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Zhang P, Li S, Zhang S, Zhang X, Wan L, Yun Z, Ji S, Gong F, Huang M, Wang L, Zhu X, Tan Y, Wan Y. GRGDS-functionalized chitosan nanoparticles as a potential intravenous hemostat for traumatic hemorrhage control in an animal model. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2018; 14:2531-2540. [PMID: 30193814 DOI: 10.1016/j.nano.2018.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/15/2018] [Accepted: 08/08/2018] [Indexed: 01/25/2023]
Abstract
Hemostats, which are used for immediate intervention during internal hemorrhage in order to reduce resulting mortality and morbidity, are relatively rare. Here, we describe novel intravenous nanoparticles (CPG-NPs-2000) with chitosan succinate (CSS) as cores, polyethylene glycol (PEG-2000) as spacers and a glycine-arginine-glycine-aspartic acid-serine (GRGDS) peptide as targeted, active hemostatic motifs. CPG-NPs-2000 displayed significant hemostatic efficacy, compared to the saline control, CSS nanoparticles, and tranexamic acid in liver trauma rat models. Further studies have demonstrated that CPG-NPs-2000 are effectively cleared from organs and blood, within 2 and 48 h, respectively. In addition, administration of CPG-NPs-2000 does not affect clotting function under normal physiological conditions, indicating their potential safety in vivo. CPG-NPs-2000 exhibit excellent thermal stability, good solubility, and redistribution ability, in addition to being low cost. These characteristics indicate that CPG-NPs-2000 may have strong potential as effective intravenous hemostats for treating severe internal bleeding.
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Affiliation(s)
- Pingyi Zhang
- School of Chemical Engineering and Technology, Guangdong Engineering Technology Research Center for Platform Chemicals from Marine Biomass and Their Functionalization, Sun Yat-sen University, Guangzhou, China
| | - Subo Li
- Institute of Health Service and Transfusion Medicine, Beijing, China
| | - Shikun Zhang
- Institute of Health Service and Transfusion Medicine, Beijing, China
| | - Xue Zhang
- Institute of Health Service and Transfusion Medicine, Beijing, China
| | - Luming Wan
- Institute of Health Service and Transfusion Medicine, Beijing, China
| | - Zhimin Yun
- Institute of Health Service and Transfusion Medicine, Beijing, China
| | - Shouping Ji
- Institute of Health Service and Transfusion Medicine, Beijing, China
| | - Feng Gong
- Institute of Health Service and Transfusion Medicine, Beijing, China
| | - Manna Huang
- School of Chemical Engineering and Technology, Guangdong Engineering Technology Research Center for Platform Chemicals from Marine Biomass and Their Functionalization, Sun Yat-sen University, Guangzhou, China
| | - Leilei Wang
- School of Chemical Engineering and Technology, Guangdong Engineering Technology Research Center for Platform Chemicals from Marine Biomass and Their Functionalization, Sun Yat-sen University, Guangzhou, China
| | - Xinhai Zhu
- School of Chemical Engineering and Technology, Guangdong Engineering Technology Research Center for Platform Chemicals from Marine Biomass and Their Functionalization, Sun Yat-sen University, Guangzhou, China
| | - Yingxia Tan
- Institute of Health Service and Transfusion Medicine, Beijing, China.
| | - Yiqian Wan
- School of Chemical Engineering and Technology, Guangdong Engineering Technology Research Center for Platform Chemicals from Marine Biomass and Their Functionalization, Sun Yat-sen University, Guangzhou, China.
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Payen JF, Berthet M, Genty C, Declety P, Garrigue-Huet D, Morel N, Bouzat P, Riou B, Bosson JL. Reduced mortality by meeting guideline criteria before using recombinant activated factor VII in severe trauma patients with massive bleeding. Br J Anaesth 2018; 117:470-476. [PMID: 28077534 DOI: 10.1093/bja/aew276] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Management of trauma patients with severe bleeding has led to criteria before considering use of recombinant activated factor VII (rFVIIa), including haemoglobin >8 g dl-1, serum fibrinogen ≥1.0 g l-1, platelets >50,000 x 109 l-1, arterial pH ≥ 7.20, and body temperature ≥34 °C. We hypothesized that meeting these criteria is associated with improved outcomes. METHODS In this prospective cohort study of 26 French trauma centres, subjects were included if they received rFVIIa for persistent massive bleeding despite appropriate care after severe blunt and/or penetrating trauma. RESULTS After surgery and/or embolization as haemostatic interventions, 112 subjects received a first dose of 103 μg kg-1 rFVIIa (82-200) (median, 25th-75th percentile) at 420 min (285-647) post-trauma. Of these, 71 (63%) "responders" were still alive at 24h post-trauma and had their transfusion requirements reduced by > 2 packed red blood cell units after rFVIIa treatment. Mortality was 54% on day 30 post-trauma. There were 21%, 44% and 35% subjects who fulfilled 0-1, 2-3 or 4-5, respectively, of the guidelines before receiving rFVIIa. Survival at day 30 was 13%, 49% and 64% and the proportion of responders was 39%, 64% and 82%, when subjects fulfilled 0-1, 2-3 or 4-5 conditions, respectively (both P <0.01). CONCLUSIONS In actively bleeding trauma patients, meeting guideline criteria before considering rFVIIa was associated with lower mortality and a higher proportion of responders to the rFVIIa.
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Affiliation(s)
- J-F Payen
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France .,INSERM, U1216, F-38000 Grenoble, France.,Univ. Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, F-38000 Grenoble, France
| | - M Berthet
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France
| | - C Genty
- Clinical Research Centre, INSERM 003, CHU Grenoble Alpes, F-38000, Grenoble, France.,Univ. Grenoble Alpes, CNRS-TIMC-IMAG UMR, 5525-ThEMAS, F-38000 Grenoble, France
| | - P Declety
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France
| | - D Garrigue-Huet
- Pôle Anesthésie Réanimation, CHU de Lille, F-59037, Lille, France
| | - N Morel
- Pôle Urgences SAMU SMUR, Groupe Hospitalier Pellegrin, CHU de Bordeaux, F-33076, Bordeaux, France
| | - P Bouzat
- Pôle Anesthésie Réanimation, CHU Grenoble Alpes, F-38000, Grenoble, France.,INSERM, U1216, F-38000 Grenoble, France.,Univ. Grenoble Alpes, Grenoble Institut des Neurosciences, GIN, F-38000 Grenoble, France
| | - B Riou
- Service d'accueil des Urgences, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, F-75651, Paris, France.,Sorbonne Universités, UPMC Univ. Paris 6, UMRS INSERM 1166, IHU ICAN, Paris, France
| | - J-L Bosson
- Clinical Research Centre, INSERM 003, CHU Grenoble Alpes, F-38000, Grenoble, France.,Univ. Grenoble Alpes, CNRS-TIMC-IMAG UMR, 5525-ThEMAS, F-38000 Grenoble, France
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Abstract
To report the results of a pharmacist-directed blood factor stewardship program targeting off-label utilization designed to limit use to established organizational guidelines in high-risk populations. Prospective evaluation of recombinant factor VIIa and prothrombin complex concentrate orders beginning June 2013 through May 2014 and a matched retrospective cohort from June 2012 to May 2013. Matched cohorts were evaluated for 28-day mortality, change in international normalized ratio (INR), adverse events, concurrent blood product use, and cost savings. Forty-two orders for blood factor were ordered between June 2013 and May 2014, 70 orders in the year before (N = 112). Twenty eight-day mortality was not different between the cohorts: 53.9% versus 50% (P = 0.77). Blood factor use with underlying liver failure and active bleeding was strongly associated with 28-day mortality: odds ratio (95% confidence interval), 2.9 (1.5-7.14) and 2.91 (0.01-2.91), respectively. Blood products dispensed increased over the year with plasma products the most significant (1 vs. 4 P = 0.004). All other clinical outcomes were nonsignificant. An annual cost savings of $375,539 was achieved, primarily through a significant reduction in recombinant factor VIIa and avoidance in high-risk patients. Use of off-label blood factors can be controlled through a pharmacist-led stewardship program. Twenty eight-day mortality was not different between the 2 cohorts; however, identification of risk factors for death associated with blood factor use allows for restriction in high-risk populations, creates a discussion of futile care, and yields cost savings.
