Acquired Hemophilia in an Elderly Patient with Non-Small Cell Lung Cancer: a Case Report

Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies against coagulation factor VIII and characterized by spontaneous hemorrhage in patients with no previous family or personal history of bleeding. We report here a case of AHA that occurred in the Department of Medicina D'Urgenza in Sant'Andrea Hospital in a patient with previous diagnosis of NSLC. The aim of this article is to allow a more comprehensive knowledge of AHA that both for the rarity and the poor literature is underdiagnosed; for all these reasons, it is important that different specialists, like emergency specialists, experts in internal medicine, hematologists, and oncologists, acquire a more complete knowledge of the clinical and laboratory features of this disease, allowing an early diagnosis crucial for the evolution of the coagulopathy.

Acquired hemophilia A that required surgical hemostasis of hematomas occupying oral cavity: a case report

Background

Acquired hemophilia A is a rare coagulopathy caused by inhibitors of blood coagulation factor VIII. Patients with acquired hemophilia A have a higher mortality risk (5–10%) than those with congenital hemophilia. Moreover, there is no established evidence of management recommended for patients with acquired hemophilia A. Previous studies have reported the presence of hematomas in the oral cavities of patients with acquired hemophilia A, which were treated conservatively. Here, we describe the case of a patient with acquired hemophilia A, where emergency surgical hemostasis was required for large intraoral hematomas.

Case presentation

A 65-year-old Japanese man was referred to our hospital with a chief complaint of bleeding from large intraoral hematomas. On examination, he could not close his mouth because of the hematomas, which were bleeding spontaneously. Computed tomography angiography revealed no evidence of arteriovenous malformation, and blood test results showed that the activated partial thromboplastin time was elevated beyond the normal limit. To avoid a life-threatening hemorrhage from hematomas, emergency surgical hemostasis was performed with nasotracheal intubation using fiberoptic bronchoscopy. Hemostasis was successfully performed, as the hematomas were carefully removed. Moreover, the clinical course was successfully completed using intravenously administered activated prothrombin complex concentrate for hemostasis after operation.

Conclusions

Acquired hemophilia A can cause a life-threatening hemorrhage without predictive factors. Intraoral hematoma may cause airway obstruction. There is no consensus regarding the management of hemorrhage in patients with acquired hemophilia A. As shown here, exophytic hematomas in the oral cavity can be safely removed and nasotracheal intubation with fiberoptic bronchoscopy may be useful in patients with coagulopathy disease.

Case report: Intraoperative thrombosis cardiac arrest in extended right hepatectomy involving use of local haemostatic agent in intraoperative cell salvage (ICS) and administration of recombinant activated factor VII (rFVIIa)

•

Intractable intraoperative haemorrhage is a result of both surgical and coagulopathic (nonsurgical) components.

•

There is increasing off-label use of rFVIIa for ceasing refractory bleeding aside from its application in patient with haemophilia.

•

rFVIIa use may be associated with increased thromboembolic events according to some literature.

•

The use of topical haemostatic agent in conjunction with ICS may potentially lead to systemic clot formation upon re-infusion of the chemical.

•

Avoid use of cell saver suction while the surgical field is contaminated with topical clotting factors before irrigation with 0.9% sodium chloride.

Introduction

In modern surgical era, local haemostatic agents and blood components such as recombinant activated factor VII (rFVIIa) have expanded surgeons’ armamentarium in controlling “surgical” and “nonsurgical bleeding”. We report a case of intraoperative thrombosis and cardiac arrest involving use of local haemostatic agent in intraoperative cell salvage and rFVIIa administration in extended right hepatectomy.

Presentation of case

A 46-year-old lady underwent extended right hepatectomy using cardiopulmonary bypass (CPB) and autotransfusion with ICS for metastatic gastrointestinal stromal tumour. She became extremely coagulopathic following weaning of CPB despite an array of fluid and blood products replacements. Decision to administer rFVIIa as a measure to arrest bleeding was unsuccessful. Extensive systemic thrombosis occurred which resulted in cardiac arrest and mortality.

Discussion

The thromboembolic event was unclear but likely multifactorial. Two important hypotheses were the administration of rFVIIa and use of local haemostatic agent in ICS.

Conclusion

Reported incidence of thromboembolism with use of rFVIIa in refractory bleeding is variable. More randomised controlled trials are needed to ascertain the efficacy and safety profile of the haemostatic agent. At present, off-label use of rFVIIa should be guided by the risk:benefit profile on a case-to-case basis. The authors also feel strongly against the use of local haemostatic gel in conjunction with ICS due to potential systemic circulation of the thrombin.

Recombinant activated factor VII (rFVIIa) in refractory haemorrhage for non-haemophiliacs: an eleven-year single-centre experience

Background

Massive bleeding is one of the commonest salvageable causes of death. The search for an ideal haemostatic agent during massive bleeding is still ongoing. One of the novel haemostatic medications is recombinant activated factor VII (rFVIIa). To date, the usage of rFVIIa during massive haemorrhage among non-haemophiliac patients remains off-label. The aim of this study is to report our experience in using rFVIIa to treat refractory bleeding.

Methods

Medical records of all patients treated with rFVIIa for massive bleeding over an eleven-year period in a single institution were recorded. Treatment indications, 24-h and 30-day mortality, changes in transfusion needs and coagulation profiles after rFVIIa administration were analysed.

