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Flynn BC, Steiner ME, Mazzeffi M. Off-label Use of Recombinant Activated Factor VII for Cardiac Surgical Bleeding. Anesthesiology 2023:138187. [PMID: 37155359 DOI: 10.1097/aln.0000000000004569] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Recombinant activated factor VII has been widely used in an off-label manner for cardiac surgical bleeding. Recent reports have administered recombinant activated factor VII earlier in the course of bleeding and at lower doses than initially reported. This review will discuss the history, mechanism, current recommendations for use, and recent data on the use of recombinant activated factor VII in cardiac surgical bleeding.
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Affiliation(s)
- Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Marie E Steiner
- Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
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2
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Ciolek AM, Arnall J, Moore DC, Palkimas S, Der-Nigoghossian J, Dane K. Eptacog Beta for Bleeding Treatment and Prevention in Congenital Hemophilia A and B With Inhibitors: A Review of Clinical Data and Implications for Clinical Practice. Ann Pharmacother 2021; 56:831-838. [PMID: 34595941 DOI: 10.1177/10600280211049394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the pharmacology, dosing and administration, safety, clinical efficacy, and role of eptacog beta in the treatment of congenital hemophilia with inhibitors. DATA SOURCES A literature search of PubMed (1966 to August 2021) was conducted using the keywords eptacog beta, recombinant FVII, and hemophilia. STUDY SELECTION AND DATA EXTRACTION All relevant published articles and prescribing information on eptacog beta for the treatment of congenital hemophilia with inhibitors were reviewed. DATA SYNTHESIS Eptacog beta is a novel recombinant activated factor VII (rVIIa) product that demonstrated efficacy in controlling bleeding and associated pain in patients with hemophilia A or B with inhibitors. Eptacog beta has limited Food and Drug Administration-approved and off-label indications compared with other bypassing agents (BPAs; activated prothrombin complex concentrates [aPCC; eptacog alfa]). Eptacog beta costs less than eptacog alfa, but still more than aPCCs. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review provides insight into the role of eptacog beta for treatment of congenital hemophilia with inhibitors and reviews important health system formulary considerations for available BPAs. CONCLUSIONS Eptacog beta is more cost-effective than eptacog alfa and, as such, may become the preferred rVIIa formulary product. However, eptacog alfa availability remains necessary for the treatment of disorders where eptacog beta has limited data. aPCC should remain the first-line BPA for the treatment of bleeding in patients with inhibitors with no contraindications to use because of its equivocal efficacy and safety and in light of the magnitude of cost savings associated with this strategy.
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Affiliation(s)
- Alana M Ciolek
- New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | | | - Donald C Moore
- Levine Cancer Institute, Atrium Health, Concord, NC, USA
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3
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Very low-dose recombinant Factor VIIa administration for cardiac surgical bleeding reduces red blood cell transfusions and renal risk: a matched cohort study. Blood Coagul Fibrinolysis 2021; 32:473-479. [PMID: 34650021 DOI: 10.1097/mbc.0000000000001079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Outcomes following administration of very-low-dose recombinant activated factor VIIa (vld-rFVIIa) for cardiac surgical bleeding remain debatable. We sought to determine the association of vld-rFVIIa and adverse surgical outcomes. Retrospective, cohort matching of patients undergoing cardiac surgery who received vld-rFVIIa (median 13.02 μg/kg) for perioperative bleeding were matched to cardiac surgical patients who had bleeding and received standard of care for bleeding without Factor VIIa administration. Of the 362 matched patients (182 in each group), patients who received rFVIIa required significantly less red blood cell transfusions [median 3 units (range 0--60, IQR = 4 units) versus 4 units (range 2-34, IQR = 4 units); P = 0.0004], decreased length of hospital stay (median 8 versus 9 days; P = 0.0158) and decreased renal risk (P < 0.0001). Incidence of renal failure, postoperative infection, postoperative thrombosis, prolonged ventilation, total ICU hours and 30-day mortality were not different between the two groups. Vld-rFVIIa for cardiac surgical bleeding was associated with decreased red blood cell transfusion, renal risk and length of hospital stay without increased thromboembolism or mortality when compared to patients who had cardiac surgical bleeding and received standard of care without Factor VIIa.
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Sutherland L, Houchin A, Wang T, Wang S, Moitra V, Sharma A, Zorn T, Flynn BC. Impact of Early, Low-Dose Factor VIIa on Subsequent Transfusions and Length of Stay in Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:147-154. [PMID: 34103218 DOI: 10.1053/j.jvca.2021.04.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Recombinant factor VII (rFVIIa) is used to treat cardiac surgical bleeding in an off-label manner. However, optimal dosing and timing of administration to provide efficacious yet safe outcomes remain unknown. DESIGN Retrospective, observational study. SETTING Tertiary care academic center. PARTICIPANTS Cardiac surgical patients (N = 214) who received low-dose rFVIIa for cardiac surgical bleeding. INTERVENTIONS Patients were allocated into one of three groups based on timing of rFVIIa administration during the course of bleeding resuscitation based on the number of hemostatic products given before rFVIIa administration: group one = ≤one products (n = 82); group two = two-to-four products (n = 73); and group three= ≥five products (n = 59). MEASUREMENTS AND MAIN RESULTS Patients who received low-dose rFVIIa later in the course of bleeding resuscitation (group three) had longer intensive care unit stays (p = 0.014) and increased incidence of postoperative renal failure when compared with group one (p = 0.039). Total transfusions were lowest in patients who received rFVIIa early in the course of resuscitation (group one) (median, two [interquartile range (IQR), 1-4.75]) and highest in group three (median, 11 [IQR, 8-14]; p < 0.001). Subsequent blood product transfusions after rFVIIa administration were highest in group two (p = 0.003); however, the median for all three groups was two products. There were no differences in thrombosis, reexplorations, or mortality in any of the groups. CONCLUSIONS This study identified no differences in adverse outcomes based on timing of administration of low-dose rFVIIa for cardiac surgical bleeding defined by stage of resuscitation, but the benefits of early administration remain unclear.
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Affiliation(s)
- Lauren Sutherland
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Abigail Houchin
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Tian Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY
| | - Shuang Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY
| | - Vivek Moitra
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Akshit Sharma
- Department of Cardiology, University of Kansas Medical Center, Kansas City, KS
| | - Trip Zorn
- Department of Cardiothoracic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
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5
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O'Donnell C, Rodriguez AJ, Madhok J, Sharifi H, Wang H, O'Brien CG, Boyd J, Hiesinger W, Hsu J, Hill CC. The Use of Factor Eight Inhibitor Bypass Activity (FEIBA) for the Treatment of Perioperative Hemorrhage in Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2021; 35:2651-2658. [PMID: 34034934 DOI: 10.1053/j.jvca.2021.04.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To test the hypothesis that factor eight inhibitor bypassing activity (FEIBA) can be used to control bleeding following left ventricular assist device (LVAD) implantation without increasing the 14-day composite thrombotic outcome of pump thrombus, ischemic cerebrovascular accidents, pulmonary embolism, and deep venous thrombosis. DESIGN Retrospective cohort study. SETTING Academic hospital. PARTICIPANTS Three hundred nineteen consecutive patients who underwent LVAD implantation (December 1, 2009 to December 30, 2018). INTERVENTION FEIBA administered to control perioperative hemorrhage. MEASUREMENTS AND MAIN RESULTS The 82 patients (25.7%) in the FEIBA cohort had more risk factors for perioperative hemorrhage, such as lower preoperative platelet count (169 ± 66 v 194 ± 68 × 103/mL, p = 0.004), prior cardiac surgery (36.6% v 21.9%, p = 0.008), and longer cardiopulmonary bypass (CPB) time (100.3 v 75.2 minutes, p = 0.001) than the 237 controls. After 16.6 units (95% CI: 14.3-18.9) of blood products were given, 992 units (95% CI: 821-1163) of FEIBA were required to control bleeding in the FEIBA cohort. Compared to the controls, there were no differences in the 14-day composite thrombotic outcome (11.0% v 7.6%, p = 0.343) or mortality rate (3.7% v 1.3%, p = 0.179). Multivariate logistical regression identified preoperative international normalized ratio (odds ratio [OR]: 1.30, 95% CI: 1.04-1.62) and CPB time (OR: 1.11, 95% CI: 1.02-1.20) as risk factors for 14-day thrombotic events, but FEIBA usage was not associated with an increased risk. CONCLUSIONS In this retrospective cohort study, the use of FEIBA (∼1,000 units, ∼13 units/kg) to control perioperative hemorrhage following LVAD implantation was not associated with increases in mortality or composite thrombotic outcome.
