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Han JH, Kroeger A, Beardsley A, Garries E, Whitmore M, Kumar M, Sichting K. Intrapulmonary recombinant FVIIa in neonatal ECMO-associated alveolar hemorrhage. Pediatr Blood Cancer 2024; 71:e31130. [PMID: 38838051 DOI: 10.1002/pbc.31130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Jennifer H Han
- Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
| | - Ashley Kroeger
- Peyton Manning Children's Hospital Pediatric Intensive Care Unit, Indianapolis, Indiana, USA
| | - Andrew Beardsley
- Peyton Manning Children's Hospital Pediatric Intensive Care Unit, Indianapolis, Indiana, USA
| | - Emily Garries
- Peyton Manning Children's Hospital Pediatric Intensive Care Unit, Indianapolis, Indiana, USA
| | - Maria Whitmore
- Peyton Manning Children's Hospital Pediatric Intensive Care Unit, Indianapolis, Indiana, USA
| | - Manjusha Kumar
- Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
| | - Kay Sichting
- Peyton Manning Children's Hospital Pediatric Intensive Care Unit, Indianapolis, Indiana, USA
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2
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Hurley C, McArthur J, Gossett JM, Hall EA, Barker PJ, Hijano DR, Hines MR, Kang G, Rains J, Srinivasan S, Suliman A, Qudeimat A, Ghafoor S. Intrapulmonary administration of recombinant activated factor VII in pediatric, adolescent, and young adult oncology and hematopoietic cell transplant patients with pulmonary hemorrhage. Front Oncol 2024; 14:1375697. [PMID: 38680864 PMCID: PMC11055461 DOI: 10.3389/fonc.2024.1375697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction Diffuse alveolar hemorrhage (DAH) is a devastating disease process with 50-100% mortality in oncology and hematopoietic cell transplant (HCT) recipients. High concentrations of tissue factors have been demonstrated in the alveolar wall in acute respiratory distress syndrome and DAH, along with elevated levels of tissue factor pathway inhibitors. Activated recombinant factor VII (rFVIIa) activates the tissue factor pathway, successfully overcoming the tissue factor pathway inhibitor (TFPI) inhibition of activation of Factor X. Intrapulmonary administration (IP) of rFVIIa in DAH is described in small case series with successful hemostasis and minimal complications. Methods We completed a single center retrospective descriptive study of treatment with rFVIIa and outcomes in pediatric oncology and HCT patients with pulmonary hemorrhage at a quaternary hematology/oncology hospital between 2011 and 2019. We aimed to assess the safety and survival of patients with pulmonary hemorrhage who received of IP rFVIIa. Results We identified 31 patients with pulmonary hemorrhage requiring ICU care. Thirteen patients received intrapulmonary rFVIIa, while eighteen patients did not. Overall, 13 of 31 patients (41.9%) survived ICU discharge. ICU survival (n=6) amongst those in the IP rFVIIa group was 46.2% compared to 38.9% (n=7) in those who did not receive IP therapy (p=0.69). Hospital survival was 46.2% in the IP group and 27.8% in the non-IP group (p=0.45). There were no adverse events noted from use of IP FVIIa. Conclusions Intrapulmonary rFVIIa can be safely administered in pediatric oncology patients with pulmonary hemorrhage and should be considered a viable treatment option for these patients.
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Affiliation(s)
- Caitlin Hurley
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jeffrey M. Gossett
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Elizabeth A. Hall
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Patricia J. Barker
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Diego R. Hijano
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Pediatrics, University of Tennessee Health and Science Center, Memphis, TN, United States
| | - Melissa R. Hines
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jason Rains
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Saumini Srinivasan
- Department of Pediatrics, Division of Pulmonary Medicine, University of Tennessee Health and Science Center, Memphis, TN, United States
| | - Ali Suliman
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Amr Qudeimat
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Saad Ghafoor
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
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3
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Lynch Y, Vande Vusse LK. Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation. J Intensive Care Med 2023:8850666231207331. [PMID: 37872657 DOI: 10.1177/08850666231207331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.