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4
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TiO2 and its composites as promising biomaterials: a review. Biometals 2018; 31:147-159. [DOI: 10.1007/s10534-018-0078-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/26/2018] [Indexed: 01/04/2023]
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Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 82:605-617. [PMID: 28225743 DOI: 10.1097/ta.0000000000001333] [Citation(s) in RCA: 253] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The resuscitation of severely injured bleeding patients has evolved into a multi-modal strategy termed damage control resuscitation (DCR). This guideline evaluates several aspects of DCR including the role of massive transfusion (MT) protocols, the optimal target ratio of plasma (PLAS) and platelets (PLT) to red blood cells (RBC) during DCR, and the role of recombinant activated factor VII (rVIIa) and tranexamic acid (TXA). METHODS Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines (PMG) Section of EAST conducted a systematic review using MEDLINE and EMBASE. Articles in English from1985 through 2015 were considered in evaluating four PICO questions relevant to DCR. RESULT A total of 37 studies were identified for analysis, of which 31 met criteria for quantitative meta-analysis. In these studies, mortality decreased with use of an MT/DCR protocol vs. no protocol (OR 0.61, 95% CI 0.43-0.87, p = 0.006) and with a high ratio of PLAS:RBC and PLT:RBC (relatively more PLAS and PLT) vs. a low ratio (OR 0.60, 95% CI 0.46-0.77, p < 0.0001; OR 0.44, 95% CI 0.28-0.71, p = 0.0003). Mortality and blood product use were no different with either rVIIa vs. no rVIIa or with TXA vs. no TXA. CONCLUSION DCR can significantly improve outcomes in severely injured bleeding patients. After a review of the best available evidence, we recommend the use of a MT/DCR protocol in hospitals that manage such patients and recommend that the protocol target a high ratio of PLAS and PLT to RBC. This is best achieved by transfusing equal amounts of RBC, PLAS, and PLT during the early, empiric phase of resuscitation. We cannot recommend for or against the use of rVIIa based on the available evidence. Finally, we conditionally recommend the in-hospital use of TXA early in the management of severely injured bleeding patients.
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Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: An update for the anesthesiologist. World J Anesthesiol 2017; 6:14-21. [DOI: 10.5313/wja.v6.i1.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
Exsanguination from trauma, gastrointestinal bleeding, and obstetric hemorrhage remains a major source of mortality across the planet. Continued research into resuscitation strategies and evolving technology and blood product storage has allowed for patient to undergo very large volume transfusions, even to the point of replacing a patient’s blood volume several times over. As massive transfusions have become more common, more studies have been performed delineating the exact patient population that would benefit, start- and stop-points of transfusions, complications and avoidance of the same. We discuss these points and provide information and strategies for massive transfusion.
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7
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Abstract
Recombinant activated factor seven (rFVIIa) is a novel and emerging therapy for the acquired coagulopathy associated with massive bleeding and hemorrhagic shock. The intent of this paper is to review the mechanism of action of rFVIIa, to discuss the current state of evidence regarding the safety and efficacy of rFVIIa, and to offer guidance regarding its use in severely traumatized patients. No study has demonstrated a survival benefit in humans. rFVIIa, is safe to use in the setting of severe trauma associated with ongoing bleeding and acquired coagulopathy. Doses of 80—200 μg/kg may be used after correction of thrombocytopenia and acidosis. Hypothermia should be corrected in any traumatized patient, but should not be a barrier to its administration. Definitive evidence supporting the use of rFVIIa is lacking, but ongoing studies will delineate survival benefits, dosing regimens, and adverse events associated with its use.
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Affiliation(s)
- Eric Bruder
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Daniel W Howes
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada,
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Gourgiotis S, Gemenetzis G, Kocher HM, Aloizos S, Salemis NS, Grammenos S. Permissive hypotension in bleeding trauma patients: helpful or not and when? Crit Care Nurse 2014; 33:18-24. [PMID: 24293553 DOI: 10.4037/ccn2013395] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Severity of hemorrhage and rate of bleeding are fundamental factors in the outcomes of trauma. Intravenous administration of fluid is the basic treatment to maintain blood pressure until bleeding is controlled. The main guideline, used almost worldwide, Advanced Trauma Life Support, established by the American College of Surgeons in 1976, calls for aggressive administration of intravenous fluids, primarily crystalloid solutions. Several other guidelines, such as Prehospital Trauma Life Support, Trauma Evaluation and Management, and Advanced Trauma Operative Management, are applied according to a patient's current condition. However, the ideal strategy remains unclear. With permissive hypotension, also known as hypotensive resuscitation, fluid administration is less aggressive. The available models of permissive hypotension are based on hypotheses in hypovolemic physiology and restricted clinical trials in animals. Before these models can be used in patients, randomized, controlled clinical trials are necessary.
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9
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Kim B, Haque A, Arnaud FG, Teranishi K, Steinbach T, Auker CR, McCarron RM, Freilich D, Scultetus AH. Use of recombinant factor VIIa (rFVIIa) as pre-hospital treatment in a swine model of fluid percussion traumatic brain injury. J Emerg Trauma Shock 2014; 7:102-11. [PMID: 24812455 PMCID: PMC4013725 DOI: 10.4103/0974-2700.130880] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/19/2013] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Recombinant factor VIIa (rFVIIa) has been used as an adjunctive therapy for acute post-traumatic hemorrhage and reversal of iatrogenic coagulopathy in trauma patients in the hospital setting. However, investigations regarding its potential use in pre-hospital management of traumatic brain injury (TBI) have not been conducted extensively. AIMS In the present study, we investigated the physiology, hematology and histology effects of a single pre-hospital bolus injection of rFVIIa compared to current clinical practice of no pre-hospital intervention in a swine model of moderate fluid percussion TBI. MATERIALS AND METHODS Animals were randomized to receive either a bolus of rFVIIa (90 μg/kg) or nothing 15 minutes (T15) post-injury. Hospital arrival was simulated at T60, and animals were euthanized at experimental endpoint (T360). RESULTS Survival was 100% in both groups; baseline physiology parameters were similar, vital signs were comparable. Animals that received rFVIIa demonstrated less hemorrhage in subarachnoid space (P = 0.0037) and less neuronal degeneration in left hippocampus, pons, and cerebellum (P = 0.00009, P = 0.00008, and P = 0.251, respectively). Immunohistochemical staining of brain sections showed less overall loss of microtubule-associated protein 2 (MAP2) and less Flouro-Jade B positive cells in rFVIIa-treated animals. CONCLUSIONS Early pre-hospital administration of rFVIIa in this swine TBI model reduced neuronal necrosis and intracranial hemorrhage (ICH). These results merit further investigation of this approach in pre-hospital trauma care.