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Affiliation(s)
- Christian O'Donnell
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Alexander J Rodriguez
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jai Madhok
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Husham Sharifi
- Department of Medicine (Pulmonary, Allergy & Critical Care Medicine), Stanford University School of Medicine, Stanford, CA
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Connor G O'Brien
- Department of Cardiovascular Medicine, University of California, San Francisco, CA
| | - Jack Boyd
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Joe Hsu
- Department of Medicine (Pulmonary, Allergy & Critical Care Medicine), Stanford University School of Medicine, Stanford, CA
| | - Charles C Hill
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Kidd B, Sutherland L, Jabaley CS, Flynn B. Efficacy, Safety, and Strategies for Recombinant-Activated Factor VII in Cardiac Surgical Bleeding: A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:1157-1168. [PMID: 33875351 DOI: 10.1053/j.jvca.2021.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/25/2021] [Accepted: 03/14/2021] [Indexed: 11/11/2022]
Abstract
As perioperative bleeding continues to be a major source of morbidity and mortality in cardiac surgery, the search continues for an ideal hemostatic agent for use in this patient population. Transfusion of blood products has been associated both with increased costs and risks, such as infection, prolonged mechanical ventilation, increased length of stay, and decreased survival. Recombinant-activated factor VII (rFVIIa) first was approved for the US market in 1999 and since that time has been used in a variety of clinical settings. This review summarizes the existing literature pertaining to perioperative rFVIIa, in addition to society recommendations and current guidelines regarding its use in cardiac surgery.
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Affiliation(s)
- Brent Kidd
- Division of Critical Care Medicine, Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Lauren Sutherland
- Division of Critical Care Medicine, Department of Anesthesiology, Columbia University, New York, NY
| | - Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, Atlanta, GA; Emory Critical Care Center, Atlanta, GA
| | - Brigid Flynn
- Division of Critical Care Medicine, Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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Katz A, Ahuja T, Arnouk S, Lewis TC, Marsh K, Papadopoulos J, Merchan C. A Comparison of Prothrombin Complex Concentrate and Recombinant Activated Factor VII for the Management of Bleeding With Cardiac Surgery. J Intensive Care Med 2021; 37:231-239. [DOI: 10.1177/0885066620984443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Bleeding following cardiac surgery that warrants transfusion of blood products is associated with significant complications, including increased mortality at 1 year following surgery. Factor concentrates, such as prothrombin complex concentrate (PCC), or recombinant activated factor VII (rFVIIa) have been used off-label for bleeding in cardiac surgery that is refractory to conventional therapy. The objective of this retrospective study is to assess the hemostatic effectiveness of 4-factor PCC or rFVIIa for bleeding after a broad range of cardiac surgeries. Patients were included if they were at least 18 years of age and had undergone cardiac surgery with bleeding requiring intervention with 4-factor PCC or rFVIIa. There were no differences observed in the number of packed red blood cells (4-factor PCC: 2 units vs. rFVIIa: 2 units), fresh frozen plasma (0 units vs. 1 unit) or platelet (2 units vs. 2 units) transfusions following the administration of 4-factor PCC or rFVIIa. The patients in the rFVIIa group, required more cryoprecipitate than those in the 4-factor PCC group (4-factor PCC: 2 units (range 0-6) vs. rFVIIa: 2 units (range 0-8), p = 0.03). There were no differences in secondary outcomes of chest tube output at 2, 6, 12 and 24 hours, nor was there a difference in reexploration rates or the median length of stay in the intensive care unit. Thromboembolic complications at 30 days were similar between the two groups (4-factor PCC: 13% vs. rFVIIa 26%, p = 0.08). The total median dose requirement for 4-factor PCC was 1000 units (15 units/kg) and 2 mg (20 mcg/kg) for rFVIIa. The results demonstrate feasibility of utilizing the minimum amount of drug in order to achieve a desired effect. Both 4-factor PCC and rFVIIa appear to be safe and effective options for the management of bleeding associated with cardiac surgery.
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Affiliation(s)
- Alyson Katz
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Serena Arnouk
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Tyler C. Lewis
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Kassandra Marsh
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
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8
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Feih JT, Juul JJ, G Rinka JR, Baumann Kreuziger LM, Pagel PS, Tawil JN. Adequacy of hemostatic resuscitation improves therapeutic efficacy of recombinant activated factor VII and reduces reexploration rate for bleeding in postoperative cardiac surgery patients with refractory hemorrhage. Ann Card Anaesth 2020; 22:388-393. [PMID: 31621674 PMCID: PMC6813715 DOI: 10.4103/aca.aca_108_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Excessive bleeding and surgical reexploration are common complications that increase the risk of multi-organ failure and prolonged hospitalization after cardiac surgery. Off-label use of recombinant activated factor VII (rFVIIa) is a recommended treatment for refractory bleeding. Objective: The objective of the study is to determine if the adequacy of hemostatic resuscitation enhances the efficacy of rFVIIa. Methods: This retrospective, observational, cohort study included patients who received rFVIIa for refractory postoperative bleeding after cardiac surgery. Patients were divided into two groups based on the presence or absence of adequate coagulation resuscitation before rFVIIa administration, defined as international ratio (INR) ≤1.5, platelet count ≥100 K/mL, and fibrinogen ≥200 mg/dL. The failure of rFVIIa treatment was defined as surgical reexploration within 24 h, thoracostomy drainage >400 mL/h within 6 h or transfusion of additional blood products or another rFVIIa dose within 6 h after initial rFVIIa dose. Results: Of the 3833 patients, screened who underwent cardiothoracic surgery procedures, 58 patients received rFVIIa for refractory postoperative bleeding. Successful hemostasis with rFVIIa was more likely in patients who were adequately resuscitated compared with those who were not (20 [71.4%] vs. 10 [33.3%], respectively; P = 0.0046). Multiple logistic regression analysis indicated that patients who were adequately resuscitated before rFVIIa were less likely to fail treatment (odds ratio, 0.16; 95% confidence interval [0.04–0.62]; P = 0.007). Conclusions: The therapeutic efficacy of rFVIIa is dependent on the adequacy of hemostatic resuscitation; restoration of normal serum fibrinogen, INR, and platelet counts >100 K/mL may provide an adequate substrate for rFVIIa to be effective in managing refractory postoperative cardiac surgical bleeding.
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Affiliation(s)
- Joel T Feih
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Janelle J Juul
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joseph R G Rinka
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee; Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, Wisconsin, USA
| | - Lisa M Baumann Kreuziger
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin; The Blood Center of Wisconsin, Blood Research Institute, Milwaukee, Wisconsin, USA
| | - Paul S Pagel
- Department of Anesthesiology, Medical College of Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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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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Abstract
The approval of several new clotting factor concentrates and anticoagulation antidotes has resulted in increased complexity and cost of care. A multidisciplinary hemostatic stewardship program is essential to optimize utilization of these resources. This article summarizes the authors' approach to the stewardship of clotting factor concentrates and anticoagulation antidotes.