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Affiliation(s)
- Ylinne Lynch
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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4
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Schoettler ML, Dandoy CE, Harris A, Chan M, Tarquinio KM, Jodele S, Qayed M, Watkins B, Kamat P, Petrillo T, Obordo J, Higham CS, Dvorak CC, Westbrook A, Zinter MS, Williams KM. Diffuse alveolar hemorrhage after hematopoietic cell transplantation- response to treatments and risk factors for mortality. Front Oncol 2023; 13:1232621. [PMID: 37546403 PMCID: PMC10399223 DOI: 10.3389/fonc.2023.1232621] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of hematopoietic cellular therapy (HCT). This study aimed to evaluate the effect of DAH treatments on outcomes using data from consecutive HCT patients clinically diagnosed with DAH from 3 institutions between January 2018-August 2022. Endpoints included sustained complete response (sCR) defined as bleeding cessation without recurrent bleeding, and non-relapse mortality (NRM). Forty children developed DAH at a median of 56.5 days post-HCT (range 1-760). Thirty-five (88%) had at least one concurrent endothelial disorder, including transplant-associated thrombotic microangiopathy (n=30), sinusoidal obstructive syndrome (n=19), or acute graft versus host disease (n=10). Fifty percent had a concurrent pulmonary infection at the time of DAH. Common treatments included steroids (n=17, 25% sCR), inhaled tranexamic acid (INH TXA,n=26, 48% sCR), and inhaled recombinant activated factor VII (INH fVIIa, n=10, 73% sCR). NRM was 56% 100 days after first pulmonary bleed and 70% at 1 year. Steroid treatment was associated with increased risk of NRM (HR 2.25 95% CI 1.07-4.71, p=0.03), while treatment with INH TXA (HR 0.43, 95% CI 0.19- 0.96, p=0.04) and INH fVIIa (HR 0.22, 95% CI 0.07-0.62, p=0.005) were associated with decreased risk of NRM. Prospective studies are warranted to validate these findings.
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Affiliation(s)
- Michelle L. Schoettler
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Christopher E. Dandoy
- Cincinnati Children’s Medical Center, Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Anora Harris
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Marilynn Chan
- Pediatric Pulmonary Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Sonata Jodele
- Cincinnati Children’s Medical Center, Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Muna Qayed
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Benjamin Watkins
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Pradip Kamat
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Toni Petrillo
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Jeremy Obordo
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Christine S. Higham
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher C. Dvorak
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
| | - Adrianna Westbrook
- Department of Pediatrics, Pediatric Biostatistics Core, Emory University, Atlanta, GA, United States
| | - Matt S. Zinter
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
- Pediatric Critical Care, University of California, San Francisco, San Francisco, CA, United States
| | - Kirsten M. Williams
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
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Li J, Zhang J, Shi M, Yu S, Ji M, Liang Y, Meng X. Crosstalk between Inflammation and Hemorrhage/Coagulation Disorders in Primary Blast Lung Injury. Biomolecules 2023; 13:biom13020351. [PMID: 36830720 PMCID: PMC9953683 DOI: 10.3390/biom13020351] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/26/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
Primary blast lung injury (PBLI), caused by exposure to high-intensity pressure waves from explosions in war, terrorist attacks, industrial production, and life explosions, is associated with pulmonary parenchymal tissue injury and severe ventilation insufficiency. PBLI patients, characterized by diffused intra-alveolar destruction, including hemorrhage and inflammation, might deteriorate into acute respiratory distress syndrome (ARDS) with high mortality. However, due to the absence of guidelines about PBLI, emergency doctors and rescue teams treating PBLI patients rely on experience. The goal of this review is to summarize the mechanisms of PBLI and their cross-linkages, exploring potential diagnostic and therapeutic targets of PBLI. We summarize the pathophysiological performance and pharmacotherapy principles of PBLI. In particular, we emphasize the crosstalk between hemorrhage and inflammation, as well as coagulation, and we propose early control of hemorrhage as the main treatment of PBLI. We also summarize several available therapy methods, including some novel internal hemostatic nanoparticles to prevent the vicious circle of inflammation and coagulation disorders. We hope that this review can provide information about the mechanisms, diagnosis, and treatment of PBLI for all interested investigators.
