In the vast majority of patients who received rFVIIa for off-label indications in teaching hospitals of the Paris area in 2010, prescriptions were in line with recommendations.

[Management of penetrating abdominal trauma: what we need to know?]

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.

Local and Systemic Hemostatics as an Adjunct to Control Bleeding in Trauma

Although surgical and angiointervention techniques remain the cornerstone for the management of severe bleeding after trauma, adjunct therapeutic strategies such as local or systemic hemostatic agents can play an important role. This article reviews the role and efficacy of the available hemostatic agents.

Hypovolemic shock resuscitation

Several changes in the way patients with hemorrhagic shock are resuscitated have occurred over the past decades, including permissive hypotension, minimal crystalloid resuscitation, earlier blood transfusion, and higher plasma and platelet-to-red cell ratios. Hemostatic adjuncts, such as tranexamic acid and prothrombin complex, and the use of new methods of assessing coagulopathy are also being incorporated into resuscitation of the bleeding patient. These ideas have been incorporated by many trauma centers into institutional massive transfusion protocols, and adoption of these protocols has resulted in improvements in mortality and morbidity. This article discusses each of these new resuscitation strategies and the evidence supporting their use.

Current management of severe pelvic and perineal trauma

Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25% to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006) [1]. The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions. Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein.

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.

Clotting factor deficiency in early trauma-associated coagulopathy

BACKGROUND

Coagulopathic bleeding is a leading cause of in-hospital death after injury. A recently proposed transfusion strategy calls for early and aggressive frozen plasma transfusion to bleeding trauma patients, thus addressing trauma-associated coagulopathy (TAC) by transfusing clotting factors (CFs). This strategy may dramatically improve survival of bleeding trauma patients. However, other studies suggest that early TAC occurs by protein C activation and is independent of CF deficiency. This study investigated whether CF deficiency is associated with early TAC.

METHODS

This is a prospective observational cohort study of severely traumatized patients (Injury Severity Score ≥ 16) admitted shortly after injury, receiving minimal fluids and no prehospital blood. Blood was assayed for CF levels, thromboelastography, and routine coagulation tests. Critical CF deficiency was defined as ≤ 30% activity of any CF.

RESULTS

Of 110 patients, 22 (20%) had critical CF deficiency: critically low factor V level was evident in all these patients. International normalized ratio, activated prothrombin time, and, thromboelastography were abnormal in 32%, 36%, and 35%, respectively, of patients with any critically low CF. Patients with critical CF deficiency suffered more severe injuries, were more acidotic, received more blood transfusions, and showed a trend toward higher mortality (32% vs. 18%, p = 0.23). Computational modeling showed coagulopathic patients had pronounced delays and quantitative deficits in generating thrombin.

CONCLUSIONS

Twenty percent of all severely injured patients had critical CF deficiency on admission, particularly of factor V. The observed factor V deficit aligns with current understanding of the mechanisms underlying early TAC. Critical deficiency of factor V impairs thrombin generation and profoundly affects hemostasis.

Cost-effectiveness of using recombinant activated factor VII as an off-label rescue treatment for critical bleeding requiring massive transfusion

BACKGROUND

Recombinant activated factor VII (rFVIIa) is widely used as an off-label rescue treatment for patients with nonhemophilic critical bleeding.

STUDY DESIGN AND METHODS

Using data from the intensive care unit, transfusion service, and death registry, the long-term survival after using rFVIIa and the associated cost per life-year gained in a consecutive cohort of patients with critical bleeding requiring massive transfusion (≥ 10 red blood cell [RBC] units in 24 hr) were assessed. rFVIIa was only used as a lifesaving treatment when conventional measures had failed.