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11
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Shen T, Huh MH, Czer LS, Vaidya A, Esmailian F, Kobashigawa JA, Nurok M. Controversies in the Postoperative Management of the Critically Ill Heart Transplant Patient. Anesth Analg 2019; 129:1023-1033. [PMID: 31162160 DOI: 10.1213/ane.0000000000004220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heart transplant recipients are susceptible to a number of complications in the immediate postoperative period. Despite advances in surgical techniques, mechanical circulatory support (MCS), and immunosuppression, evidence supporting optimal management strategies of the critically ill transplant patient is lacking on many fronts. This review identifies some of these controversies with the aim of stimulating further discussion and development into these gray areas.
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Affiliation(s)
- Tao Shen
- From the Departments of Anesthesiology.,Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Lawrence S Czer
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Ajay Vaidya
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Jon A Kobashigawa
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael Nurok
- From the Departments of Anesthesiology.,Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
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12
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Li Y, Zhao W, Luo Q, Wu X, Ding J, Yan F. A Propensity-Score Matched Analysis on Outcomes Using Recombinant Activated Factor VII in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:1269-1275. [DOI: 10.1053/j.jvca.2018.12.016] [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: 08/15/2018] [Indexed: 11/11/2022]
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13
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A role for very low-dose recombinant activated factor VII in refractory bleeding after cardiac surgery: Lessons from an observational study. J Thorac Cardiovasc Surg 2018; 156:1564-1573.e8. [DOI: 10.1016/j.jtcvs.2018.03.167] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/22/2018] [Accepted: 03/31/2018] [Indexed: 01/25/2023]
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14
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Mehringer SL, Klick Z, Bain J, McNeely EB, Subramanian S, Pass LJ, Drinkwater D, Reddy VS. Activated Factor 7 Versus 4-Factor Prothrombin Complex Concentrate for Critical Bleeding Post–Cardiac Surgery. Ann Pharmacother 2018; 52:533-537. [DOI: 10.1177/1060028017752365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Recombinant and plasma-derived factor products, such as activated factor seven (rFVIIa) and four-factor prothrombin complex concentrate (4-factor PCC), have been used off-label for bleeding after cardiac surgery, but little evidence has been published regarding their efficacy and safety. Objective: To determine whether there is a difference in chest tube output in patients who have received 4-factor PCC or rFVIIa for critical postoperative bleeding associated with cardiovascular surgery. Methods: A retrospective chart review was conducted utilizing the electronic medical record system at a 657-bed community, tertiary care hospital in Nashville, Tennessee. Nonpregnant patients ≥18 years of age experiencing significant bleeding during cardiac surgery who received either PCC or rFVIIa perioperatively or postoperatively between April 2015 through December 2016 were eligible for inclusion. Patients were excluded if they received 4-factor PCC or rFVIIa for any indication other than bleeding during cardiac surgery or if they received both agents. Results: Data conclude that there is no significant difference in chest tube output 24 hours postoperatively between patients treated with 4-factor PCC or rFVIIa. There was no difference in bleeding, thromboembolic events, or re-exploration between the rFVIIa and 4-factor PCC groups, but there was a difference in units of fresh frozen plasma administered and hospital length of stay. Conclusion: 4-Factor PCC may be an equally efficacious alternative to rFVIIa for patients experiencing significant bleeding during cardiac surgery. There is no difference in chest tube output; therefore, there is no difference in bleeding—either at 24 hours postoperatively or total.
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Affiliation(s)
| | - Zachary Klick
- University of Kentucky Healthcare Gill Heart and Vascular Institute, Lexington, KY, USA
| | - Jonathan Bain
- TriStar Centennial Medical Center, Nashville, TN, USA
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15
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Levy JH, Ghadimi K, Quinones QJ, Bartz RR, Welsby I. Adjuncts to Blood Component Therapies for the Treatment of Bleeding in the Intensive Care Unit. Transfus Med Rev 2017; 31:258-263. [PMID: 28552276 DOI: 10.1016/j.tmrv.2017.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/11/2017] [Accepted: 04/21/2017] [Indexed: 11/19/2022]
Abstract
Patients who are critically ill following surgical or traumatic injury often present with coagulopathy as a component of the complex multisystem dysfunction that clinicians must rapidly diagnose and treat in the intensive care environment. Failure to recognize coagulopathy while volume resuscitation with crystalloid or colloid takes place, or an unbalanced transfusion strategy focused on packed red blood cell transfusion can all significantly worsen coagulopathy, leading to increased transfusion requirements and poor outcomes. Even an optimized transfusion strategy directed at correcting coagulopathy and maintaining clotting factor levels carries the risk of a number of transfusion reactions including transfusion-related acute lung injury, transfusion-related circulatory overload, anaphylaxis, and septic shock. A number of adjunctive strategies can be used either to augment a balanced transfusion approach or as alternatives to blood component therapy. Coupled with an appropriate and timely laboratory testing, this approach can quickly diagnose a patient's specific coagulopathy and work to correct it as quickly as possible, minimizing the requirement of blood transfusion and the pathophysiologic effects of excessive bleeding and fibrinolysis. We will review the literature supporting this approach and provide insight into how these approaches can be best used to care for bleeding patients in the intensive care unit. Finally, the increasing use of several novel oral anticoagulants, novel antiplatelet drugs, and low-molecular weight heparin to clinical practice has complicated the care of the coagulopathic patient when these drugs are involved. Many clinicians familiar with heparin and warfarin reversal are not familiar with the optimal way to reverse the action of these new drugs. Patients treated with these drugs for a wide variety of conditions including atrial fibrillation, stroke, coronary artery stent, deep venous thrombosis, and pulmonary embolism will present for emergency surgery and will require management of pharmacologically induced postoperative coagulopathy. We will discuss optimized strategies for reversal of these agents and strategies that are currently under development.
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Affiliation(s)
- Jerrold H Levy
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC.
| | - Kamrouz Ghadimi
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Quintin J Quinones
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Raquel R Bartz
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Ian Welsby
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
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Hollis AL, Lowery AV, Pajoumand M, Pham SM, Slejko JF, Tanaka KA, Mazzeffi M. Impact on postoperative bleeding and cost of recombinant activated factor VII in patients undergoing heart transplantation. Ann Card Anaesth 2017; 19:418-24. [PMID: 27397445 PMCID: PMC4971969 DOI: 10.4103/0971-9784.185523] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Cardiac transplantation can be complicated by refractory hemorrhage particularly in cases where explantation of a ventricular assist device is necessary. Recombinant activated factor VII (rFVIIa) has been used to treat refractory bleeding in cardiac surgery patients, but little information is available on its efficacy or cost in heart transplant patients. Methods: Patients who had orthotopic heart transplantation between January 2009 and December 2014 at a single center were reviewed. Postoperative bleeding and the total costs of hemostatic therapies were compared between patients who received rFVIIa and those who did not. Propensity scores were created and used to control for the likelihood of receiving rFVIIa in order to reduce bias in our risk estimates. Results: Seventy-six patients underwent heart transplantation during the study period. Twenty-one patients (27.6%) received rFVIIa for refractory intraoperative bleeding. There was no difference in postoperative red blood cell transfusion, chest tube output, or surgical re-exploration between patients who received rFVIIa and those who did not, even after adjusting with the propensity score (P = 0.94, P = 0.60, and P = 0.10, respectively). The total cost for hemostatic therapies was significantly higher in the rFVIIa group (median $10,819 vs. $1,985; P < 0.0001). Subgroup analysis of patients who underwent redo-sternotomy with left ventricular assist device explantation did not show any benefit for rFVIIa either. Conclusions: In this relatively small cohort, rFVIIa use was not associated with decreased postoperative bleeding in patients undergoing heart transplantation; however, it led to significantly higher cost.