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Affiliation(s)
- Junfeng Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Jianfeng Zhang
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou 325000, China
- Key Laboratory of Medical Rescue Key Technology and Equipment, Ministry of Emergency Management, Wenzhou 325000, China
| | - Mingyu Shi
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Sifan Yu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Mengjun Ji
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Yangfan Liang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou 325000, China
- Key Laboratory of Medical Rescue Key Technology and Equipment, Ministry of Emergency Management, Wenzhou 325000, China
- Correspondence:
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6
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Gumulec J, Demel I, Lančová K, Drbohlavová E, Piegzová A, Kořístek Z, Navrátil M, Černý V. Selected severe „haematological“ syndromes in adult intensive care patients. VNITRNI LEKARSTVI 2022; 68:498-507. [PMID: 36575067 DOI: 10.36290/vnl.2022.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Haemophagocytic syndrome, diffuse alveolar haemorrhage, catastrophic antiphospholipid syndrome and various types of thrombotic microangiopathies are rare conditions with significant morbidity and mortality. A common feature is late diagnosis, which can affect the success of treatment. The aim of this review article is to summarize the basic diagnostic and therapeutic steps of the present subpopulation of critically ill patients.
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7
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Williams KM. Noninfectious complications of hematopoietic cell transplantation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:578-586. [PMID: 34889438 PMCID: PMC8791176 DOI: 10.1182/hematology.2021000293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Noninfectious lung diseases contribute to nonrelapse mortality. They constitute a spectrum of diseases that can affect the parenchyma, airways, or vascular pulmonary components and specifically exclude cardiac and renal causes. The differential diagnoses of these entities differ as a function of time after hematopoietic cell transplantation. Specific diagnosis, prognosis, and optimal treatment remain challenging, although progress has been made in recent decades.
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Affiliation(s)
- Kirsten M. Williams
- Correspondence Kirsten M. Williams, Blood and Marrow
Transplant Program, Aflac Cancer and Blood Disorders Center, Emory University
School of Medicine, Children's Healthcare of Atlanta, 1760 Haygood Dr,
3rd floor W362, Atlanta, GA 30322; e-mail:
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8
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Pulmonary Complications of Pediatric Hematopoietic Cell Transplantation. A National Institutes of Health Workshop Summary. Ann Am Thorac Soc 2021; 18:381-394. [PMID: 33058742 DOI: 10.1513/annalsats.202001-006ot] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Approximately 2,500 pediatric hematopoietic cell transplants (HCTs), most of which are allogeneic, are performed annually in the United States for life-threatening malignant and nonmalignant conditions. Although HCT is undertaken with curative intent, post-HCT complications limit successful outcomes, with pulmonary dysfunction representing the leading cause of nonrelapse mortality. To better understand, predict, prevent, and/or treat pulmonary complications after HCT, a multidisciplinary group of 33 experts met in a 2-day National Institutes of Health Workshop to identify knowledge gaps and research strategies most likely to improve outcomes. This summary of Workshop deliberations outlines the consensus focus areas for future research.
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9
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Lubnin AY, Usachev DY, Kurbasov AA, Shmigelsky AV, Gvazava GI, Tarasova NY. [Local application of recombinant activated factor VII for massive surgical bleeding]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:78-83. [PMID: 34156209 DOI: 10.17116/neiro20218503178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors report resection of anaplastic convexital meningioma in a middle-aged woman complicated by expected massive blood loss. The most intense bleeding occurred at the final stage of resection and it was impossible to stop it with traditional approaches. The surgeon pressed a standard tachocomb plate moistened with a diluted solution of recombinant activated factor VII (coagil, Russia) to the most bleeding area for 5 minutes. Subsequently, surgeon replaced finger pressure with a permanent napkin. Hemostatic effect of recombinant activated factor VII following its systemic administration is well known and convincingly proven in many surgical areas including neurosurgery. However, we do not know any descriptions of its local application in neurosurgical patients.