RESULTS

Of the 353 patients with critical bleeding requiring massive transfusion, 81 (23%) required rFVIIa as a lifesaving rescue treatment. The patients requiring rFVIIa received a greater number of transfusions (number of units: RBCs, 18 vs. 12; fresh-frozen plasma, 16 vs. 10; platelets, 4 vs. 2; p < 0.001) and had a shorter survival time (24 months vs. 33 months; p = 0.002) than those who did not require rFVIIa. The total cost per life-year gained of massive transfusion and incremental cost of rFVIIa as a lifesaving treatment were US$1,148,000 (£711,760; 95% confidence interval [CI], US$825,000-US$1,471,000) and US$736,000 (£456,320; 95% CI, US$527,000-US$945,000), respectively. The incremental costs of rFVIIa increased with severity of illness and transfusion requirement and were greater than the usual acceptable cost-effective limit (<US$100,000 per life-year) for most patients with critical bleeding.

CONCLUSIONS

As a lifesaving treatment for critical bleeding, the incremental cost of rFVIIa was high. Careful patient selection is critical to balance the potential benefits of rFVIIa in an individual patient against the cost to the community.

Prophylactic activated recombinant factor VII in liver resection and liver transplantation: systematic review and meta-analysis

Background and Aim

Intraoperative blood loss is a frequent complication of hepatic resection and orthotopic liver transplantation. Recombinant activated coagulation factor VII (rFVIIa) is a coagulation protein that induces hemostasis by directly activating factor X. There is no clear information about the prophylactic value of rFVIIa in hepatobiliary surgery, specifically in liver resection and orthotopic liver transplantation. The aim of this study was to assess the effect of rFVIIa prophylaxis to prevent mortality and bleeding resulting from hepatobiliary surgery.

Methods

Relevant randomized trials were identified by searching The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index. Randomized clinical trials comparing different rFVIIa prophylactic schemas against placebo or no intervention to prevent bleeding in hepatobiliary surgery were included. Adults undergoing liver resection, partial hepatectomy, or orthotopic liver transplantation were included. Dichotomous data were analyzed calculating odds ratios (ORs) and 95% confidence intervals (CIs). Continuous data were analyzed calculating mean differences (MD) and 95% CIs.

Results

Four randomized controlled trials were included. There were no significant differences between rFVIIa and placebo for mortality (OR 0.96; 95% CI 0.35–2.62), red blood cell units (MD 0.32; 95% CI −0.08–0.72) or adverse events (OR 1.55; 95% CI 0.97–2.49).

Conclusions

The available information is limited, precluding the ability to draw conclusions regarding bleeding prophylaxis in hepatobiliary surgery using rFVIIa. Although an apparent lack of effect was observed in all outcomes studied, further research is needed.

Resuscitation and monitoring in gastrointestinal bleeding

INTRODUCTION

Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately.

MATERIALS AND METHODS

Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards.

RESULTS

Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. "Functional hemodynamic monitoring" requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding.

CONCLUSIONS

Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

The acute management of trauma hemorrhage: a systematic review of randomized controlled trials

Introduction

Worldwide, trauma is a leading cause of death and disability. Haemorrhage is responsible for up to 40% of trauma deaths. Recent strategies to improve mortality rates have focused on optimal methods of early hemorrhage control and correction of coagulopathy. We undertook a systematic review of randomized controlled trials (RCT) which evaluated trauma patients with hemorrhagic shock within the first 24 hours of injury and appraised how the interventions affected three outcomes: bleeding and/or transfusion requirements; correction of trauma induced coagulopathy and mortality.

Methods

Comprehensive searches were performed of MEDLINE, EMBASE, CENTRAL (The Cochrane Library Issue 7, 2010), Current Controlled Trials, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and the National Health Service Blood and Transplant Systematic Review Initiative (NHSBT SRI) RCT Handsearch Database.

Results

A total of 35 RCTs were identified which evaluated a wide range of clinical interventions in trauma hemorrhage. Many of the included studies were of low methodological quality and participant numbers were small. Bleeding outcomes were reported in 32 studies; 7 reported significantly reduced transfusion use following a variety of clinical interventions, but this was not accompanied by improved survival. Minimal information was found on traumatic coagulopathy across the identified RCTs. Overall survival was improved in only three RCTs: two small studies and a large study evaluating the use of tranexamic acid.