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Affiliation(s)
- Allison L Hollis
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Ashleigh V Lowery
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Mehrnaz Pajoumand
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Si M Pham
- Department of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Julia F Slejko
- School of Pharmacy, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Michael Mazzeffi
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD 21201, USA
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Habib AM. Comparison of low- and high-dose recombinant activated factor VII for postcardiac surgical bleeding. Indian J Crit Care Med 2016; 20:497-503. [PMID: 27688624 PMCID: PMC5027741 DOI: 10.4103/0972-5229.190365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim of the Study: A retrospective observational study to compare safety and efficacy of high and low doses of recombinant activated factor VIIa (rFVIIa) in severe postcardiac surgical bleeding. Patients and Methods: From 2004 to 2014, all patients who received rFVIIa for bleeding after cardiac surgery were included and arranged in two groups; Group 1: Low dose (40–50 mcg/kg) (n = 98) and Group 2: High dose (90–120 mcg/kg) (n = 156). Results: There was no significant difference in demographic and surgical characteristics of both groups on admission to Cardiac Surgical Intensive Care Unit (CSICU). There was no significant difference between the two groups regarding the reduction in chest tube bleeding in the first 6 h or the transfusion requirement in the 24 h after admission to CSICU. A total of 15 patients (5.9%) had thromboembolic adverse events. (Seven (7.1%) patients in Group 1 compared to 8 (5.1%) patients in Group 2, P = 0.58). There were no significant differences in all-cause mortality at 30 days (2% in Group 1 vs. 3.2% in Group 2, P = 0.6) and at hospital discharge between the two study groups (6.1% in Group 1 vs. 8.3% in Group 2, P = 0.5), respectively. There was no significant difference between the two groups regarding the need for re-exploration, days on mechanical ventilation, CSICU, or hospital stay. Conclusion: In this report, Low-dose rFVIIa showed equivalent efficacy and safety to high-dose rFVIIa. Further prospective randomized studies are needed to confirm these findings.
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Affiliation(s)
- Aly Makram Habib
- Department of Intensive Care, Adult Cardiac Intensive Care Unit, Prince Sultan Cardiac Centre, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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Habib AM, Mousa AY, Al-Halees Z. Recombinant activated factor VII for uncontrolled bleeding postcardiac surgery. J Saudi Heart Assoc 2016; 28:222-31. [PMID: 27688669 PMCID: PMC5034489 DOI: 10.1016/j.jsha.2016.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 02/09/2016] [Accepted: 03/01/2016] [Indexed: 01/10/2023] Open
Abstract
A retrospective observational study to review the safety and efficacy of rFVIIa in persistent hemorrhage in post cardiac surgical patients. Methods Patients who had bleeding of 3 ml/kg/h or more for 2 consecutive hours after cardiac surgery were arranged into two groups; control group, who received conventional treatment and rFVIIa group, who received conventional treatment and rFVIIa. Results There was no significant difference in demographic and surgical characteristics of both groups. The chest tube output significantly decreased in the rFVIIa group compared to the other group 4 hours after admission {1.4 (IQR: 1–2.2) ml/kg/h vs 3.9 (IQR: 3.1–5.6) ml/kg/h; p = 0.004} and continues to be significant till 9 hours after CSICU admission {0.6 (IQR: 0.4–1.1) ml/kg/h vs 1.9 (IQR: 1.2–2.2) ml/kg/h; p = 0.04}. The median number of blood products units transfused to rFVIIa group was significantly lower compared to control group in the period from 3–12 hours after CSICU admission. 13 (5.5%) patients in rFVIIa group had Thromboembolic adverse events (TAE) compared to 7 (2.4%) patients in other group p = 0.27. 8 patients in the rFVIIa group needed reexploration compared to 19 patients in the other group, p = 0.01. No significant difference was noticed between the 2 groups regarding: new onset renal failure, median number of mechanical ventilator days, pneumonia, mediastinitis, ICU and hospital lengths of stay, survival at 30 days and at discharge. Conclusion In this analysis, rFVIIa succefully reduced the chest tube bleeding and blood products transfused during severe post cardiac surgical bleeding. However, safety of rFVIIa remains unclear. Prospective controlled trials are still needed to confirm the role of rFVIIa.
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Affiliation(s)
- Aly Makram Habib
- Cardiac Surgical Intensive Care Unit, King Faisal Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
- Corresponding author was working at King Faisal Heart Center till June 2015 before he moves to: Adult Surgical Intensive Care Unit, Intensive Care Department, Prince Sultan Cardiac Center, Prince Sultan Military Medical City, Post office Box 7897-x966, Riyadh 11159, Saudi Arabia.
| | - Ahmed Yehia Mousa
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Zohair Al-Halees
- Cardiac Surgery Section, King Faisal Heart Center, King Faisal Specialist Center and Research Center, Riyadh, Saudi Arabia
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Rao VK, Lobato RL, Bartlett B, Klanjac M, Mora-Mangano CT, David Soran P, Oakes DA, Hill CC, van der Starre PJ. Factor VIII Inhibitor Bypass Activity and Recombinant Activated Factor VII in Cardiac Surgery. J Cardiothorac Vasc Anesth 2014; 28:1221-6. [DOI: 10.1053/j.jvca.2014.04.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Indexed: 11/11/2022]
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Mackenzie CF, Shander A. What to do if no blood is available but the patient is bleeding? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2008.10872520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Song HK, Tibayan FA, Kahl EA, Sera VA, Slater MS, Deloughery TG, Scanlan MM. Safety and efficacy of prothrombin complex concentrates for the treatment of coagulopathy after cardiac surgery. J Thorac Cardiovasc Surg 2013; 147:1036-40. [PMID: 24365268 DOI: 10.1016/j.jtcvs.2013.11.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 10/22/2013] [Accepted: 11/11/2013] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Coagulopathy is an important cause of bleeding after complex cardiac surgery. The conventional treatment for coagulopathy is transfusion, which is associated with adverse outcomes. We report our initial experience with the prothrombin complex concentrate FEIBA (factor VIII inhibitor bypassing activity) for the rescue treatment of coagulopathy and life-threatening bleeding after cardiac surgery. METHODS Twenty-five patients who underwent cardiac surgery with coagulopathy and life-threatening bleeding refractory to conventional treatment received FEIBA as rescue therapy at our institution. This cohort represents approximately 2% of patients undergoing cardiac surgery in our university-based practice during the study. RESULTS The patients were at high risk for postoperative coagulopathy with nearly all patients having at least 2 risk factors for this. Aortic root replacement (Bentall or valve-sparing procedure) and heart transplant with or without left ventricular assist device explant were the most common procedures. The mean FEIBA dose was 2154 units. The need for fresh frozen plasma and platelet transfusion decreased significantly after FEIBA administration (P = .0001 and P < .0001). The mean internationalized normalized ratio decreased from 1.58 to 1.13 (P < .0001). Clinical outcomes were excellent. No patient returned to the operating room for reexploration. There was no hospital mortality and all patients were discharged home. One patient who had a central line and transvenous pacemaker developed an upper extremity deep vein thrombosis. CONCLUSIONS Our initial experience with FEIBA administration for the rescue treatment of postoperative coagulopathy and life-threatening bleeding has been favorable. Further studies are indicated to confirm its efficacy and safety and determine specific clinical indications for its use in patients undergoing cardiac surgery.