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Affiliation(s)
- A Yu Lubnin
- Burdenko Center of Neurosurgery, Moscow, Russia
| | | | | | | | - G I Gvazava
- Burdenko Center of Neurosurgery, Moscow, Russia
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10
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Use of recombinant activated factor VII for uncontrolled bleeding in a haematology/oncology paediatric ICU cohort. Blood Coagul Fibrinolysis 2021; 31:440-444. [PMID: 32833802 DOI: 10.1097/mbc.0000000000000942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
: Bleeding among critically ill paediatric haematology/oncology (CIPHO) patients leads to significant morbidity and mortality. Recombinant activated factor VII (rFVIIa) has shown some benefits in previous reported off-label use when conventional therapies have failed. However, data in CIPHO are lacking. We retrospectively studied (2006-2014) the efficacy and outcomes in CIPHO patients younger than 21 years who received at least one rFVIIa dose for bleeding in the ICU. Of 39 patients, the majority had leukaemia (59%), bone marrow transplantation (77%) and a life-threatening bleed (80%) with most common site being pulmonary haemorrhage (44%). Most needed invasive mechanical ventilation (87%) or vasopressor support (59%). After rFVIIa administration, 56% had cessation or decreased bleeding. Packed red blood cell transfusion requirements decreased significantly 48-72 h after rFVIIa administration. Lower baseline prothrombin time and more rFVIIa doses were related to bleeding control. A favourable response was associated with higher survival (55% in responders versus 18% in nonresponders, P = 0.019). Overall, bleeding-related mortality was 37.5%, highest in pulmonary haemorrhage. Two patients had thromboembolic events. Use of rFVIIa for CIPHO patients appears to be well tolerated with low adverse events. Despite half of the patients having a favourable response of cessation or decrease in bleeding after rFVIIa administration, mortality was high. These findings highlight the need for prospective studies to evaluate interventions to improve outcomes in this population.
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11
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Tret’yakov AY, Radenska-Lopovok SG, Novikov PI, Tret’yakova VA, Zakharchenko SP. Pulmonary embolism and diffuse alveolar bleeding: combination options and therapy features. TERAPEVT ARKH 2021; 93:311-319. [DOI: 10.26442/00403660.2021.03.200657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/22/2022]
Abstract
The analysis of the mechanisms of the formation of a rare clinical combination of pulmonary embolism (PE) and diffuse alveolar hemorrhage (DAH), which are complications of systemic vasculitis associated with antibodies to the cytoplasm of neutrophils (primarily granulomatosis with polyangiitis), systemic lupus erythematosus and secondary antiphlogistic syndrome primary antiphospholipid syndrome and Goodpastures syndrome. Taking into account the chronological sequence of the occurrence of PE and DAH, 3 variants of the onset of these potentially fatal additions to the underlying disease were considered: the anticipatory DAH development of PE, delayed from DAH PE and joint (within 24 hours) formation of PE and DAH. A review of single descriptions of such a combination of complications of granulomatosis with polyangiitis is carried out, criteria are indicated, a working classification of severity is given and, taking this into account, a modern program of therapy for DAH as an independent event and in combination with PE.
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12
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Elbahlawan L, Galdo AM, Ribeiro RC. Pulmonary Manifestations of Hematologic and Oncologic Diseases in Children. Pediatr Clin North Am 2021; 68:61-80. [PMID: 33228943 DOI: 10.1016/j.pcl.2020.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pulmonary complications are common in children with hematologic or oncologic diseases, and many experience long-term effects even after the primary disease has been cured. This article reviews pulmonary complications in children with cancer, after hematopoietic stem cell transplant, and caused by sickle cell disease and discusses their management.
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Affiliation(s)
- Lama Elbahlawan
- Division of Critical Care, Department of Pediatrics, St. Jude Children's Research Hospital, MS 620, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA.