Conclusions

Despite 35 RCTs there has been little improvement in outcomes over the last few decades. No clear correlation has been demonstrated between transfusion requirements and mortality. The global trauma community should consider a coordinated and strategic approach to conduct well designed studies with pragmatic endpoints.

Hemotransfusion in Combat Trauma

The collaboration of blood transfusion service in the management of severely combat-injured individuals has proved to be an essential factor for the successful treatment of these patients. While the operating and anesthesiology teams are engaged in maintaining the vital signs and controlling blood loss of the injured, the transfusion service representatives follow the information on the amount of blood products given and the latest laboratory tests, as well as provide consultations regarding further blood component requirements on the basis of data obtained. A major effort of the treating team should be aimed at diagnosis and correction of coagulopathy, acidosis, and hypothermia. For the massively bleeding combat trauma injured, which can amount to as high as 8% of all trauma patients, a generous use of plasma at a one-to-one ratio with packed cells, along with the early addition of platelets and cryoprecipitates, should be considered. Early point-of-care thromboelastography is helpful for identification of coagulopathies. The use of a preset massive transfusion protocol is beneficial; however, it should be tailored according to the patient’s actual needs, depending on the type of injury and the individual’s general condition.

Hemoglobin-based oxygen carrier (HBOC-201) and escalating doses of recombinant factor VIIa (rFVIIa) as a novel pre-hospital resuscitation fluid in a swine model of severe uncontrolled hemorrhage

Exsanguinating hemorrhage and unavailability of blood are major problems in pre-hospital trauma care. We investigated if combining rFVIIa with HBOC-201 reduces blood loss and improves physiologic parameters compared to HBOC alone. Swine underwent liver injury and were resuscitated with HBOC-201 alone or HBOC+90, 180 or 360 μg/kg rFVIIa before hospital arrival at 240 min; animals survived to 72 hours. Blood loss was reduced; MAP, CI, transcutaneous oxygen saturation, and 72-hour survival improved in the 90 and 180 μg/kg rFVIIa groups. Lactate was cleared faster in the HBOC+rFVIIa 90 μg/kg group. Verification in a large, well-powered study is indicated.

Correction of coagulation in dilutional coagulopathy: use of kinetic and capacitive coagulation assays to improve hemostasis

The management of dilutional coagulopathy due to fluid infusion and massive blood loss is a topic that deserves a biochemical approach. In this review article, we provide an overview of current guidelines and recommendations on diagnosis and on management of transfusion in acquired coagulopathy. We discuss the biochemical differences between kinetic clotting assays (clotting times) and new capacitive coagulation measurements that provide time-dependent information on thrombin generation and fibrin clot formation. The available evidence suggests that a combination of assay types is required for evaluating new transfusion protocols aimed to optimize hemostasis and stop bleeding. Although there is current consensus on the application of fresh frozen plasma to revert coagulopathy, factor concentrates may appear to be useful in the future.

Permissive hypotension and desmopressin enhance clot formation

BACKGROUND

Experimental studies of uncontrolled hemorrhage demonstrated that permissive hypotension (PH) reduces blood loss, but its effect on clot formation remains unexplored. Desmopressin (DDAVP) enhances platelet adhesion promoting stronger clots. We hypothesized PH and DDAVP have additive effects and reduce bleeding in uncontrolled hemorrhage.