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Affiliation(s)
- Howard K Song
- Division of Cardiothoracic Surgery, Department of Anesthesiology and Perioperative Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Ore.
| | - Frederick A Tibayan
- Division of Cardiothoracic Surgery, Department of Anesthesiology and Perioperative Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Ore
| | - Ed A Kahl
- Division of Cardiothoracic Surgery, Department of Anesthesiology and Perioperative Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Ore
| | - Valerie A Sera
- Division of Cardiothoracic Surgery, Department of Anesthesiology and Perioperative Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Ore
| | - Matthew S Slater
- Division of Cardiothoracic Surgery, Department of Anesthesiology and Perioperative Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Ore
| | - Thomas G Deloughery
- Division of Cardiothoracic Surgery, Department of Anesthesiology and Perioperative Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Ore
| | - Mick M Scanlan
- Division of Cardiothoracic Surgery, Department of Anesthesiology and Perioperative Medicine, Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Ore
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Gruber SN, Volles DF. Usefulness of laboratory values in predicting effectiveness of recombinant factor VIIa in surgical patients with bleeding. Am J Health Syst Pharm 2013; 70:1528-32. [PMID: 23943185 DOI: 10.2146/ajhp120651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The results of a study to determine whether certain laboratory values can predict the effectiveness of recombinant factor VIIa (rFVIIa) therapy to control postoperative bleeding in surgical patients are presented. METHODS In a retrospective observational study at a large university hospital, the records of all adult patients on the cardiothoracic surgery (CTS) and general or trauma surgery (GTS) units who received rFVIIa for treatment-refractory nonsurgical bleeding episodes (an off-label use) during a 17-month period were reviewed. Collected data included blood product requirements before and after administration of rFVIIa, selected periadministration laboratory values (e.g., International Normalized Ratio, platelet count, arterial pH, fibrinogen concentration), 24-hour and 30-day mortality, and documented adverse thrombotic events. RESULTS Among the 18 GTS and 32 CTS patients who received rFVIIa during the study period, hemostasis (as defined according to 12- and 24-hour transfusion requirements) was achieved in 50% of patients in both groups. Two of the evaluated laboratory values were found to be predictive of reduced rFVIIa effectiveness. Hemostasis was not achieved in any patient with an arterial pH of ≤7.1 or a fibrinogen concentration of <100 mg/dL. The study results did not support the hypothesis that a platelet count of <50,000 cells/L is associated with reduced effectiveness of rFVIIa therapy for the studied indication. Adverse thrombotic events occurred in 14 patients (28%) after rFVIIa administration. CONCLUSION CTS and GTS patients with bleeding episodes and an arterial pH of ≤7.1 or a fibrinogen concentration of <100 mg/dL were not likely to achieve hemostasis after rFVIIa therapy.
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Affiliation(s)
- Sarah N Gruber
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA.
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Camkiran A, Pirat A, Zeyneloglu P, Ozkan M, Arslan G. Use of recombinant activated factor VIIa for nonsurgical, refractory bleeding in neonatal cardiac surgery patients: case series. J Cardiothorac Vasc Anesth 2013; 27:e14-5. [PMID: 23507020 DOI: 10.1053/j.jvca.2012.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Indexed: 11/11/2022]
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Experience with prothrombin complex for the emergent reversal of anticoagulation in rural geriatric trauma patients. Surgery 2012; 152:722-6; discussion 726-8. [PMID: 22943840 DOI: 10.1016/j.surg.2012.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 07/13/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Therapeutic anticoagulation in the geriatric trauma population is increasingly common. Fresh frozen plasma, while the criterion standard for correction, has limited availability and associated transfusion risks. We examined our use of prothrombin complex concentrate for immediate reversal of therapeutically anticoagulated geriatric trauma patients. METHODS This was a 1-year, retrospective review of 25 geriatric trauma patients who received either fresh frozen plasma alone or prothrombin complex concentrate and met the inclusion criteria of age >55 years, current warfarin use, and an admission international normalized ratio of >1.5. Fifteen patients received prothrombin complex concentrate and 10 patients received fresh frozen plasma alone. We examined demographics, laboratory values, and blood product use. RESULTS The mean ages were similar (77 vs 80 years). Patients had similar mean Injury Severity Score (19.1 vs 19.2). Survivor duration of hospital stay (7.7 vs 9.5; P = .37) and duration of stay in the intensive care unit (4.4 vs 7.1; P = .25) trended positively in the prothrombin complex concentrate group. The prothrombin complex concentrate group received fewer units of fresh frozen plasma (1.6 [range, 0-6] vs 2.7 [range, 2-4]; P = .05), with a greater decrease in international normalized ratio (51% vs 43%; P = .05). Six patients (40%) in the prothrombin complex concentrate group avoided fresh frozen plasma transfusion altogether. CONCLUSION Prothrombin complex may be used safely and effectively to reverse emergently anticoagulation in geriatric trauma patients.
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Christensen MC, Dziewior F, Kempel A, von Heymann C. Increased Chest Tube Drainage Is Independently Associated With Adverse Outcome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2012; 26:46-51. [DOI: 10.1053/j.jvca.2011.09.021] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Indexed: 11/11/2022]
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Tarzia V, Bottio T, Buratto E, Spiezia L, Simioni P, Gerosa G. The hazard of comparing apples and oranges: the proper indication for the use of recombinant activated clotting factor VII in cardiac surgery. J Thorac Cardiovasc Surg 2012; 142:1588-9; author reply 1589. [PMID: 22093717 DOI: 10.1016/j.jtcvs.2011.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 08/10/2011] [Indexed: 01/17/2023]
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Dunne B, Xiao P, Andrews D. Successful use of factor VIIa to control life-threatening post-operative haemorrhage in a patient on extra-corporeal membrane oxygenation. Heart Lung Circ 2011; 21:229-30. [PMID: 22036715 DOI: 10.1016/j.hlc.2011.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 08/30/2011] [Accepted: 09/10/2011] [Indexed: 11/16/2022]
Abstract
Recombinant Factor VII (Novoseven) is gaining recognition as an established treatment option for post-cardiac surgery bleeding. However, little information is available on its use in patients being maintained on Extra-Corporeal Membrane Oxygenation (ECMO) support, particularly in the adult population. We present the first case of the successful use of Factor VIIa to control bleeding in an adult patient on ECMO post cardiac surgery.
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Affiliation(s)
- Ben Dunne
- Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, WA 6000, Australia.
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Nalla BP, Freedman J, Hare GMT, Mazer CD. Update on blood conservation for cardiac surgery. J Cardiothorac Vasc Anesth 2011; 26:117-33. [PMID: 22000983 DOI: 10.1053/j.jvca.2011.07.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Bhanu P Nalla
- Department of Anesthesia, Keenan Research Center in the Li Ka Shing Knowledge Translation Institute of St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Ponschab M, Landoni G, Biondi-Zoccai G, Bignami E, Frati E, Nicolotti D, Monaco F, Pappalardo F, Zangrillo A. Recombinant Activated Factor VII Increases Stroke in Cardiac Surgery: A Meta-analysis. J Cardiothorac Vasc Anesth 2011; 25:804-10. [PMID: 21596585 DOI: 10.1053/j.jvca.2011.03.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Indexed: 02/08/2023]
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Administration of recombinant activated factor VII in the intensive care unit after complex cardiovascular surgery: clinical and economic outcomes. J Thorac Cardiovasc Surg 2011; 141:1469-77.e2. [PMID: 21457998 DOI: 10.1016/j.jtcvs.2011.02.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 11/12/2010] [Accepted: 02/25/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Refractory bleeding after complex cardiovascular surgery often leads to increased length of stay, cost, morbidity, and mortality. Recombinant activated factor VII administered in the intensive care unit can reduce bleeding, transfusion, and surgical re-exploration. We retrospectively compared factor VII administration in the intensive care unit with reoperation for refractory bleeding after complex cardiovascular surgery. METHODS From 1501 patients who underwent cardiovascular procedures between December 2003 and September 2007, 415 high-risk patients were identified. From this cohort, 24 patients were divided into 2 groups based on whether they either received factor VII in the intensive care unit (n = 12) or underwent reoperation (n = 12) for refractory bleeding. Preoperative and postoperative data were collected to compare efficacy, safety, and economic outcomes. RESULTS In-hospital survival for both groups was 100%. Factor VII was comparable with reoperation in achieving hemostasis, with both groups demonstrating decreases in chest tube output and need for blood products. Freedom from reoperation was achieved in 75% of patients receiving factor VII, whereas reoperation was effective in achieving hemostasis alone in 83.3% of patients. Prothrombin time, international normalized ratio, and median operating room time were significantly less (P < .05) in patients who received factor VII. Both groups had no statistically significant differences in other efficacy, safety, or economic outcomes. CONCLUSIONS Factor VII administration in the intensive care unit appears comparable with reoperation for refractory bleeding after complex cardiovascular surgical procedures and might represent an alternative to reoperation in selected patients. Future prospective, randomized controlled trials might further define its role.