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Affiliation(s)
- Bobby Kim
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Ashraful Haque
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Françoise G Arnaud
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kohsuke Teranishi
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Thomas Steinbach
- Department of Veterinary Pathology, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Charles R Auker
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Richard M McCarron
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Daniel Freilich
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Anke H Scultetus
- Department of Neuro Trauma, Naval Medical Research Center, Silver Spring, Maryland, USA ; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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10
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Mangar D, Sprenker CJ, Karlnoski R, Puri S, Hoffman MS, Camporesi EM. Late Postoperative Segmental Lung Infarction After Use of Recombinant Activated Factor VII to Achieve Hemostasis. J Gynecol Surg 2013. [DOI: 10.1089/gyn.2012.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Devanand Mangar
- Florida Gulf to Bay Anesthesiology, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL
| | - Collin J. Sprenker
- Florida Gulf to Bay Anesthesiology, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL
| | - Rachel Karlnoski
- Florida Gulf to Bay Anesthesiology, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL
- Department of Surgery, University of South Florida, Tampa, FL
| | - Suvikram Puri
- Department of Anesthesiology, Georgia Health Sciences University, Augusta, GA
| | - Mitchel S. Hoffman
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL
| | - Enrico M. Camporesi
- Florida Gulf to Bay Anesthesiology, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL
- Department of Surgery, University of South Florida, Tampa, FL
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Abstract
Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.
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Affiliation(s)
- Sanjay M Bhananker
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
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12
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Mamtani R, Nascimento B, Rizoli S, Pinto R, Lin Y, Tien H. The utility of recombinant factor VIIa as a last resort in trauma. World J Emerg Surg 2012; 7 Suppl 1:S7. [PMID: 23531130 PMCID: PMC3424973 DOI: 10.1186/1749-7922-7-s1-s7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction The use of recombinant factor VII (rFVIIa) as a last resort for the management of coagulopathy when there is severe metabolic acidosis during large bleedings in trauma might be deemed inappropriate. The objective of this study was to identify critical degrees of acidosis and associated factors at which rFVIIa might be considered of no utility. Methods All massively transfused (≥ 8 units of red blood cells within 12 hours) trauma patients from Jan 2000 to Nov 2006. Demographic, baseline physiologic and rFVIIa dosage data were collected. Rate of red blood cell transfusion in the first 6 hours of hospitalization (RBC/hr) was calculated and used as a surrogate for bleeding. Last resort use of rFVIIa was defined by a pH≤ 7.02 based on ROC analysis for survival. In-hospital mortality was analyzed in last resort and non-last resort groups. Univariate analysis was performed to assess for differences between groups and identify factors associates with no utility of rFVIIa. Results 71 patients who received rFVIIa were analyzed. The pH> 7.02 had 100% sensitivity for the identification of potential survivors. All 11 coagulopathic, severely acidotic (pH ≤ 7.02) patients with high rates of bleeding (4RBC/hr) died despite administration of rFVIIa. The financial cost of administering rFVIIa as a last resort to these 11 severely acidotic and coagulophatic cases was $75,162 (CA). Conclusions Our study found no utility of rFVIIa in treating severely acidotic, coagulopathic trauma patients with high rates of bleeding; and thus restrictions should be set on its usage in these circumstances.
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Affiliation(s)
- Rishi Mamtani
- Trauma Services, Division of General Surgery, Sunnybrook Health Sciences Centre and Canadian Forces Health Services, 2075 Bayview Avenue, Room H1 86, Toronto, ON M4N 3M5, USA.
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13
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Koh YR, Cho SJ, Yeom SR, Chang CL, Lee EY, Son HC, Kim HH. Evaluation of recombinant factor VIIa treatment for massive hemorrhage in patients with multiple traumas. Ann Lab Med 2012; 32:145-52. [PMID: 22389882 PMCID: PMC3289780 DOI: 10.3343/alm.2012.32.2.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/28/2011] [Accepted: 11/07/2011] [Indexed: 11/19/2022] Open
Abstract
Background Recent studies and case reports have shown that recombinant factor VIIa (rFVIIa) treatment is effective for reversing coagulopathy and reducing blood transfusion requirements in trauma patients with life-threatening hemorrhage. The purpose of this study is to evaluate the effect of rFVIIa treatment on clinical outcomes and cost effectiveness in trauma patients. Methods Between January 2007 and December 2010, we reviewed the medical records of patients who were treated with rFVIIa (N=18) or without rFVIIa (N=36) for life-threatening hemorrhage due to multiple traumas at the Emergency Department of Pusan National University Hospital in Busan, Korea. We reviewed patient demographics, baseline characteristics, initial vital signs, laboratory test results, and number of units transfused, and then analyzed clinical outcomes and 24-hr and 30-day mortality rates. Thromboembolic events were monitored in all patients. Transfusion costs and hospital stay costs were also calculated. Results In the rFVIIa-treated group, laboratory test results and clinical outcomes improved, and the 24-hr mortality rate decreased compared to that in the untreated group; however, 30-day mortality rate did not differ between the groups. Thromboembolic events did not occur in both groups. Transfusion and hospital stay costs in the rFVIIa-treated group were cost effective; however, total treatment costs, including the cost of rFVIIa, were not cost effective. Conclusions In our study, rFVIIa treatment was shown to be helpful as a supplementary drug to improve clinical outcomes and reduce the 24-hr mortality rate, transfusion and hospital stay costs, and transfusion requirements in trauma patients with life-threatening hemorrhage.
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Affiliation(s)
- Young Rae Koh
- Department of Laboratory Medicine, Pusan National University School of Medicine, Busan, Korea
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Design and preliminary results of a pilot randomized controlled trial on a 1:1:1 transfusion strategy: the trauma formula-driven versus laboratory-guided study. ACTA ACUST UNITED AC 2012; 71:S418-26. [PMID: 22071998 DOI: 10.1097/ta.0b013e318232e591] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Retrospective reviews have recently shown an survival benefit for adopting a resuscitation strategy that transfuses plasma and platelets at a near 1:1 ratio with red blood cells (RBCs). However, a randomized controlled trial on the topic is lacking. We report on the design and preliminary results of our ongoing randomized control pilot trial (ClinicalTrial.gov NCT00945542). METHODS This is a 2-year feasibility randomized control trial at a single tertiary trauma center. Bleeding trauma patients were randomized to either a laboratory-driven or a formula-driven (1 plasma:1 platelet:1 RBC) transfusion protocols. Feasibility was assessed by analyzing for ability to enroll patients, appropriate activation of transfusion protocols, time to transfusion of each type of blood product, laboratory turnaround time, ratio of blood products transfused, and wastage of blood products. RESULTS From July 6, 2009, to May 31, 2010, n = 18 patients were randomized and included in the study. Issues that we noted were the need to do postrandomization exclusions, the need to have rapid and accurate predictors of massive bleeding to enroll patients quickly, and the need to have waived consent for study participation. As well, we noted that the logistics of administering 1:1:1 were formidable and required rapid access to thawed plasma. Similarly, challenges in the control arm of such a study included the turnaround time for obtaining laboratory results. CONCLUSION Despite major challenges, our initial experience suggests that with an organized system, it is possible to prospectively randomize massively bleeding trauma patients. The accomplishment of high ratios of plasma to RBCs is challenging with current thawing methods and unavailability of thawed plasma in Canada. Longer shelf-life for plasma and faster plasma thawing microwaves should overcome some of these obstacles. For a laboratory-guided transfusion protocol, massive transfusion protocols should be in place with faster turnaround time for coagulation tests. Finally, further research on predictors of massive transfusion is needed.