| | - Antonio Moreno Galdo
- Pediatric Pulmonology Section, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Raul C Ribeiro
- Leukemia/Lymphoma Division, International Outreach Program, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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13
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Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis. Int J Mol Sci 2021; 22:ijms22020793. [PMID: 33466873 PMCID: PMC7830514 DOI: 10.3390/ijms22020793] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic findings show pulmonary capillaritis, bland hemorrhage, diffuse alveolar damage, and hemosiderin-laden macrophages, but in the majority of cases, pathogenesis remains unclear. Despite the severity and high mortality, the current treatment options for DAH remain empirical. Systemic treatment to control inflammatory activity including high-dose corticosteroids, cyclophosphamide, and rituximab and supportive care have been applied, but largely unsuccessful in critical cases. Activated recombinant factor VII (FVIIa) can achieve rapid local hemostasis and has been administered either systemically or intrapulmonary for the treatment of DAH. However, there is no randomized controlled study to evaluate the efficacy and safety, and the use of FVIIa for DAH remains open to debate. This review discusses the pathogenesis, diverse etiologies causing DAH, diagnosis, and treatments focusing on hemostasis using FVIIa. In addition, the risks and benefits of the off-label use of FVIIa in pediatric patients will be discussed in detail.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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14
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Fan K, McArthur J, Morrison RR, Ghafoor S. Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Stem Cell Transplantation. Front Oncol 2020; 10:1757. [PMID: 33014865 PMCID: PMC7509147 DOI: 10.3389/fonc.2020.01757] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022] Open
Abstract
Pulmonary complications are common following hematopoietic cell transplantation (HCT) and contribute significantly to its morbidity and mortality. Diffuse alveolar hemorrhage is a devastating non-infectious complication that occurs in up to 5% of patients post-HCT. Historically, it carries a high mortality burden of 60–100%. The etiology remains ill-defined but is thought to be due to lung injury from conditioning regimens, total body irradiation, occult infections, and other comorbidities such as graft vs. host disease, thrombotic microangiopathy, and subsequent cytokine release and inflammation. Clinically, patients present with hypoxemia, dyspnea, and diffuse opacities consistent with an alveolar disease process on chest radiography. Diagnosis is most commonly confirmed with bronchoscopy findings of progressively bloodier bronchoalveolar lavage or the presence of hemosiderin-laden macrophages on microscopy. Treatment with glucocorticoids is common though dosing and duration of therapy remains variable. Other agents, such as aminocaproic acid, tranexamic acid, and activated recombinant factor VIIa have also been tried with mixed results. We present a review of diffuse alveolar hemorrhage with a focus on its pathogenesis and treatment options.
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Affiliation(s)
- Kimberly Fan
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - R Ray Morrison
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - Saad Ghafoor
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
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Xie J, Zhao YY, Liu J, Nong GM. Diffuse alveolar hemorrhage with histopathologic manifestations of pulmonary capillaritis: Three case reports. World J Clin Cases 2020; 8:2662-2666. [PMID: 32607347 PMCID: PMC7322415 DOI: 10.12998/wjcc.v8.i12.2662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/28/2020] [Accepted: 05/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is a multicause pulmonary capillary hemorrhage or pulmonary vascular small vessel injury (mainly capillaries, including arteries and veins), causing pulmonary microcirculation blood to accumulate in the alveolar space. DAH is classified by the histological absence or presence of pulmonary capillaritis (PC) and is rarely reported in the literature.
CASE SUMMARY This is a report of three girls aged 6-11 years with DAH and PC. Two patients had decreased hemoglobin and one had increased erythrocyte sedimentation rate. High-resolution computed tomography showed bilateral diffuse pulmonary infiltrate, and diagnosis of PC was confirmed by lung biopsy. Immunofluorescence test in one case showed granular IgG and a small amount of granular IgA deposit on the alveolar walls, and was negative in the other two cases, describing isolated pauci-immune PC. Treatment was with glucocorticoid alone or combination with immunosuppressants, and the symptoms resolved in all patients.
CONCLUSION PC is classified as isolated and immune-mediated PC associated with systemic disease. It can be controlled in most children with glucocorticoid alone or combined with immunosuppressants.
