Use of recombinant activated factor VII for uncontrolled bleeding in a haematology/oncology paediatric ICU cohort

Off-label use of recombinant activated factor VII in hemophagocytic lymphohistiocytosis patients with major bleeding

Hemophagocytic lymphohistiocytosis (HLH) is a fatal multi-systemic disorder. Patients with HLH are more prone to bleeding, which implies a poor outcome. The objective was to investigate the efficacy of recombinant activated factor VII (rFVIIa) in major intractable bleeding of HLH. A total of 20 patients with secondary HLH received at least one dose of rFVIIa. When bleeding occurs, 88.9% cases had a nadir platelet counts below 25*109/L. Median number of doses of rFVIIa was 3.5 (range, 1 to 78) with a mean dose of 76.45 µg/kg/dose. Total of 60% (12 of 20) patients obtained a response to rFVIIa therapy, however, in patients with a history of chronic active EBV infection (CAEBV), only 27.3% achieved a response. The mortality rate was 90% (18 of 20) in the cohort, none of the deaths were attributed to rFVIIa administration. Thromboembolism rate was low.

Life-Threatening Hemoptysis in a Pediatric Referral Center

OBJECTIVES

Hemoptysis is uncommon in children, even among the critically ill, with a paucity of epidemiological data to inform clinical decision-making. We describe hemoptysis-associated ICU admissions, including those who were critically ill at hemoptysis onset or who became critically ill as a result of hemoptysis, and identify predictors of mortality.

DESIGN

Retrospective cohort study. Demographics, hemoptysis location, and management were collected. Pediatric Logistic Organ Dysfunction-2 score within 24 hours of hemoptysis described illness severity. Primary outcome was inhospital mortality.

SETTING

Quaternary pediatric referral center between July 1, 2010, and June 30, 2017.

PATIENTS

Medical/surgical (PICU), cardiac ICU, and term neonatal ICU admissions with hemoptysis during or within 24 hours of ICU admission.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

There were 326 hemoptysis-associated ICU admissions in 300 patients. Most common diagnoses were cardiac (46%), infection (15%), bronchiectasis (10%), and neoplasm (7%). Demographics, interventions, and outcomes differed by diagnostic category. Overall, 79 patients (26%) died inhospital and 109 (36%) had died during follow-up (survivor mean 2.8 ± 1.9 yr). Neoplasm, bronchiectasis, renal dysfunction, inhospital hemoptysis onset, and higher Pediatric Logistic Organ Dysfunction-2 score were independent risk factors for inhospital mortality (p < 0.02). Pharmacotherapy (32%), blood products (29%), computerized tomography angiography (26%), bronchoscopy (44%), and cardiac catheterization (36%) were common. Targeted surgical interventions were rare. Of survivors, 15% were discharged with new respiratory support. Of the deaths, 93 (85%) occurred within 12 months of admission. For patients surviving 12 months, 5-year survival was 87% (95% CI, 78-92) and mortality risk remained only for those with neoplasm (log-rank p = 0.001).

CONCLUSIONS

We observed high inhospital mortality from hemoptysis-associated ICU admissions. Mortality was independently associated with hemoptysis onset location, underlying diagnosis, and severity of critical illness at event. Additional mortality was observed in the 12-month posthospital discharge. Future directions include further characterization of this vulnerable population and management recommendations for life-threatening pediatric hemoptysis incorporating underlying disease pathophysiology.