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Impact of improved combat casualty care on combat wounded undergoing exploratory laparotomy and massive transfusion. ACTA ACUST UNITED AC 2011; 71:S82-6. [PMID: 21795883 DOI: 10.1097/ta.0b013e3182218ddb] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations. METHODS A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥ 10 units RBC in 24 hours) and exploratory laparotomy. Patients were divided into two cohorts based on year wounded: C1 between December 2003 and June 2004, and C2 between September 2007 and May 2008. Admission data, amount of blood products and fluid transfused, and 48 hour mortality were compared. Statistical significance was set at p < 0.05. RESULTS There was decreased mortality in C2 (47% vs. 20%). Patients arrived warmer with higher hemoglobin. They were transfused more RBC and FFP in the emergency department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ± 2 units vs. 0 units ± 1 units, respectively) and received less crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9 L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775 ± 0.32 vs. 0.511 ± 0.21). CONCLUSIONS The combination of improved prehospital care, trauma systems approach, performance improvement projects, and improved transfusion or resuscitation practices have led to a 50% decrease in mortality for this critically injured population. We are now transfusing blood products in a ratio more consistent with 1 FFP to 1 RBC. Simultaneously, crystalloid use has decreased by 61%, all of which is consistent with hemostatic resuscitation principles.
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011. [PMID: 21502651 DOI: 10.1059/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. PURPOSE To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. DATA SOURCES Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. STUDY SELECTION Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. DATA EXTRACTION Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. DATA SYNTHESIS 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. LIMITATIONS The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. CONCLUSION Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
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Yank V, Tuohy CV, Logan AC, Bravata DM, Staudenmayer K, Eisenhut R, Sundaram V, McMahon D, Olkin I, McDonald KM, Owens DK, Stafford RS. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011; 154:529-40. [PMID: 21502651 PMCID: PMC4102260 DOI: 10.7326/0003-4819-154-8-201104190-00004] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. PURPOSE To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. DATA SOURCES Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. STUDY SELECTION Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. DATA EXTRACTION Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. DATA SYNTHESIS 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. LIMITATIONS The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. CONCLUSION Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
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Knudson MM, Cohen MJ, Reidy R, Jaeger S, Bacchetti P, Jin C, Wade CE, Holcomb JB. Trauma, Transfusions, and Use of Recombinant Factor VIIa: A Multicenter Case Registry Report of 380 Patients from the Western Trauma Association. J Am Coll Surg 2011; 212:87-95. [DOI: 10.1016/j.jamcollsurg.2010.08.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 08/28/2010] [Accepted: 08/30/2010] [Indexed: 10/18/2022]
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Nascimento B, Lin Y, Callum J, Reis M, Pinto R, Rizoli S. Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients. Clinics (Sao Paulo) 2011; 66:101-6. [PMID: 21437444 PMCID: PMC3044583 DOI: 10.1590/s1807-59322011000100018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 10/18/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS Consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients.
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Affiliation(s)
- Bartolomeu Nascimento
- Tory Regional Trauma Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada
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Hong I, Stachnik J. Unlabeled uses of factor VIIa (recombinant) in pediatric patients. Am J Health Syst Pharm 2010; 67:1909-19. [DOI: 10.2146/ajhp090667] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Irene Hong
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, NY; when this article was written, she was Postgraduate Year 2 Drug Information Resident, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Joan Stachnik
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago
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Abstract
Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.
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Abstract
PURPOSE OF REVIEW Trauma patients requiring massive transfusion represent a population at high risk for potentially preventable death. This review describes recent advances in the early recognition and treatment of the coagulopathy of trauma, as well as ongoing work to define optimal resuscitation strategies. RECENT FINDINGS Damage control resuscitation involves the rapid correction of hypothermia and acidosis, direct treatment of coagulopathy, and early transfusion in trauma patients. Recent evidence demonstrates improved mortality and lower overall blood product usage with higher ratios of plasma and platelets to red blood cells transfused. Adjuncts to damage control resuscitation such as factor VIIa may also be beneficial. Thrombelastography and advances in point-of-care testing may provide timely measurements to help guide massive transfusion in patients based on their individual needs. SUMMARY As optimal resuscitation strategies continue to evolve, recent efforts have focused on early and aggressive treatment of coagulopathy, with higher ratios of plasma and platelets to red blood cells transfused. Early evidence suggests that such strategies have a beneficial outcome in regards to trauma-related mortality.
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Prothrombin complex concentrate versus recombinant factor VIIa for reversal of hemodilutional coagulopathy in a porcine trauma model. ACTA ACUST UNITED AC 2010; 68:1151-7. [PMID: 19996804 DOI: 10.1097/ta.0b013e3181b06364] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fluid resuscitation after traumatic injury may necessitate coagulation factor replacement to prevent bleeding complications of dilutional coagulopathy. Recombinant activated factor VII (rFVIIa) is being widely investigated as a hemostatic agent in trauma. Multicomponent therapy with prothrombin complex concentrate (PCC) containing coagulation factors II, VII, IX, and X might offer potential advantages. METHODS Anesthetized mildly hypothermic normotensive pigs were hemodiluted by substituting 65% to 70% of total blood volume in phases with hydroxyethyl starch and red cells. Thereafter, animals received 12.5 mL . kg isotonic saline placebo, 35 IU . kg PCC, or 180 microg x kg rFVIIa. Immediately afterward, a standardized spleen injury was inflicted, and prothrombin time (PT) and hemostasis were assessed. Thrombin generation was also determined. RESULTS Hemodilution depleted levels of factors II, VII, IX, and X markedly, prolonged PT and decreased thrombin formation. PCC and rFVIIa both fully normalized the hemodilution-induced lengthening of PT. In PCC recipients, peak thrombin generation was greater by a median of 60.7 nM (confidence interval 56.4-64.9 nM) compared with the rFVIIa group (p = 0.008). After spleen trauma, time to hemostasis was shortened to a median of 35 minutes in animals treated with PCC versus 94 minutes with rFVIIa (p = 0.016). CONCLUSIONS In a pilot study involving an in vivo large-animal model of spleen trauma, PCC accelerated hemostasis and augmented thrombin generation compared with rFVIIa. Further investigations are warranted on PCC as a hemostatic agent in trauma.