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Affiliation(s)
- Jun Xie
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Ying-Yue Zhao
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Jing Liu
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Guang-Min Nong
- Department of Pediatrics, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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16
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Gkogkou E, Broux I, Kempeneers C, Boboli H, Viellevoye R, Janssen A, Seghaye MC, Mastouri M. Diffuse alveolar hemorrhage in infants: Report of five cases. Respir Med Case Rep 2020; 31:101121. [PMID: 32802736 PMCID: PMC7289102 DOI: 10.1016/j.rmcr.2020.101121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/06/2020] [Accepted: 06/07/2020] [Indexed: 11/29/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare life-threatening condition in children. In this entity, the bleeding originates from the pulmonary microvasculature as a result of microvascular damage leading to blood leakage into the alveolar spaces. DAH can occur as an isolated medical entity or may be associated with other organ system injury or dysfunction. The classic triad of symptoms includes hemoptysis, anemia and diffuse pulmonary infiltrates. Hemoptysis is the usual presenting symptom but is not constant. A variety of diseases is associated with the development of DAH. Current classification organize the etiologies of diffuse alveolar hemorrhage based on the presence of severe immune disorders (such as systemic vasculitis and collagenosis) or non-immunodeficiency disorders (with an identified cardiac or non-cardiac origin, or idiopathic). The five cases of DAH presented in this study were all diagnosed in full-term infants, four males and one female, with normal neonatal adaptation and without family history of notable diseases. In all cases the diagnosis was made between the age of three and eighteen weeks-old. Moreover, all five patients, at the time of diagnosis, presented with hemoptysis, mild or severe dyspnea, anemia and abnormal chest X-rays. Consequently, the diagnosis of DAH was strongly suspected and, eventually, confirmed by bronchoscopy. Additional laboratory tests, as well as selected serologic and radiographic studies were performed in order to identify a specific etiology. The final diagnoses reflect a variety of causes: infections, idiopathic pulmonary hemosiderosis, accidental suffocation and Heiner syndrome. Treatment included oral corticosteroids except from one patient that received antimicrobial therapy.
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Affiliation(s)
- E. Gkogkou
- Department of Pediatrics, University Hospital of Liege, Belgium
| | - I. Broux
- Department of Neonatology, University Hospital of Liege, Belgium
| | - C. Kempeneers
- Department of Pediatrics, University Hospital of Liege, Belgium
| | - H. Boboli
- Department of Pediatrics, University Hospital of Liege, Belgium
| | - R. Viellevoye
- Department of Neonatology, University Hospital of Liege, Belgium
| | - A. Janssen
- Department of Pediatrics, University Hospital of Liege, Belgium
| | - M.-C. Seghaye
- Department of Pediatrics, University Hospital of Liege, Belgium
| | - M. Mastouri
- Department of Pediatrics, University Hospital of Liege, Belgium
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17
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Fan K, Hurley C, McNeil MJ, Agulnik A, Federico S, Qudeimat A, Saini A, McArthur J, Morrison RR, Sandhu H, Shah S, Ghafoor S. Case Report: Management Approach and Use of Extracorporeal Membrane Oxygenation for Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Cell Transplant. Front Pediatr 2020; 8:587601. [PMID: 33520888 PMCID: PMC7838496 DOI: 10.3389/fped.2020.587601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Diffuse alveolar hemorrhage (DAH) is an early pulmonary complication of hematopoietic cell transplantation (HCT) associated with severe hypoxemic respiratory failure and mortality. Extracorporeal membrane oxygenation (ECMO) support is often used for respiratory failure refractory to conventional interventions; however, its use has been limited in HCT patients with DAH due to potential for worsening alveolar hemorrhage and reported high mortality. Case Presentation: We report two cases of DAH following HCT who developed refractory hypoxemic respiratory failure despite cessation of bleeding and were successfully supported with ECMO. Conclusion: DAH after HCT should not automatically preclude ECMO support; rather, these patients must be evaluated individually for ECMO within the context of their overall clinical picture.
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Affiliation(s)
- Kimberly Fan
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Caitlin Hurley
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Michael J McNeil
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Asya Agulnik
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Sara Federico
- Division of Solid Tumor, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Amr Qudeimat
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Arun Saini
- Division of Pediatric Critical Care, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, United States
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Ronald Ray Morrison
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Hitesh Sandhu
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Samir Shah
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Saad Ghafoor
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
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Ansari A, Cobert J, Navuluri N, Cheng G, Haney JC, Welsby I. Intrapulmonary Activated Factor VII for Hemoptysis Complicating Pulmonary Thromboendarterectomy. Ann Thorac Surg 2019; 109:e243-e245. [PMID: 31470015 DOI: 10.1016/j.athoracsur.2019.06.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 11/29/2022]
Abstract
Massive hemoptysis represents a life-threatening disorder that has numerous different causes. The development of recombinant factor concentrates has allowed for novel treatments in this emergency setting. This report describes a patient with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy. The postoperative course was complicated by massive hemoptysis resulting in severe hypoxemia that required extracorporeal membrane oxygenation and multiple daily blood transfusions. After failure of conservative and interventional approaches, recombinant factor VII was administered by bronchial isolation. After treatment, the patient's hemoptysis dramatically resolved, with eventual hospital discharge and excellent function at follow-up. This case presents the use of intrapulmonary activated factor VII to control massive hemoptysis.