METHODS

Rabbits (n = 42) randomized as follows: sham; normal blood pressure (NBP) resuscitation; PH resuscitation-60% baseline mean arterial pressure; NBP plus DDAVP 1 hour before (DDAVP NBP) or 15 minutes after beginning of shock (DDAVP T1 NBP); and PH plus DDAVP 1 hour before (DDAVP PH) or 15 minutes after beginning of shock (DDAVP T1 PH). Fluid resuscitation started 15 minutes after aortic injury and ended at 85 minutes. Intraabdominal blood loss was calculated, aortic clot sent for electron microscopy. Activated partial thromboplastin time, platelet count, thromboelastometry, arterial blood gases, and complete blood count were performed at baseline and 85 minutes. Analysis of variance was used for comparison.

RESULTS

NBP received more fluid volume and had greater intraabdominal blood loss. DDAVP, when administered preshock, significantly reduced blood loss in NBP and fluid requirement when given postshock. Platelets, arterial blood gas, complete blood count, and activated partial thromboplastin time were similar at 85 minutes. NBP delayed clot formation and worsened thrombodynamic potential on thromboelastometry, whereas PH and DDAVP improved. Electron microscopy showed lack of fibrin on NBP clots, whereas DDAVP and PH clots displayed exuberant fibrin/platelet aggregates. DDAVP NBP presented intermediate clots.

CONCLUSION

PH reduced bleeding and improved hemostasis compared with normotensive resuscitation. DDAVP given preshock exerted similar effects with normotensive resuscitation.

Role of factor VII in correcting dilutional coagulopathy and reducing re-operations for bleeding following non-traumatic major gastrointestinal and abdominal surgery

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.

Massive transfusion: new insights

Massive transfusion (MT) is used for the treatment of uncontrolled hemorrhage. Earlier definitive control of life-threatening hemorrhage has significantly improved patient outcomes, but MT is still required. A number of recent advances in the area of MT have emerged, including the use of "hypotensive" or "delayed" resuscitation for victims of penetrating trauma before hemorrhage is controlled and "hemostatic resuscitation" with increased use of plasma and platelet transfusions in an attempt to maintain coagulation. These advances include the earlier use of hemostatic blood products (plasma, platelets, and cryoprecipitate), recombinant factor VIIa as an adjunct to the treatment of dilutional and consumptive coagulopathy, and a reduction in the use of isotonic crystalloid resuscitation. MT protocols have been developed to simplify and standardize transfusion practices. The authors of recent studies have advocated a 1:1:1 ratio of packed RBCs to fresh frozen plasma to platelet transfusions in patients requiring MT to avoid dilutional and consumptive coagulopathy and thrombocytopenia, and this has been associated with decreased mortality in recent reports from combat and civilian trauma. Earlier assessment of the exact nature of abnormalities in hemostasis has also been advocated to direct specific component and pharmacologic therapy to restore hemostasis, particularly in the determination of ongoing fibrinolysis.

The role of recombinant-activated factor VII in bleeding trauma patients

PURPOSE OF REVIEW

Exsanguinating hemorrhage and postshock organ failure account for 35-40% of deaths from trauma, and there is an increasing recognition of the importance of coagulopathy in the evolution of this disease.

RECENT FINDINGS

Since 1999, case reports, small series, retrospective studies and a few controlled trials have reported the use of recombinant-activated factor VII (rFVIIa) as an adjunct for reversal of coagulopathy in trauma patients, and numerous other publications have examined the use of rFVIIa in related conditions such as traumatic brain injury, hemorrhagic stroke and uncontrolled surgical bleeding.

SUMMARY

We present a brief discussion of the mechanism of action of rFVIIa and its role in facilitating hemostasis and a review of the recent medical literature on the use of rFVIIa in trauma patients, including current guidelines and controversies.

Prothrombin complex concentrate (Beriplex P/N) for control of bleeding after kidney trauma in a rabbit dilutional coagulopathy model

INTRODUCTION

Fluid resuscitation after trauma often results in dilutional coagulopathy that may hinder control of bleeding and, once initial hemostasis has been secured, heighten risk of perioperative bleeding when further surgery is required. Since multiple coagulation factor deficiencies typically accompany fluid resuscitation, prothrombin complex concentrate (PCC) containing factors II, VII, IX and X may potentially offer greater hemostatic efficacy than coagulation factor monotherapy.