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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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Abstract
BACKGROUND Experimental studies of uncontrolled hemorrhage demonstrated that permissive hypotension (PH) reduces blood loss, but its effect on clot formation remains unexplored. Desmopressin (DDAVP) enhances platelet adhesion promoting stronger clots. We hypothesized PH and DDAVP have additive effects and reduce bleeding in uncontrolled hemorrhage. METHODS Rabbits (n = 42) randomized as follows: sham; normal blood pressure (NBP) resuscitation; PH resuscitation-60% baseline mean arterial pressure; NBP plus DDAVP 1 hour before (DDAVP NBP) or 15 minutes after beginning of shock (DDAVP T1 NBP); and PH plus DDAVP 1 hour before (DDAVP PH) or 15 minutes after beginning of shock (DDAVP T1 PH). Fluid resuscitation started 15 minutes after aortic injury and ended at 85 minutes. Intraabdominal blood loss was calculated, aortic clot sent for electron microscopy. Activated partial thromboplastin time, platelet count, thromboelastometry, arterial blood gases, and complete blood count were performed at baseline and 85 minutes. Analysis of variance was used for comparison. RESULTS NBP received more fluid volume and had greater intraabdominal blood loss. DDAVP, when administered preshock, significantly reduced blood loss in NBP and fluid requirement when given postshock. Platelets, arterial blood gas, complete blood count, and activated partial thromboplastin time were similar at 85 minutes. NBP delayed clot formation and worsened thrombodynamic potential on thromboelastometry, whereas PH and DDAVP improved. Electron microscopy showed lack of fibrin on NBP clots, whereas DDAVP and PH clots displayed exuberant fibrin/platelet aggregates. DDAVP NBP presented intermediate clots. CONCLUSION PH reduced bleeding and improved hemostasis compared with normotensive resuscitation. DDAVP given preshock exerted similar effects with normotensive resuscitation.
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Abstract
PURPOSE OF REVIEW Recombinant factor VIIa (rFVIIa) and thromboelastography have acquired increasing importance in patients with severe bleeding and coagulopathy. This article reviews the current opinions regarding their use, with the purpose of clarifying the ambiguities that exist in dealing with trauma patients. RECENT FINDINGS Recent evidence encourages the early use of rFVIIa and thromboelastography in the severe trauma patient with hemorrhagic shock, as a component of the damage control strategy. rFVIIa may decrease short-term mortality and the rate of required blood components during resuscitation, with no apparent increase in thromboembolic complications. Thromboelastometry enables better and earlier recognition of the coagulopathy accompanying such trauma patients. In patients with traumatic brain injury and coagulopathy, rFVIIa may delay or even halt the need for surgery, with no proven decrease in mortality. In those who needed urgent neurosurgical intervention, rFVIIa may rapidly correct the coagulopathy, enabling earlier and safer surgical intervention. SUMMARY Thromboelastometry may guide the medical staff when and to whom rFVIIa could be administered. Evidence also encourages the use of rFVIIa in traumatic brain injury. More research is required to prove decreases in mortality using both thromboelastography and rFVIIa in trauma, with a focus on clear end points and goal-directed therapy.
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Abstract
PURPOSE OF REVIEW Exsanguinating hemorrhage and postshock organ failure account for 35-40% of deaths from trauma, and there is an increasing recognition of the importance of coagulopathy in the evolution of this disease. RECENT FINDINGS Since 1999, case reports, small series, retrospective studies and a few controlled trials have reported the use of recombinant-activated factor VII (rFVIIa) as an adjunct for reversal of coagulopathy in trauma patients, and numerous other publications have examined the use of rFVIIa in related conditions such as traumatic brain injury, hemorrhagic stroke and uncontrolled surgical bleeding. SUMMARY We present a brief discussion of the mechanism of action of rFVIIa and its role in facilitating hemostasis and a review of the recent medical literature on the use of rFVIIa in trauma patients, including current guidelines and controversies.
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McQuay N, Cipolla J, Franges EZ, Thompson GE. The use of recombinant activated factor VIIa in coagulopathic traumatic brain injuries requiring emergent craniotomy: is it beneficial? J Neurosurg 2009; 111:666-71. [DOI: 10.3171/2009.4.jns081611] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The role of recombinant activated factor VII (rFVIIa) in traumatic brain injury (TBI) has not been well established. This study evaluates the outcomes of using rFVIIa as first-line therapy in patients with a severe TBI requiring emergent craniotomy that are coagulopathic.
Methods
The authors retrospectively reviewed patients admitted between 2003 and 2006 to a Level I trauma center with a severe TBI requiring an emergency craniotomy. Eighteen patients with coagulopathy that was corrected using rFVIIa were identified. Variables evaluated included age, injury severity score, head abbreviated injury score, Glasgow Coma Scale score, international normalized ratio, time to operation, operative procedure, thromboembolic events, and death.
Results
The cohort consisted of 18 patients, predominantly male (55.6%) with a mean age of 80.5 years. The most common mechanism of injury was a fall. Coagulopathy was due to premorbid anticoagulants in 50% of the cohort. Time from admission to operation was 130 minutes. Coagulopathy reversal was complete in all 18 cases (100%). A high mortality rate (55.6%) was attributed to a high incidence of withdrawal of care (50%). The incidence of thromboembolic events was low (5.6%). Survivors, when compared with nonsurvivors, had a > 3-fold increase in postoperative Glasgow Coma Scale score for similar preoperative scores. A good functional outcome was achieved in 75% of survivors with a mean follow-up period of 4.2 months.
Conclusions
The use of rFVIIa in the correction of coagulopathy in patients having sustained severe TBI requiring emergency craniotomy appears to be safe and effective even among the elderly. This allows a shorter transit time to craniotomy. Its effects on mortality and long-term neurological outcome requires further investigation prospectively.
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Affiliation(s)
- Nathaniel McQuay
- 1Department of Surgery, University of Pennsylvania Health System, Trauma/Critica Division, St. Luke's Hosptial; and
| | - James Cipolla
- 1Department of Surgery, University of Pennsylvania Health System, Trauma/Critica Division, St. Luke's Hosptial; and
| | - Eleanor Z. Franges
- Department of Neurosurgery, St. Luke's Hospital, Bethlehem, Pennsylvania
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Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study. Can J Anaesth 2009; 56:740-50. [PMID: 19641979 DOI: 10.1007/s12630-009-9151-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 07/09/2009] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To determine associations between red blood cell (RBC) transfusion and early and late clinical outcomes in massively transfused adult trauma patients. METHODS A retrospective cohort study (1992-2001) including 260 patients receiving >or=10 RBC units <or=24 hr after admission to a university-affiliated trauma centre. We extracted demographic and clinical data and used multivariable regression to determine independent effects of RBC transfusion on clinical outcomes. RESULTS Patients had a high (mean [standard deviation]) injury severity score (ISS) (42.5 [15.1]), a high admission sequential organ failure assessment (SOFA) score (8.4 [3.8]), and a high hospital mortality (58.5%). They received 38 (25-64) (median [interquartile range]) blood components within 48 hr, including 19 (14-28) RBC units. For 143 patients surviving >or=48 hr, the maximum SOFA score was associated with RBC units transfused before 48 hr (linear regression beta coefficient 0.075, P < 0.0001), lower nadir hemoglobin before 48 hr (0.034, P = 0.03), age (0.032, P = 0.015), and admission SOFA (0.59, P < 0.0001). The RBC units transfused by 48 hr were not associated with either hospital mortality (n = 35) among patients surviving >or=48 hr (independent predictors, age [logistic regression odds ratio (OR) 1.06, 95% confidence interval 1.03-1.10], ISS [OR 1.07, 1.02-1.13], and maximum SOFA score [OR 1.56, 1.27-1.93]) or 48-hr mortality (n = 117) (independent predictors, admission SOFA [1.65, 1.45-1.88] and later year of hospital admission [OR 1.15, 1.02-1.29]). CONCLUSIONS Hospital mortality is high among massively transfused trauma patients. Among early survivors, 48-hr RBC transfusion volume is associated with increased organ dysfunction, but not hospital mortality. Also, it is not associated with 48-hr mortality. Future research should continue to explore methods to improve hemostasis and minimize the need for RBC transfusion.