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Mazer CD, Leong-Poi H, Chhina T, Alfardan Z, Lapierre H, Wang Z, Jackson ZS, Qiang B, Mahoney J, Latter D, Hare GMT, Strauss BH, Teitel J. Recombinant factor VIIa affects anastomotic patency of vascular grafts in a rabbit model. J Thorac Cardiovasc Surg 2011; 142:418-23. [PMID: 21281943 DOI: 10.1016/j.jtcvs.2010.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 10/03/2010] [Accepted: 11/14/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Recombinant factor VIIa can decrease postoperative bleeding after cardiac surgery. However, the potential for recombinant factor VIIa to cause early vascular graft occlusion at the site of new vascular anastomoses has not been fully explored. We hypothesized that recombinant factor VIIa would cause a dose-dependent reduction in vascular graft patency in rabbits. METHODS Reversed end-to-end interpositional vein grafts were sutured into the carotid artery of heparinized rabbits, and then recombinant factor VIIa (300 μg/kg, 90 μg/kg, or 20 μg/kg intravenously) or placebo was administered (n = 16/group). Graft patency was assessed at 24 hours using a vascular ultrasound probe. Factor VII activity levels were measured using a prothrombin time-based assay. In different rabbits, the patency of venous end-to-side anastomoses and simple carotid arterial repairs was assessed (recombinant factor VIIa, 300 μg/kg vs placebo, n = 8/group). Data were analyzed using Fisher's exact test, t tests, or analysis of variance. RESULTS Physiologic variables (activated clotting time, hemoglobin, pH, Pao(2)) and vessel diameter were not different between groups. Vein graft patency was reduced (93.8%, 81.2%, 13.8%, and 6.3%) as factor VII activity levels increased (1.8 ± 0.4, 4.4 ± 2.1, 11.8 ± 4.7, and 23.6 ± 16.9 U/mL, respectively) with increasing doses of recombinant factor VIIa administered (0, 20, 90, and 300 μg/kg, respectively, P < .05). Patency in the arterial repairs and end-to-side venous grafts was also reduced in recombinant factor VIIa-treated rabbits (P < .05 for both). CONCLUSIONS This study suggests that recombinant factor VIIa is associated with a dose-dependent increase in fresh vascular graft occlusion. Higher doses of recombinant factor VIIa may be associated with increased thrombotic outcomes.
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Affiliation(s)
- C David Mazer
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
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Ensor CR, Paciullo CA, Cahoon WD, Nolan PE. Pharmacotherapy for Mechanical Circulatory Support: A Comprehensive Review. Ann Pharmacother 2011; 45:60-77. [DOI: 10.1345/aph.1p459] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To provide a comprehensive review of the pharmacotherapy associated with the provision of mechanical circulatory support (MCS) to patients with end-stage heart failure and guidance regarding the selection, assessment, and optimization of drug therapy for this population. Data Sources: The MEDLINE/PubMed, EMBASE, and Cochrane databases were searched from 1960 to July 2010 for articles published in English using the search terms mechanical circulatory support, ventricular assist system, ventricular assist device, left ventricular assist device, right ventricular assist device, biventricular assist device, total artificial heart, pulsatile, positive displacement, axial, centrifugal, hemostasis, bleeding, hemodynamic, blood pressure, thrombosis, antithrombotic therapy, anticoagulant, antiplatelet, right ventricular failure, ventricular arrhythmia, anemia, arteriovenous malformation, stroke, infection, and clinical pharmacist. Study Selection And Data Extraction: All relevant original studies, metaanalyses, systematic reviews, guidelines, and reviews were assessed for inclusion. References from pertinent articles were examined for content not found during the initial search. Data Synthesis: MCS has advanced significantly since the first left ventricular assist device was implanted in 1966. Further advancements in MCS technology that occurred in the tatter decade are changing the overall management of end-stage heart failure care and cardiac transplantation. These pumps allow for improved bridge-to-transplant rates, enhanced survival, and quality of life. Pharmacotherapy associated with MCS devices may optimize the performance of the pumps and improve patient outcomes, as well as minimize morbidity related to their adverse effects. This review highlights the knowledge needed to provide appropriate clinical pharmacy services for patients supported by MCS devices. Conclusions: The HeartMate II clinical investigators called for the involvement of pharmacists in MCS patient assessment and optimization. Pharmacotherapeutic management of patients supported with MCS devices requires individualized care, with pharmacists as part of the team, based on the characteristics of each pump and recipient.
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Affiliation(s)
- Christopher R Ensor
- Cardiothoracic Transplantation and Mechanical Circulatory Support; Clinical Assistant Professor, School of Pharmacy, University of Maryland; Department of Pharmacy, Comprehensive Transplant Center, The Johns Hopkins Hospital, Baltimore, MD
| | - Christopher A Paciullo
- Cardiothoracic Surgery Critical Care, Department of Pharmacy, Emory University Hospital, Atlanta, GA
| | - William D Cahoon
- Cardiology; Clinical Assistant Professor, School of Pharmacy, Virginia Commonwealth University, Virginia Commonwealth University Health System; Department of Pharmacy, Medical College of Virginia Hospitals, Richmond, VA
| | - Paul E Nolan
- College of Pharmacy, University of Arizona; Senior Clinical Scientist, The University Medical Center, Tucson, AZ
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Sniecinski RM, Chen EP, Makadia SS, Kikura M, Bolliger D, Tanaka KA. Changing from Aprotinin to Tranexamic Acid Results in Increased Use of Blood Products and Recombinant Factor VIIa for Aortic Surgery Requiring Hypothermic Arrest. J Cardiothorac Vasc Anesth 2010; 24:959-63. [DOI: 10.1053/j.jvca.2010.02.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Indexed: 11/11/2022]
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Lehr EJ, Alford TJ, Wang SH. Recombinant Activated Factor VII for Postoperative Hemorrhage Following Repair of Acute Type A Aortic Dissection. Heart Surg Forum 2010; 13:E275-9. [DOI: 10.1532/hsf98.20101027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Thrombophilias, an inherited and/or acquired predisposition to vascular thrombosis beyond hemostatic needs are common in cardiovascular medicine and include systemic disorders such as coronary atherosclerosis, atrial fibrillation, exogenous obesity, metabolic syndrome, collagen vascular disease, human immunodeficiency virus, blood replacement therapy and several commonly used medications. A contemporary approach to patients with suspected thrombophilias, in addition to a very selective investigation for gain-of-function and loss-of-function gene mutations affecting thromboresistance, must consider prevalent diseases and management decisions encountered regularly by cardiologists in clinical practice. An appropriate recognition of common disease states as thrombophilias will also stimulate platforms for much needed scientific investigation.
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Affiliation(s)
- Richard C Becker
- Divisions of Cardiology and Hematology, Duke University School of Medicine, Duke Clinical Research Institute, 2400 Pratt Street, DUMC 3850, Durham, NC 27705, USA.