MATERIALS AND METHODS

Anesthetized normothermic rabbits were hemodiluted 50-60% by phased blood withdrawal and infusion of hydroxyethyl starch and erythrocytes. The animals were randomly assigned to receive saline placebo, 25 IU x kg(-1) PCC (Beriplex P/N) or 180 microg x kg(-1) activated recombinant factor VII (rFVIIa; NovoSeven). Immediately thereafter, bleeding was precipitated by a standardized kidney incision.

RESULTS

PCC accelerated hemostasis compared both with saline and rFVIIa (p=0.002 for both comparisons). The median times to hemostasis in the PCC, saline and rFVIIa groups were 12, 19 and 28 min, respectively. PCC reduced blood loss by a median of 43 mL with a 95% confidence interval (CI) of 8.0-67.5 mL vs. saline and 82 mL (CI, 35.0-110.0 mL) vs. rFVIIa. PCC augmented peak thrombin generation by a median of 104.1 nM (CI, 78.3-142.3 nM) compared with saline and 105.8 nM (CI, 70.7-139.5 nM ) relative to rFVIIa. At the respective 180 microg x kg(-1) and 25 IU x kg(-1) doses tested, rFVIIa displayed thrombogenicity in the Wessler stasis model, while PCC did not.

CONCLUSIONS

In an animal model of dilutional coagulopathy and kidney trauma, PCC accelerated hemostasis and diminished blood loss compared with rFVIIa monotherapy.

High incidence of thromboembolic events in left ventricular assist device patients treated with recombinant activated factor VII

BACKGROUND

Dosing of recombinant activated factor VII (rFVIIa) is controversial and unstandardized, and there is growing concern about thromboembolic complications, especially in left ventricular assist device (LVAD)-supported patients. We reviewed our experience with rFVIIa administration in patients with LVADs and examined its effectiveness and adverse effects, including the incidence of thromboembolic events and its correlation with increasing doses.

METHODS

We retrospectively reviewed the records of 62 patients who received an LVAD and rFVIIa at our center between January 2004 and November 2006. Patients who received a single dose of 10 to 20 microg/kg (n = 32; 52%) constituted the "low-dose" cohort, and patients who received 30 to 70 microg/kg (n = 30; 48%) constituted the "high-dose" cohort. Laboratory values obtained before and after rFVIIa administration, as well as patients' transfusion requirements, were compared to determine the effectiveness of rFVIIa in reversing coagulopathy and reducing blood loss. We also compared the incidence of thromboembolic events in the low- and high-dose groups.

RESULTS

Administration of rFVIIa was associated with significant decreases in prothrombin time, activated partial thromboplastin time and transfusion requirements. This association was seen in both the low- and high-dose groups. In addition, the incidence of thromboembolic events was significantly higher in the high-dose group (36.7%) than in the low-dose group (9.4%) (p < or = 0.001).

CONCLUSIONS

Although rFVIIa administration seemed helpful in controlling life-threatening hemorrhage, patients requiring higher doses (30 to 70 microg/kg) had a dramatically higher incidence of serious thromboembolic events.

Current and future role of therapeutic hypothermia

Therapeutic moderate hypothermia has been advocated for use in traumatic brain injury, stroke, cardiac arrest-induced encephalopathy, neonatal hypoxic-ischemic encephalopathy, hepatic encephalopathy, and spinal cord injury, and as an adjunct to aneurysm surgery. In this review, we address the trials that have been performed for each of these indications, and review the strength of the evidence to support treatment with mild/moderate hypothermia. We review the data to support an optimal target temperature for each indication, as well as the duration of the cooling, and the rate at which cooling is induced and rewarming instituted. Evidence is strongest for prehospital cardiac arrest and neonatal hypoxic-ischemic encephalopathy. For traumatic brain injury, a recent meta-analysis suggests that cooling may increase the likelihood of a good outcome, but does not change mortality rates. For many of the other indications, such as stroke and spinal cord injury, trials are ongoing, but the data are insufficient to recommend routine use of hypothermia at this time.