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Abstract
Postpartum hemorrhage (PPH) is an obstetric emergency that can occur following vaginal or cesarean delivery. Rapid diagnosis of PPH using laboratory and clinical parameters is an important first step in its management. Traditional blood components, including packed red blood cells, platelets, plasma, and cryoprecipitate, should be used in patients with significant bleeding. Recent studies underline the utility of transfusing these components in defined ratios to prevent dilutional coagulopathy. Disseminated intravascular coagulation (DIC) should be considered in severely bleeding obstetric patients and should be treated aggressively using blood components. Newer hemostatic agents, such as activated factor VII, will play significant roles in patients with bleeding that is refractory to standard therapy. Implementation of an obstetric bleeding protocol that integrates new knowledge in coagulation should aid physicians in improving outcomes for the mother and her fetus.
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Affiliation(s)
- Anand Padmanabhan
- The Section of Transfusion Medicine and Cell Therapy, Department of Pathology and Cell Biology, Columbia University Medical Center, College of Physicians and Surgeons of Columbia University, New York, NY, USA
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Alten JA, Benner K, Green K, Toole B, Tofil NM, Winkler MK. Pediatric off-label use of recombinant factor VIIa. Pediatrics 2009; 123:1066-72. [PMID: 19255041 DOI: 10.1542/peds.2008-1685] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our goal was to report our institutional experience with recombinant factor VIIa for the treatment and/or prevention of bleeding in nonhemophiliac children. METHODS This was a retrospective case series in a tertiary pediatric referral hospital. RESULTS During 1999-2006, 135 patients received recombinant factor VIIa for off-label use. The median number of doses was 2; the median dose was 88 mug/kg. The most common diagnoses among patients receiving recombinant factor VIIa were disseminated intravascular coagulation/sepsis (28), surgical bleeding (19), procedural prophylaxis (16), and trauma (15). The median volume of blood products administered 24 hours before recombinant factor VIIa treatment was 29.7 vs 11.7 mL/kg 24 hours after treatment. Only 1 high-risk patient had significant bleeding after receiving prophylactic recombinant factor VIIa before an invasive procedure. Nonsurvivors had significantly increased incidence of multiple organ dysfunction syndrome (75%) compared with survivors (23%). The largest group of patients (n = 28) received recombinant factor VIIa for bleeding and/or coagulopathy because of disseminated intravascular coagulation; the mortality in this group was 26 (93%) of 28. Eleven patients received multiple doses of recombinant factor VIIa to treat bleeding complications after hematopoietic stem cell transplant, without improvement in blood use. Mortality in medical patients was 58% vs 16% in surgical patients. Three patients had significant thrombotic adverse events after receiving recombinant factor VIIa, resulting in 2 deaths and 1 leg amputation. CONCLUSIONS Off-label use of recombinant factor VIIa significantly decreases blood-product administration; surgical patients had control of life-threatening bleeding with low associated mortality. Prophylactic recombinant factor VIIa may be effective in preventing bleeding if given before invasive procedures in children at high risk. Prolonged use of recombinant factor VIIa for bleeding complications after hematopoietic stem cell transplant is not effective in preventing packed red blood cell transfusion. Presence of disseminated intravascular coagulation and mulitorgan dysfunction syndrome may help predict futility of recombinant factor VIIa treatment. Off-label use of recombinant factor VIIa is associated with thromboembolic events in children.
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Affiliation(s)
- Jeffrey A Alten
- University of Alabama at Birmingham, 1600 7th Ave South, ACC 504, Birmingham, AL 35233, USA.
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Reversal of coagulopathy in critically ill patients with traumatic brain injury: recombinant factor VIIa is more cost-effective than plasma. ACTA ACUST UNITED AC 2009; 66:63-72; discussion 73-5. [PMID: 19131807 DOI: 10.1097/ta.0b013e318191bc8a] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of death and disability after trauma. Coagulopathy is common in this patient population and requires rapid reversal to allow for safe neurosurgical intervention and prevent worsening of the primary injury. Typically reversal of coagulopathy is accomplished with the use of plasma. Recombinant factor VIIa (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) has become increasingly used "off-label" in patients with neurosurgical emergencies to rapidly reverse coagulopathy. We hypothesized that the use of rFVIIa in this patient population would prove to be cost-effective as well as demonstrate clinical benefit. METHODS The trauma registry at the R Adams Cowley Shock Trauma Center was used to identify all coagulopatic trauma patients admitted between January 2002 and December 2007 with relatively isolated TBI (head Abbreviated Injury Scale score of >or=4). The medical records of patients were reviewed and demographics, injury-specific data, medications administered, laboratory values, blood product utilization, neurosurgical procedures, length of stay (LOS), discharge disposition, and outcome data were abstracted. Patients who received rFVIIa for reversal of coagulopathy were compared against those who did not receive rFVIIa. t Tests were used to compare differences between continuous variables, and chi2 analysis was used to compare categorical variables. A p value of <0.05 was considered significant for all statistical tests. RESULTS During a 6-year period, there were 179 patients who met inclusion criteria. One hundred eleven patients (62.0%) were treated with conventional therapy alone whereas 68 (38.0%) received rFVIIa. Baseline characteristics between the two groups were similar except that Injury Severity Score and admission International normalized ratio were higher in the rFVIIa group and the rFVIIa group had a higher percentage of patients with head Abbreviated Injury Scale score of 5 injuries, patients who underwent neurosurgical procedures and patients with preinjury warfarin use. There was no difference in total charges between these groups (mean US $63,403 in the conventionally treated group vs. $66,086). When patients who required admission to the intensive care unit were analyzed (n = 110, 50% received rFVIIa), total mean charges and costs were significantly lower in the group that received rFVIIa (mean US $108,900 vs. $77,907). Hospital LOS, days of mechanical ventilation, and plasma utilization were lower in the rFVIIa group. Mortality and thromboembolic complication rates were not different between the two groups. CONCLUSION In this study, we were able to demonstrate a significant economic benefit of the use of rFVIIa for reversal of coagulopathy in severely injured patients with TBI. Not all patients with coagulopathy and an anatomic brain injury benefit, but in patients who are neurologically or physiologically compromised, using rFVIIa decreases total charges and costs of hospitalization. This decrease in overall cost is directly attributable to the significant decrease in LOS and decrease in the need for mechanical ventilation. This study demonstrates that in coagulopathic patients with TBI who require intensive care unit admission, rFVIIa is cost-effective and safe. Prospective studies are needed to confirm these findings and establish clinical effectiveness.