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37
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Altman R, Scazziota A, de Lourdes Herrera M, Gonzalez CD. The hemostatic profile of recombinant activated factor VII. Can low concentrations stop bleeding in off-label indications? Thromb J 2010; 8:8. [PMID: 20444280 PMCID: PMC2885319 DOI: 10.1186/1477-9560-8-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 05/05/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High concentrations of recombinant activated factor VII (rFVIIa) can stop bleeding in hemophilic patients. However the rFVIIa dose needed for stopping haemhorrage in off-label indications is unknown. Since thrombin is the main hemostatic agent, this study investigated the effect of rFVIIa and tissue factor (TF) on thrombin generation (TG) in vitro. METHODS Lag time (LT), time to peak (TTP), peak TG (PTG), and area under the curve after 35 min (AUCo-35 min) with the calibrated automated thrombography was used to evaluate TG. TG was assayed in platelet-rich plasma (PRP) samples from 29 healthy volunteers under basal conditions and after platelet stimulation with 5.0 mug/ml, 2.6 mug/ml, 0.5 mug/ml, 0.25 mug/ml, and 0.125 mug/ml rFVIIa alone and in normal platelet-poor plasma (PPP) samples from 22 healthy volunteers, rFVIIa in combination with various concentrations of TF (5.0, 2.5, 1.25 and 0.5 pM). RESULTS In PRP activated by rFVIIa, there was a statistically significant increase in TG compared to basal values. A significant TF dose-dependent shortening of LT and increased PTG and AUCo-->35 min were obtained in PPP. The addition of rFVIIa increased the effect of TF in shorting the LT and increasing the AUCo-->35 min with no effect on PTG but were independent of rFVIIa concentration. CONCLUSION Low concentrations of rFVIIa were sufficient to form enough thrombin in normal PRP or in PPP when combined with TF, and suggest low concentrations for normalizing hemostasis in off-label indications.
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Affiliation(s)
- Raul Altman
- Centro de Trombosis de Buenos Aires, Viamonte 2008, 1056 Buenos Aires, Argentina.
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38
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Grottke O, Henzler D, Rossaint R. Activated recombinant factor VII (rFVIIa). Best Pract Res Clin Anaesthesiol 2010; 24:95-106. [DOI: 10.1016/j.bpa.2009.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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39
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Millán C, Quintana B, Rodríguez A, Iglesias M, Barranco M, Navia J. [Efficacy of recombinant activated factor VII for massive bleeding after cardiac surgery: experience with 32 patients]. ACTA ACUST UNITED AC 2010; 56:485-92. [PMID: 19994617 DOI: 10.1016/s0034-9356(09)70439-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the efficacy of recombinant activated factor VII (rFVIIa) to treat massive bleeding refractory to conventional treatment following cardiac surgery. PATIENTS AND METHODS Retrospective study of 32 adults who underwent cardiac surgery and received rFVIIa to treat life-threatening postoperative bleeding after conventional means of correcting coagulopathy had failed. RESULTS After administration of rFVIIa (90 microg x kg(-1), coagulation parameters soon became normal and blood loss decreased, with drainage going from a mean (SD) of 463 (321) mL in the hour when rFVIIa was infused to 155 (101) mL in the next hour (P < .001). Blood loss decreased by between 22% and 90% (mean, 66%), and the reduction was over 75% in 45% of the patients. Decreases in the transfusion of packed red blood cells (from 7A.4 [4.1] units to 2.7 [ 2.9] units; P < .001), plasma (from 4.7 [2.9] units to 1.6 [2.0] units; P < .001), and platelets were also noted. Mortality was 25%, although only 1 patient died from hemorrhagic shock. One patient developed thromboembolic complications (ischemic stroke). CONCLUSION rFVIIa was effective in treating refractory bleeding after cardiac surgery, reducing blood loss and transfusion requirements and restoring blood parameters to normal.
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Affiliation(s)
- C Millán
- Departamento de Anestesiología y Reanimación, Hospital General Universitario "Gregorio Marañńon", Madrid.
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40
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Fritsch N, Pouquet O, Roux B, Abdelmoumen Y, Janvier G. [Successful use of recombinant factor VIIa in the control of a massive bleeding in two patients with biventricular assist device (Thoratec)]. ACTA ACUST UNITED AC 2010; 29:45-7. [PMID: 20080378 DOI: 10.1016/j.annfar.2009.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 10/06/2009] [Indexed: 10/20/2022]
Abstract
Massive bleeding is a dreaded complication of biventricular mechanical assistance implantation. Its origin is multifactorial. Blood products transfusion associated with correction of coagulopathy are sometimes insufficient. We report two cases of massive bleeding after a Thoratec biventricular assistance implantation. After surgical haemostasis failure and despite the correction of coagulation disorders, a major bleeding persisted, so these patients received a single injection of 90 microg/kg of rFVIIa. This allowed in both cases a significant reduction of the bleeding and the restoration of normal haemodynamic conditions. This treatment was not complicated by any thrombotic accident.
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Affiliation(s)
- N Fritsch
- Service de réanimation de chirurgie cardiaque, hôpital du Haut-Lévèque, CHU de Bordeaux, 1, avenue de Magellan, 33600 Pessac, France
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41
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Lessons from the aprotinin saga: current perspective on antifibrinolytic therapy in cardiac surgery. J Anesth 2009; 24:96-106. [DOI: 10.1007/s00540-009-0866-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 06/04/2009] [Indexed: 11/26/2022]
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42
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Willis C, Bird R, Mullany D, Cameron P, Phillips L. Use of rFVIIa for critical bleeding in cardiac surgery: dose variation and patient outcomes. Vox Sang 2009; 98:531-7. [PMID: 19878495 DOI: 10.1111/j.1423-0410.2009.01276.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Recombinant activated factor VIIa (rFVIIa) is increasingly being used in non-haemophiliac patients for the treatment of severe bleeding refractory to standard interventions. Optimal dosing regimens remain debated in cardiac surgery. Therefore, this study investigated the use of different rFVIIa dosing practices on response to bleeding and patient outcomes in cardiac surgery patients using data from the Haemostasis Registry. METHODS Data were extracted from the Haemostasis Registry that records cases of off-licence rFVIIa use in participating institutions. Univariate analyses compared patients receiving < or =40 microg/kg, 41-60 microg/kg, 61-80 microg/kg, 81-100 microg/kg and >100 microg/kg of rFVIIa on key parameters. Logistic regression models investigated the relationship between independent variables and 28-day mortality. RESULTS Complete data was available on 804 cardiac surgery patients who received rFVIIa. Of these, 42 (5.2%) were treated with doses < or =40 microg/kg, while the dose group containing the most patients was 81-100 microg/kg (368, 45.77%). Results demonstrated no significant differences in the rate of thromboembolic adverse events, response to bleeding or 28-day mortality. CONCLUSIONS These findings raise the important question of whether lower doses of rFVIIa may be as effective as higher doses in the treatment of severe bleeding in cardiac surgery patients.
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Affiliation(s)
- C Willis
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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43
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Bruckner BA, DiBardino DJ, Ning Q, Adeboygeun A, Mahmoud K, Valdes J, Eze J, Allison PM, Cooley DA, Gregoric ID, Frazier OH. High incidence of thromboembolic events in left ventricular assist device patients treated with recombinant activated factor VII. J Heart Lung Transplant 2009; 28:785-90. [PMID: 19632574 DOI: 10.1016/j.healun.2009.04.028] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 04/02/2009] [Accepted: 04/26/2009] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Brian A Bruckner
- Department of Cardiology, DeBakey Heart Center, Methodist Hospital, Houston, TX 77030, USA.
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44
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Abstract
Background—
Blood loss is a common complication of cardiac surgery. Evidence suggests that recombinant activated factor VII (rFVIIa) can decrease intractable bleeding in patients after cardiac surgery. Our objective was to investigate the safety and possible benefits of rFVIIa in patients who bleed after cardiac surgery.
Methods and Results—
In this phase II dose-escalation study, patients who had undergone cardiac surgery and were bleeding were randomized to receive placebo (n=68), 40 μg/kg rFVIIa (n=35), or 80 μg/kg rFVIIa (n=69). The primary end points were the number of patients suffering critical serious adverse events. Secondary end points included rates of reoperation, amount of blood loss, and transfusion of allogeneic blood. There were more critical serious adverse events in the rFVIIa groups. These differences did not reach statistical significance (placebo, 7%; 40 μg/kg, 14%;
P
=0.25; 80 μg/kg, 12%;
P
=0.43). After randomization, significantly fewer patients in the rFVIIa group underwent a reoperation as a result of bleeding (
P
=0.03) or required allogeneic transfusions (
P
=0.01).