Effect of Recombinant Activated Factor VII in Critical Bleeding: Clinical Experience of a Single Center

Recombinant activated factor VII (rFVIIa) has been successfully used ‘‘off-label’’ in patients with refractory life-threatening hemorrhage. Intravenous rFVIIa was given to 31 patients unresponsive to standard therapy with blood products and surgical reexploration, who were bleeding due to trauma, surgery, organ transplantation, liver cirrhosis, ruptured uterus. We recorded their coagulation and hematologic profiles, acid-base balance, blood loss, number of red blood cells (RBC), plasma and platelet transfusions, complications, and survival. rFVIIa (mean dose 132.2 ± 56.3 μg/kg) effectively contained the hemorrhage in 28/31 (90.3%) cases, with a mean reduction in blood loss from 12.4 ± 10.2 to 2.7 ± 2.2 L (P < .0001). The need for RBC, platelet, and plasma transfusion decreased significantly after rFVIIa, with a consequent significant improvement in clotting of test hematocrit, pH, and bicarbonates. Four patients had adverse events potentially related to rFVIIa. The survival rates after 1 and 30 days were 48.4% and 29.1%, respectively.

Lessons from the battlefield in the management of major trauma

Continuing the Journal's series of leading articles on trauma, Mr Streets of Bristol Royal Infirmary explains what civilian practitioners can learn from their military colleagues.

Effect of recombinant factor VIIa as an adjunctive therapy in damage control for wartime vascular injuries: a case control study

OBJECTIVES

Military casualties with vascular injuries often present with severe acidosis and coagulopathy that can negatively influence limb salvage decisions. We previously reported the value of a damage control resuscitation (DCR) strategy that can correct physiologic shock during simultaneous vascular reconstruction. The effect of recombinant factor VIIa (rFVIIa) on the repair of injured vessels and vascular grafts when used as an adjunctive therapy during DCR is unclear in the setting of wartime vascular injuries. The primary aim of this study was to assess the effect of rFVIIa use during DCR for vascular trauma and the impact on vessel repair.

METHODS

A retrospective two cohort case control study was performed using the Joint Theater Trauma Registry to identify patients with major vascular injury and DCR. Group 1 (n = 12) had DCR and repair of the injured vessels. Group 2 (n = 41) included early rFVIIa as an adjunctive therapy with DCR to control bleeding and perform simultaneous vascular reconstruction.

RESULTS

Age, injury severity score, presenting physiology, and operative time were similar between groups. Postoperative data show that early physiologic recovery from acidosis, coagulopathy, and anemia was associated with rFVIIa and DCR. Extremity graft failures in groups 1 and 2 (follow-up range, 10-26 months) were either from early thrombosis (1 vs. 5 p = 1), graft dehiscence (1 vs. 2 p = 0.55), or infection (1 vs. 1 p = 0.41) and were the result of inadequate soft tissue coverage or technical factors that eventually resulted in eight (15%) amputations. All cause mortality (group 1: 0% vs. group 2: 7.3%, p = 1) and amputation rates (group 1: 25% vs. groups 2: 12.2%, p = 0.36) were similar between the two groups.

CONCLUSIONS

DCR using rFVIIa is effective for controlling hemorrhage and reversing coagulopathy for severe vascular injuries. Early graft failures seem unrelated to rFVIIa use in the setting of wartime vascular injuries. No differences in amputation rate or mortality were seen. Although rFVIIa may be a useful damage control adjunct during vessel repair, the overall impact of this strategy on long-term outcomes such as mortality and limb salvage remains to be determined.

[Acute traumatic haemorrhagic shock and transfusion: what's new in 2009?]