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Papathanasopoulos A, Nikolaou V, Petsatodis G, Giannoudis PV. Multiple trauma: an ongoing evolution of treatment modalities? Injury 2009; 40:115-9. [PMID: 19128800 DOI: 10.1016/j.injury.2008.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 09/04/2008] [Indexed: 02/02/2023]
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Use of Recombinant Factor VIIa to Facilitate Organ Donation in Trauma Patients with Devastating Neurologic Injury. J Am Coll Surg 2009; 208:120-5. [DOI: 10.1016/j.jamcollsurg.2008.09.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 09/19/2008] [Accepted: 09/24/2008] [Indexed: 11/18/2022]
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Perioperative Use of Recombinant Factor VII to Prevent Intraoperative Aneurysm Rupture in High Risk Patients: A Preliminary Safety Evaluation. Neurocrit Care 2008; 10:55-60. [DOI: 10.1007/s12028-008-9149-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 09/05/2008] [Indexed: 10/21/2022]
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Zalstein S, Pearce A, Scott DM, Rosenfeld JV. Damage control resuscitation: a paradigm shift in the management of haemorrhagic shock. Emerg Med Australas 2008; 20:291-3. [PMID: 18782203 DOI: 10.1111/j.1742-6723.2008.01102.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hardy JF, Bélisle S, Van der Linden P. Efficacy and Safety of Recombinant Activated Factor VII to Control Bleeding in Nonhemophiliac Patients: A Review of 17 Randomized Controlled Trials. Ann Thorac Surg 2008; 86:1038-48. [DOI: 10.1016/j.athoracsur.2008.05.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 05/05/2008] [Accepted: 05/06/2008] [Indexed: 11/27/2022]
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Abstract
Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.
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Affiliation(s)
- R. Lemaire
- University Hospital (CHU du Sart-Tilman), 4000 Liège, Belgium
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40
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41
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Kluger Y, Riou B, Rossaint R, Rizoli SB, Boffard KD, Choong PIT, Warren B, Tillinger M. Safety of rFVIIa in hemodynamically unstable polytrauma patients with traumatic brain injury: post hoc analysis of 30 patients from a prospective, randomized, placebo-controlled, double-blind clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R85. [PMID: 17686152 PMCID: PMC2206502 DOI: 10.1186/cc6092] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 08/08/2007] [Indexed: 01/03/2023]
Abstract
BACKGROUND Trauma is a leading cause of mortality and morbidity, with traumatic brain injury (TBI) and uncontrolled hemorrhage responsible for the majority of these deaths. Recombinant activated factor VIIa (rFVIIa) is being investigated as an adjunctive hemostatic treatment for bleeding refractory to conventional replacement therapy in trauma patients. TBI is a common component of polytrauma injuries. However, the combination of TBI with polytrauma injuries is associated with specific risk factors and treatment modalities somewhat different from those of polytrauma without TBI. Although rFVIIa treatment may offer added potential benefit for patients with combined TBI and polytrauma, its safety in this population has not yet been assessed. We conducted a post hoc sub analysis of patients with TBI and severe blunt polytrauma enrolled into a prospective, international, double-blind, randomized, placebo-controlled study. METHODS A post hoc analysis of study data was performed for 143 patients with severe blunt trauma enrolled in a prospective, randomized, placebo-controlled study, evaluating the safety and efficacy of intravenous rFVIIa (200 + 100 + 100 microg/kg) or placebo, to identify patients with a computed tomography (CT) diagnosis of TBI. The incidences of ventilator-free days, intensive care unit-free days, and thromboembolic, serious, and adverse events within the 30-day study period were assessed in this cohort. RESULTS Thirty polytrauma patients (placebo, n = 13; rFVIIa, n = 17) were identified as having TBI on CT. No significant differences in rates of mortality (placebo, n = 6, 46%, 90% confidence interval (CI): 22% to 71%; rFVIIa, n = 5, 29%, 90% CI: 12% to 56%; P = 0.19), in median numbers of intensive care unit-free days (placebo = 0, rFVIIa = 3; P = 0.26) or ventilator-free days (placebo = 0, rFVIIa = 10; P = 0.19), or in rates of thromboembolic adverse events (placebo, 15%, 90% CI: 3% to 51%; rFVIIa, 0%, 90% CI: 0% to 53%; P = 0.18) or serious adverse events (placebo, 92%, 90% CI: 68% to 98%; rFVIIa, 82%, 90% CI: 60% to 92%; P = 0.61) were observed between treatment groups. CONCLUSION The use of a total dose of 400 (200 + 100 + 100) microg/kg rFVIIa in this group of hemodynamically unstable polytrauma patients with TBI was not associated with an increased risk of mortality or with thromboembolic or adverse events.
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Affiliation(s)
- Yoram Kluger
- Department of Surgery, Rambam Medical Center, POB 9602, Haifa 31096, Israel
| | - Bruno Riou
- Departments of Emergency Medicine and Surgery and Anesthesiology and Critical Care, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris, Paris, France
| | - Rolf Rossaint
- Institute for Anesthesiology, University Clinics, Aachen, Germany
| | - Sandro B Rizoli
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | | | - Brian Warren
- Department of Surgery, University of Stellenbosch, Tygerberg, South Africa
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Sapsford W. Should the ‘C’ in ‘ABCDE’ Be Altered to Reflect the Trend towards Hypotensive Resuscitation? Scand J Surg 2008; 97:4-11; discussion 12-3. [DOI: 10.1177/145749690809700102] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Fluid resuscitation of trauma victims currently differs, depending on whether the Advanced Trauma Life Support (ATLS), Prehospital Trauma Life Support (PHTLS) or Battlefield Advanced Trauma Life Support (BATLS) algorithm is utilised. Resuscitation protocol depends on the situation of the patient before definitive surgical control of the haemorrhage can be achieved, that is, in the prehospital phase (the urban, rural or battlefield setting) or in the emergency room. The principle difference is between hypotensive (PHTLS and BATLS, in the prehospital phase) and normotensive (ATLS, in the emergency room) resuscitation. The aim of this review was to determine if there is sufficient evidence to consider altering the ATLS resuscitation algorithm to a hypotensive model prior to definitive surgical control of haemorrhage. Method: A literature review was conducted of the experimental and clinical evidence for hypotensive resuscitation. Results: Uncontrolled haemorrhage models are too severe. They do not realistically mimic — And their results cannot easily be extrapolated into — Clinical scenarios. One important clinical trial, inspired by these experimental models, has rightly influenced resuscitation of shocked prehospital patients towards a ‘scoop and run’ approach and permissive hypotension but it is specific to patients with penetrating trauma alone. Conclusion: There is insufficient evidence to alter the current ATLS algorithm in the emergency room in favour of hypotensive resuscitation. The future of resuscitation is considered.