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Affiliation(s)
- Andrea Ansari
- Duke University School of Medicine, Durham, North Carolina
| | - Julien Cobert
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
| | - Neelima Navuluri
- Department of Pulmonology and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - George Cheng
- Division of Interventional Pulmonology, Department of Pulmonology and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ian Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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19
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Yang F, Kong LJ, Hu JW, Liu N, Su YF, Li YH, Chen JL, Yu ZY, Qiao ZQ, Wang QH, Jiang M. [Clinical efficacy of recombinant activated factor Ⅶ a for 16 hematonosis with moderate or severe bleeding]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 38:216-221. [PMID: 28395445 PMCID: PMC7348376 DOI: 10.3760/cma.j.issn.0253-2727.2017.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
目的 观察重组人凝血因子Ⅶa(rFⅦa)对血液病及其异基因造血干细胞移植(allo-HSCT)术后出血患者的止血疗效。 方法 以2013年5月至2016年5月住院治疗的16例合并中至重度出血的血液病患者为观察对象,非移植组及移植组患者各8例,两组患者应用rFⅦa的用法、用量无明显差异。同时,以同期15例allo-HSCT后发生肠道急性移植物抗宿主病(aGVHD)肠出血患者为对照组(未应用rFⅦa),将其与allo-HSCT后肠道aGVHD肠出血应用rFⅦa患者进行生存比较,总结患者应用rFⅦa治疗的临床疗效。 结果 ①非移植组与移植组患者中,rFⅦa止血显效率分别为75.0%(6/8)和37.5%(3/8),显效中位时间分别为38.5和63.0 h,中位总生存(OS)时间分别为201.0和29.0 d,OS率分别为50.0%(4/8)和25.0%(2/8),出血相关死亡率分别为50.0%(2/4)和83.3%(5/6)。②16例患者中显效者9例,无效者7例,显效组与无效组患者中,中位OS时间分别为268.0和24.0 d,OS率分别为66.7%(6/9)和0(0/7)。③同期肠道aGVHD合并肠出血患者,观察组(6例)与对照组(15例)患者的中位OS时间分别为25.5和20.0 d。 结论 血液病患者尤其是allo-HSCT患者出血相关死亡率高,rFⅦa治疗有一定止血疗效;显效组患者OS率较无效组高;allo-HSCT后肠道出血患者采用rFⅦa治疗止血效果不佳的原因可能与移植后导致出血的并发症控制不佳有关。
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Affiliation(s)
- F Yang
- Department of Hematopoietic Stem Cell Transplantation, Affiliated Hospital to Academy of Military Medical Sciences, Beijing 100071, China
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21
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Intrapulmonary Recombinant Factor VII as an Effective Treatment for Diffuse Alveolar Hemorrhage: A Case Series. J Bronchology Interv Pulmonol 2017; 23:255-8. [PMID: 27261934 DOI: 10.1097/lbr.0000000000000286] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The diffuse alveolar hemorrhage (DAH) syndrome is a life-threatening pulmonary complication related to systemic vasculitides, posthematopoietic stem cell transplantation, drugs, or toxins. Once DAH develops, the mortality rate is as high as 50% to 80%. Initial treatment consists of high-dose steroids and supportive measures, including mechanical ventilation. We present a case series of 6 patients treated with intrapulmonary recombinant factor VIIa (rFVIIa) to treat refractory DAH. METHODS Six patients with DAH were treated with intrapulmonary instillation of rFVIIa. Doses were divided equally between the right and the left lungs. Doses were 30, 50, or 60 mcg/kg and frequencies varied from a single administration to repeated doses on subsequent days on the basis of the clinical response. All patients received high-dose steroids, and 4 also received an aminocaproic acid infusion. RESULTS Intrapulmonary rVFIIa treated DAH effectively in 5 of 6 patients. Doses used were smaller and less frequent than those described previously. CONCLUSIONS Intrapulmonary factor VII is an effective adjunctive treatment for DAH. We achieved treatment success with both smaller and less frequent doses than those described previously. This may be a good therapeutic option for DAH, particularly when standard therapies have failed or bleeding is immediately life threatening. It is possible that intrapulmonary rFVIIa could save costs, while improving the intensive care unit length of stay. Further prospective studies are needed to assess the optimal dose and frequency for adequate therapeutic efficacy.