Conclusions—
On the basis of this preliminary evidence, rFVIIa may be beneficial for treating bleeding after cardiac surgery, but caution should be applied and further clinical trials are required because there is an increase in the number of critical serious adverse events, including stroke, in those patients randomized to receive rFVIIa.
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45
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Lewis NR, Brunker P, Lemire SJ, Kaufman RM. Failure of recombinant factor VIIa to correct the coagulopathy in a case of severe postpartum hemorrhage. Transfusion 2009; 49:689-95. [PMID: 19347977 DOI: 10.1111/j.1537-2995.2008.02029.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH)remains an important cause of maternal morbidity and mortality. Several published reports suggest that recombinant factor VIIa (rFVIIa) is effective in controlling bleeding in PPH. This study reports a case of severe PPH complicated by disseminated intravascular coagulation(DIC), in which early rFVIIa (44 mg/kg) administration not only failed to control the bleeding in vivo but also, surprisingly, failed to correct the patient's international normalized ratio (INR) in vitro. It was hypothesized that the failure of rFVIIa to correct the INR indicated a deficiency in a downstream coagulation factor(s). To investigate this, coagulation factor levels were measured in blood samples that had been drawn periodically during resuscitation in the operating room. STUDY DESIGN AND METHODS Clinical and laboratory data were extracted from the medical record.Plasma samples that had been obtained during resuscitation were frozen, and activity levels of the following factors were subsequently measured: fibrinogen, FII, FV, FVII, F IX, and FX. RESULTS After rFVIIa administration, the patient's INR remained elevated at 1.9, and bleeding continued. It was determined that at the time rFVIIa was administered, the patient's fibrinogen level was very low(60 mg/dL). INR normalization and control of bleeding was achieved only after the patient's fibrinogen level was restored to normal. FII, F IX, and FX remained at hemostatic levels throughout resuscitation. CONCLUSIONS In this case of severe PPH complicated by DIC, fibrinogen appears to have been limiting at the time rFVIIa was administered. It is suggested that fibrinogen levels should be corrected during PPH resuscitation before rFVIIa use is considered.
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Affiliation(s)
- Nicole R Lewis
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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46
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Efficacy and safety of activated recombinant factor VII in cardiac surgical patients. Curr Opin Anaesthesiol 2009; 22:95-9. [DOI: 10.1097/aco.0b013e32831a40a3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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47
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Zangrillo A, Mizzi A, Biondi-Zoccai G, Bignami E, Calabrò MG, Pappalardo F, Dedola E, Tritapepe L, Marino G, Landoni G. Recombinant Activated Factor VII in Cardiac Surgery: A Meta-analysis. J Cardiothorac Vasc Anesth 2009; 23:34-40. [PMID: 19081268 DOI: 10.1053/j.jvca.2008.09.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Indexed: 02/08/2023]
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48
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Miskolczi S, Vaszily M, Papp C, Péterffy A. [Our experience with recombinant activated factor VII (NovoSeven) in the high risk cardiosurgical patients with bleeding complication]. Magy Seb 2008; 61 Suppl:45-7. [PMID: 18504237 DOI: 10.1556/maseb.61.2008.suppl.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Haemorrhagic complications significantly increase mortality and cost of treatment in cardiac surgery. A few years ago recombinant activated factor VII has been introduced to decrease such complications. In our department recombinant activated factor VII has been used in 11 patients between 2004 and 2007. Nine of them underwent a combined (simultaneous CABG and valve replacement) high risk surgery with long aortic cross clamp time and long extracorporeal circulation time. One patient underwent a repeat coronary artery bypass operation and one was operated for aortic dissection. The average dose given was 6.5 mg (2.4-9.6 mg). The average amount of bleeding without NovoSeven given was 5440 ml, however it was only 987 ml when NovoSeven was used. Nine of the patients were completely recovered and discharged from hospital, but two of them died in the postoperative period for delayed use of the recombinant factor VII-a and for severe co-morbidities (bowel ischaemia, cirrhosis of the liver). NovoSeven given in the proper time and dose significantly reduces bleeding following cardiac surgery, even if it cannot be stopped surgically. Using recombinant factor VIIa can save life in case of severe non-surgical diffuse bleeding or in case of suture insufficiency caused by friable soft tissues following high risk combined surgery with extremely long aortic cross clamp time and extracorporeal circulation time. Significant delay in the use of NovoSeven should be avoided because the temporary reduction of bleeding usually does not change fatal outcome.
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Affiliation(s)
- Szabolcs Miskolczi
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Kardiológiai Intézet, Szívsebészeti Központ, Debrecen.
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Balsam LB, Timek TA, Pelletier MP. Factor Eight Inhibitor Bypassing Activity (FEIBA) for Refractory Bleeding in Cardiac Surgery: Review of Clinical Outcomes. J Card Surg 2008; 23:614-21. [DOI: 10.1111/j.1540-8191.2008.00686.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Leora B. Balsam
- Stanford Program in Cardiac Surgery at El Camino Hospital, Mountain View, California
| | - Tomasz A. Timek
- Stanford Program in Cardiac Surgery at El Camino Hospital, Mountain View, California
| | - Marc P. Pelletier
- Stanford Program in Cardiac Surgery at El Camino Hospital, Mountain View, California
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50
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Masud F, Bostan F, Chi E, Pass SE, Samir H, Stuebing K, Liebl MG. Recombinant factor VIIa treatment of severe bleeding in cardiac surgery patients: a retrospective analysis of dosing, efficacy, and safety outcomes. J Cardiothorac Vasc Anesth 2008; 23:28-33. [PMID: 18948033 DOI: 10.1053/j.jvca.2008.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe rFVIIa dosing and clinical outcomes in cardiovascular surgery patients with refractory bleeding. DESIGN Retrospective chart review of patients receiving rFVIIa from January 1, 2004 to September 30, 2005, in the cardiovascular surgery setting. SETTING Tertiary care, private teaching hospital. PARTICIPANTS Ninety-three patients who received rFVIIa after cardiovascular surgery for the management of refractory bleeding. INTERVENTIONS None. MEASURES AND MAIN RESULTS Patients received an average of 7.6 +/- 6.8 units of red blood cells (RBCs) before rFVIIa dosing (mean dose, 56.2 +/- 26.5 microg/kg). Median and 25th and 75th quartile blood product consumption was significantly reduced 6 hours after rFVIIa versus 6 hours before (RBCs, -3 units, [-1, -7]; cryoprecipitate, -7.5 units [0, -20]; platelet, -3 units [-1, -4]; fresh frozen plasma, -4 units [-2, -7]). Repeated rFVIIa dosing occurred in 10% of patients, with 8 (8.6%) and 2 (2.25%) patients receiving second and third doses, respectively. Subgroup analysis of each rFVIIa dosing quartile >30 microg/kg showed a significant reduction in RBCs; however, no significant differences were found in the magnitude of RBC reduction or percent of patients requiring massive transfusion among the quartiles. No adverse thrombotic episodes were noted, and the observed mortality (22.6%) was not attributed to rFVIIa therapy. CONCLUSIONS rFVIIa effectively reduces blood product use in cardiovascular surgery patients having massive blood loss. Although the optimal dose of rFVIIa for use in cardiovascular surgery remains undetermined, these data provide evidence that dosing regimens using <90 microg/kg are effective in this population and may provide guidance for centers establishing standardized protocols for rFVIIa use in cardiovascular surgery patients.
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Affiliation(s)
- Faisal Masud
- Department of Anesthesiology, Methodist Hospital, Houston, TX 77030, USA.
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