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Affiliation(s)
- W. Sapsford
- The Royal London Hospital, Whitechapel, London, U.K
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Recombinant Factor VIIa: Decreasing Time to Intervention in Coagulopathic Patients With Severe Traumatic Brain Injury. ACTA ACUST UNITED AC 2008; 64:620-7; discussion 627-8. [DOI: 10.1097/ta.0b013e3181650fc7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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In vitro effect of activated recombinant factor VII (rFVIIa) on coagulation properties of human blood at hypothermic temperatures. ACTA ACUST UNITED AC 2008; 63:1079-86. [PMID: 17993954 DOI: 10.1097/ta.0b013e31815885f1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) is currently administered off-label to control diffuse coagulopathic bleeding of patients with traumatic injuries. These patients are often cold, acidotic, and coagulopathic upon arrival and each responds differently to rFVIIa therapy. This study investigated the effects of hypothermia on clotting and the potential benefit of rFVIIa administration on blood coagulation at different hypothermic temperatures. METHOD Citrated blood samples were collected from eight healthy volunteers (20-45 years old) and incubated at 37 degrees C, 34 degrees C, 31 degrees C, and 28 degrees C for 30 minutes. rFVIIa (1.26 microg/mL equivalent to 90 microg/kg in vivo dose) or vehicle solution (saline) was added to each blood sample, incubated (10 minutes), and analyzed at the respective temperatures by standard coagulation tests and thrombelastography. RESULTS The clot reaction time of blood samples, measured as prothrombin time, activated partial thromboplastin time, and R time (thrombelastography analysis), was significantly prolonged at 31 degrees C or below compared with at 37 degrees C. The clot formation rate ([alpha] angle, maximum clotting velocity [Vmax]) was decreased at all cold temperatures. Maximum clot strength (maximum amplitude) was only affected (reduced) at 28 degrees C. Addition of rFVIIa shortened the prothrombin time, activated partial thromboplastin time, and R times at every temperature, surpassing the normal (37 degrees C) temperature values in 31 degrees C and 34 degrees C cold samples. Similarly, clot formation rate parameters (clotting time, [alpha] angle, Vmax) were also improved by rFVIIa addition and normothermic values were restored in 31 degrees C and 34 degrees C cold blood samples. rFVIIa did not affect maximum amplitude at any temperature. CONCLUSIONS Mild to moderate hypothermia delayed the initial clot reaction and reduced clot formation rate without affecting ultimate clot strength. FVIIa effectively compensated for the adverse effects of hypothermia except in severe cases. These results suggest that administration of FVIIa should be beneficial in enhancing hemostasis in hypothermic trauma patients without the need for prior correction of the patient's body temperature.
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Vick LR, Islam S. Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children. J Pediatr Surg 2008; 43:195-8; discussion 198-9. [PMID: 18206482 DOI: 10.1016/j.jpedsurg.2007.09.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 09/02/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ongoing bleeding after blunt solid organ injury in children may require invasive therapy in the form of either angiographic or operative control. We report our experience in the use of a procoagulant, recombinant activated factor VII (rFVIIa), for controlling persistent bleeding in blunt abdominal trauma in children. METHODS After institutional review board approval, the records of 8 children with blunt abdominal trauma, persistent bleeding, and managed nonoperatively with rFVIIa were reviewed. RESULTS All 8 patients presented to our institution after sustaining blunt abdominal trauma and solid organ injury. All children had evidence of persistent bleeding with a drop in hematocrit and elevation in heart rate. Patients received a single dose of rFVIIa at 75 to 90 microg/kg (1 patient had 24 microg/kg) and had successful control of their bleeding without any further therapeutic intervention. Only 3 patients required a blood transfusion after rFVIIa administration--2 who had subarachnoid hemorrhages and the third during pelvic fixation. There were no cases of thromboembolic events after treatment with rFVIIa. CONCLUSIONS Recombinant factor VIIa is a useful adjunctive therapy in pediatric patients with evidence of ongoing hemorrhage from blunt abdominal injury and may reduce the need for invasive therapeutic procedures and transfusions.
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Affiliation(s)
- Laura R Vick
- Division of Pediatric Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Hodgetts T, Kirkman E, Mahoney P, Russell R, Thomas R, Midwinter M. UK Defence Medical Services Guidance for the Use of Recombinant Factor VIIA (RFVIIA) in the Deployed Military Setting. J ROY ARMY MED CORPS 2007; 153:307-9. [DOI: 10.1136/jramc-153-04-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cooper B, Mellor A, Bruce A, Hall A, Mahoney P. Paediatric Thoracic Damage Control Resuscitation for Ballistic Injury: A Case Report. J ROY ARMY MED CORPS 2007; 153:317-8. [DOI: 10.1136/jramc-153-04-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
PURPOSE OF REVIEW Reduction in combat zone morbidity and mortality requires rapid delivery of safe blood products as an integral element of advanced trauma surgical care. This review of the current literature presents scientific aspects of supplying blood for rapid delivery to enhance survival and patient outcome in the combat zone. RECENT FINDINGS Most deaths due to hemorrhage can be averted by transfusion during the first hour from injury; therefore, maintaining a dependable inventory of blood products in combat support hospitals is essential. Current casualty care in distant geographic locations involves rapid air evacuation to combat support hospitals or fleet hospitals, where massive transfusions may be required. Resuscitation by forward surgical teams utilizing red blood cells before air evacuation or in-flight has also been reported. To improve survival, these massive transfusions should be composed of not only red blood cells but also other blood components and plasma factors. SUMMARY Rapid on-site combat casualty transfusion support requires specialized blood transport containers and transfusion practices not observed in noncombat settings, such as the mobile walking blood bank and a frozen blood program. Additionally, technology for improved transport containers, cell-free hemoglobin-based oxygen carriers, freeze-dried blood, and recombinant activated coagulation factor has attracted focused interest.
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Affiliation(s)
- Viviana V Johnson
- Department of Pathology and Laboratory Medicine, National Naval Medical Center, Bethesda, Maryland 20889-5600, USA.
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Tien HCN, Gough MRC, Farrell R, Macdonald J. Successful Use of Recombinant Activated Coagulation Factor VII in a Patient with Massive Hemoptysis From a Penetrating Thoracic Injury. Ann Thorac Surg 2007; 84:1373-4. [PMID: 17889002 DOI: 10.1016/j.athoracsur.2007.05.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Revised: 05/02/2007] [Accepted: 05/11/2007] [Indexed: 11/28/2022]
Abstract
Acute massive hemoptysis is a rare complication of pulmonary injury and contusion, and it is particularly difficult to manage in the nontertiary care setting. Recombinant activated coagulation factor VII (rFVIIa) is a prothrombotic drug that is increasingly being used to treat coagulopathy in massively exsanguinating trauma patients. We report a case in which recombinant activated coagulation factor VII successfully controlled massive hemoptysis and improved ventilation from a severe pulmonary contusion in a noncoagulopathic patient who suffered a penetrating thoracic injury in a military setting in Afghanistan.
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Affiliation(s)
- Homer C N Tien
- The Trauma Program and the Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Hospital pharmacists are often consulted for their knowledge about coagulation and therapeutic interventions for the management of critical bleeding. Many pharmacotherapies are available for this purpose, both systemic and topical, and others are in development. These agents and their mechanisms of action are reviewed, and perspectives are provided regarding their use in various clinical settings. Also provided are associated precautions to promote safe use. Current controversies surrounding pharmacotherapeutic agents used to control serious bleeding (e.g., in various types of surgery, trauma, obstetrics, and intracranial hemorrhage) are also discussed.
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Affiliation(s)
- Stacy Voils
- School of Pharmacy, Virginia Commonwealth University, Medical College of Virginia Hospitals, Richmond, Virginia 23298, USA.
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