In spite of continuous progress in surgery and in interventional radiology, massive haemorrhage remains a leading cause of death in traumatology. The transfusional strategy appears a key step in the treatment of haemorrhagic shock. In the light of new insights into the pathophysiology of coagulopathies associated with traumatic shock it seems reasonable to transfuse patients with haemorrhagic shock earlier than previously recommended.

Reversal of coagulopathy in critically ill patients with traumatic brain injury: recombinant factor VIIa is more cost-effective than plasma

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of death and disability after trauma. Coagulopathy is common in this patient population and requires rapid reversal to allow for safe neurosurgical intervention and prevent worsening of the primary injury. Typically reversal of coagulopathy is accomplished with the use of plasma. Recombinant factor VIIa (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) has become increasingly used "off-label" in patients with neurosurgical emergencies to rapidly reverse coagulopathy. We hypothesized that the use of rFVIIa in this patient population would prove to be cost-effective as well as demonstrate clinical benefit.

METHODS

The trauma registry at the R Adams Cowley Shock Trauma Center was used to identify all coagulopatic trauma patients admitted between January 2002 and December 2007 with relatively isolated TBI (head Abbreviated Injury Scale score of >or=4). The medical records of patients were reviewed and demographics, injury-specific data, medications administered, laboratory values, blood product utilization, neurosurgical procedures, length of stay (LOS), discharge disposition, and outcome data were abstracted. Patients who received rFVIIa for reversal of coagulopathy were compared against those who did not receive rFVIIa. t Tests were used to compare differences between continuous variables, and chi2 analysis was used to compare categorical variables. A p value of <0.05 was considered significant for all statistical tests.

RESULTS

During a 6-year period, there were 179 patients who met inclusion criteria. One hundred eleven patients (62.0%) were treated with conventional therapy alone whereas 68 (38.0%) received rFVIIa. Baseline characteristics between the two groups were similar except that Injury Severity Score and admission International normalized ratio were higher in the rFVIIa group and the rFVIIa group had a higher percentage of patients with head Abbreviated Injury Scale score of 5 injuries, patients who underwent neurosurgical procedures and patients with preinjury warfarin use. There was no difference in total charges between these groups (mean US $63,403 in the conventionally treated group vs. $66,086). When patients who required admission to the intensive care unit were analyzed (n = 110, 50% received rFVIIa), total mean charges and costs were significantly lower in the group that received rFVIIa (mean US $108,900 vs. $77,907). Hospital LOS, days of mechanical ventilation, and plasma utilization were lower in the rFVIIa group. Mortality and thromboembolic complication rates were not different between the two groups.

CONCLUSION

In this study, we were able to demonstrate a significant economic benefit of the use of rFVIIa for reversal of coagulopathy in severely injured patients with TBI. Not all patients with coagulopathy and an anatomic brain injury benefit, but in patients who are neurologically or physiologically compromised, using rFVIIa decreases total charges and costs of hospitalization. This decrease in overall cost is directly attributable to the significant decrease in LOS and decrease in the need for mechanical ventilation. This study demonstrates that in coagulopathic patients with TBI who require intensive care unit admission, rFVIIa is cost-effective and safe. Prospective studies are needed to confirm these findings and establish clinical effectiveness.

30 years of polytrauma care: An analysis of the change in strategies and results of 4849 cases treated at a single institution