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Birnkrant DJ, Yilmaz O, Nicolai T, Black JB, Mhanna MJ, Noah TL. Pediatric pulmonology year in review 2015: Part 3. Pediatr Pulmonol 2016; 51:747-53. [PMID: 27105321 DOI: 10.1002/ppul.23413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 03/03/2016] [Accepted: 03/12/2016] [Indexed: 12/21/2022]
Abstract
Our journal covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review (Part 3) covers articles on asthma, diagnostic testing/endoscopy, respiratory complications of neuromuscular disorders, and rare lung diseases. Pediatr Pulmonol. 2016;51:747-753. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- David J Birnkrant
- MetroHealth Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ozge Yilmaz
- Division of Pediatric Allergy and Pulmonology, Department of Pediatrics, Celal Bayar University, Manisa, Turkey
| | | | - Jane B Black
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Maroun J Mhanna
- MetroHealth Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, 450 Macnider Building, Campus Box 7217, Chapel Hill, North Carolina, 27599-7217
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23
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Park JA. Diffuse alveolar hemorrhage and recombinant factor VIIa treatment in pediatric patients. KOREAN JOURNAL OF PEDIATRICS 2016; 59:105-13. [PMID: 27186216 PMCID: PMC4865620 DOI: 10.3345/kjp.2016.59.3.105] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/12/2015] [Accepted: 07/07/2015] [Indexed: 01/13/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or autoimmune disorders. The current treatment options, which include corticosteroids, transfusions, extracorporeal membrane oxygenation (ECMO), and immunosuppressants, have been limited and largely unsuccessful. Recombinant activated factor VII (rFVIIa) has been successfully administered, either systemically or bronchoscopically, to adults for the treatment of DAH, but there are few data on its use in pediatric patients. The current literature in the PubMed database was reviewed to evaluate the efficacy and risk of rFVIIa treatment for DAH in pediatric patients. This review discusses the diagnosis and treatment of DAH, as well as a new treatment paradigm that includes rFVIIa. Additionally, the risks and benefits of off-label use of rFVIIa in pediatric patients are discussed.
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Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Inje University Haeundae-Paik Hospital, Inje University College of Medicine, Busan, Korea
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Matsuura T, Yoshimaru K, Yanagi Y, Esumi G, Hayashida M, Taguchi T. Massive pulmonary hemorrhage before living donor liver transplantation in infants. Pediatr Transplant 2016; 20:89-95. [PMID: 26691206 DOI: 10.1111/petr.12650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2015] [Indexed: 01/30/2023]
Abstract
A massive pulmonary hemorrhage in patients with liver cirrhosis is a life-threatening complication that may result in a contraindication of a liver transplantation because of its high mortality rate. Herein, we present two infant biliary atresia cases that successfully underwent an LDLT that was followed by intensive respiratory care for the pretransplant massive pulmonary hemorrhage. Both cases exhibited severe respiratory failure (minimum PaO2/FiO2; 46 mmHg and 39 mmHg, respectively). To arrest the bleeding, we applied a very high positive pressure ventilation treatment (maximum PIP/PEEP; 38/14 cmH2O and 55/15 cmH2O, respectively), plasma exchange, several FFP transfusions, and recombinant factor VIIa via intrapulmonary administration. In addition, we used CHDF treatment, applied HFOV transiently, and treated the patient with inhalation of nitric oxide. Although we prepared ECMO for intra-operative use, both cases were successfully managed with conventional mechanical ventilation without using ECMO, which may have worsened the pulmonary hemorrhage due to the use of an anticoagulant. Use of an excessive positive pressure management, although it poses a risk for barotrauma, could be acceptable to arrest the pulmonary bleeding in selected cases of liver failure patients who have no time remaining before LDLT.
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Affiliation(s)
- Toshiharu Matsuura
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichiro Yoshimaru
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Yanagi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Genshiro Esumi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Hayashida
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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