The quality and progress of treatment of 4849 multiple trauma patients treated at one institution was reviewed retrospectively. Three periods, 1975-1984 (decade I; n=1469) and 1985-1994 (decade II; n=1937) and 1995-2004 (decade III; n=1443) were compared. 65% of multiple trauma patients had cerebral injuries, 58% thoracic trauma and 81% extremity fractures (37% open injuries). Injury combinations decreased during all decades with head/extremity injuries being the most common combination. Throughout the three decades pre-hospital care became more aggressive with an increase of intravenous fluid resuscitation (I: 80%, II: 97%, III: 98%). Chest tube insertion decreased after an initial increase (I: 41%, II: 83%, III: 27%) as well as intubation (I: 82%, II: 94%, III: 59%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal haemorrhage ultrasound (I: 17%, II: 92%, III: 97%) replaced peritoneal lavage (I: 44%, II: 28%, III: 0%). CT-scans were used more frequently for the initial diagnosis of head injuries and other injuries to the trunk throughout the observation time. With regard to complications, acute renal failure decreased by half (I: 8.4%; II: 3.7%; III: 3.9%), ARDS initially decreased but increased again in the last decade (I: 18.1%, II: 13.4%, III: 15.3%), whereas the rate of multiple organ dysfunction syndrome (MODS) increased continuously (I: 14.2%, II: 18.9%, III: 19.8%) probably due to a decline of the mortality rate from 37% in the first to 22% in the second and 18% in the third decade and parallel increase of the time of death. These treatment results summarise the enormous clinical effort as well as medical progress in polytrauma management over the past 30 years. Further reduction of mortality is desirable, but probably only possible when immediate causal therapy of later posttraumatic organ failure can be established.

Recombinant factor VIIa and other pro-haemostatic therapies in primary postpartum haemorrhage

Blood products are an essential component of the management of postpartum haemorrhage, although there is lack of evidence to guide optimal use. Prospective intervention studies, including randomized trials, are needed to clarify optimal timing and dosage. The new generation of virally inactivated blood products, such as fibrinogen concentrate, might further enhance our knowledge of the value of individual blood components. It seems likely that antifibrinolytic agents will receive less attention in future. However, rFVIIa promises to be a powerful tool in managing massive obstetric haemorrhage, although many questions concerning its efficacy and safety in differing clinical scenarios remain unanswered.

[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.

Coagulopathy in trauma: optimising haematological status

It is estimated that 10 000 people per year die following trauma in England and Wales and 30—40% do so due to uncontrolled haemorrhage. By the time the patient reaches hospital, coagulopathy is often already installed and needs to be corrected promptly to prevent further haemorrhage and allow effective treatment of injuries. The coagulopathy is multifactorial with the leading causes being acidosis, hypothermia and massive transfusion. Early recognition of the condition is imperative using standard coagulation testing; however, there are limitations in this setting. Newer methods of testing `global haemostasis' using thromboelastography are becoming more popular but need further validation. Treatment of coagulopathy requires a multidisciplinary approach. Blood product transfusion remains the cornerstone of management but newer pharmacological agents such as recombinant factor VIIa are increasingly being used. Here we review the pathogenesis, investigation and management of the coagulopathy of trauma.

Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children

BACKGROUND

Ongoing bleeding after blunt solid organ injury in children may require invasive therapy in the form of either angiographic or operative control. We report our experience in the use of a procoagulant, recombinant activated factor VII (rFVIIa), for controlling persistent bleeding in blunt abdominal trauma in children.

METHODS

After institutional review board approval, the records of 8 children with blunt abdominal trauma, persistent bleeding, and managed nonoperatively with rFVIIa were reviewed.

RESULTS

All 8 patients presented to our institution after sustaining blunt abdominal trauma and solid organ injury. All children had evidence of persistent bleeding with a drop in hematocrit and elevation in heart rate. Patients received a single dose of rFVIIa at 75 to 90 microg/kg (1 patient had 24 microg/kg) and had successful control of their bleeding without any further therapeutic intervention. Only 3 patients required a blood transfusion after rFVIIa administration--2 who had subarachnoid hemorrhages and the third during pelvic fixation. There were no cases of thromboembolic events after treatment with rFVIIa.

CONCLUSIONS

Recombinant factor VIIa is a useful adjunctive therapy in pediatric patients with evidence of ongoing hemorrhage from blunt abdominal injury and may reduce the need for invasive therapeutic procedures and transfusions.