Results

rFVIIa were administered in 76 patients. Of these, 41 (53.9%) were non-surgical bleeding, followed by 22 patients (28.9%) with trauma, other surgery bleedings in 9 patients (11.8%) and 4 patients (5.4%) with peripartum haemorrhage. Total survival rate was 78.9% within 24 h and 44.7% over 30 days. Among all these patients who had received rFVIIa due to life-threatening haemorrhage, blood and blood product requirements were significantly reduced (P < 0.001), and the coagulation profiles improved significantly (P < 0.05). Two patients with preexisting thromboembolism were given rFVIIa due to intractable bleeding, both survived. No thromboembolic events were reported after the administration of rFVIIa.

Conclusions

rFVIIa significantly improved coagulation parameters and reduced blood product requirements during refractory haemorrhage. Additionally, usage of rFVIIa in trauma and peripartum haemorrhage patients yield better outcomes than other groups of patients. However, the overall mortality rate remained high.

Identification and Management of Obstetric Hemorrhage

Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.

Eptacog alfa activated: a recombinant product to treat rare congenital bleeding disorders

Glanzmann's thrombasthenia (GT) and congenital factor VII deficiency (FVII CD) are rare autosomal recessive bleeding disorders: GT is the most frequent congenital platelet function disorder, and FVII CD is the most common factor-deficiency disease after haemophilia. The frequency of these disorders in the general population ranges from 1:500,000 to 1:2,000,000. Because GT and FVII CD are both rare, registries are the only approach possible to allow the collection and analysis of sufficient observational data. Recombinant activated factor VII (rFVIIa, eptacog alfa activated) is indicated for the treatment of acute bleeding episodes and for surgery coverage in patients with GT who are refractory to platelets and have antiplatelet or anti-human leukocyte antigen (HLA) antibodies, and for the prevention and treatment of bleeding in patients with FVII CD. This article summarises published data on the mechanism of action and use of rFVIIa in these disorders from two international, prospective, observational registries: the Glanzmann's Thrombasthenia Registry (GTR) for GT; and the Seven Treatment Evaluation Registry (STER) for FVII CD. Haemostatic effectiveness rates with rFVIIa were high across all patients with GT and those with FVII CD, and treatment with rFVIIa in the GTR and STER registries was well tolerated. The GTR and the STER are the largest collections of data in GT and FVII CD, respectively, and have expanded our knowledge of the management of these two rare bleeding disorders.

Massive oral bleeding after full-mouth extraction in a patient with B-cell lymphocytic leukemia/small lymphocytic lymphoma reversed with recombinant activated factor VII

BACKGROUND AND OVERVIEW

Full-mouth extraction can be associated with intraoral bleeding, which usually is controlled with local hemostatic measures. Recombinant activated factor VII (rFVIIa) occasionally is used to stop bleeding in a variety of off-label indications, with the main argument curtailing its use being thrombotic events. The authors describe the use of rFVIIa for bleeding after full-mouth extraction in a patient with undiagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma.

CASE DESCRIPTION

A 72-year-old man underwent full-mouth extraction (18 teeth). The next day, the patient experienced massive oral bleeding. The authors administered tranexamic acid, aminocaproic acid, and a total of 12 units of packed red blood cells in addition to local hemostatic measures without control of bleeding. On postoperative day 10, the authors administered 5,000 micrograms of rFVIIa, and within 2 hours oral the bleeding ceased. The authors performed flow cytometry and diagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Unexplained massive oral bleeding despite adequate local hemostatic measures should prompt further investigations for underlying bleeding or coagulation disorders. The authors describe the successful use of rFVIIa in massive oral bleeding. Further studies are mandatory to study the effectiveness of this drug for this off-label indication.

Role of prothrombin complex concentrate in perioperative coagulation therapy

Prothrombin complex concentrate (PCC) is a term to describe pharmacological products that contain lyophilized, human plasma-derived vitamin K-dependent factors (F), FII, FVII, FIX, FX, and various amounts of proteins C and S. PCCs can be rapidly reconstituted in a small volume (20 ml for about 500 international units (IU)) at bedside and administered regardless of the patient’s blood type. PCCs are categorized as 4-factor PCC if they contain therapeutic amounts of FVII, and 3-factor PCC when FVII content is low. In addition, activated PCC which contains activated FVII and FX with prothrombin is available for factor VIII bypassing therapy in hemophilia patients with inhibitors. Currently, 4-factor PCC is approved for the management of bleeding in patients taking warfarin, but there has been increasing use of various PCCs in the treatment of acquired perioperative coagulopathy unrelated to warfarin therapy and in the management of bleeding due to novel oral anticoagulants. There is also an ongoing controversy about plasma transfusion and its potential hazards including transfusion-related lung injury (TRALI). Early fixed ratio plasma transfusion has been implemented in many trauma centers in the USA, whereas fibrinogen concentrate and PCC are preferred over plasma transfusion in some European centers.

In this review, the rationales for including PCCs in the perioperative hemostatic management will be discussed in conjunction with plasma transfusion.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prediction score for effective bleeding control using recombinant activated factor VII in perioperative nonhemophilic patients

BACKGROUND

Although there has been growing evidence from off-label use of recombinant activated factor VII (rFVIIa) in surgical bleeding, there is limited information on prediction scores.

METHODS

A retrospective study was conducted from 2004 to 2009. The primary outcome was efficacy of bleeding control. Multivariate logistic regression was performed to develop a new prediction score for success of rFVIIa.

RESULTS

A total of 320 bleeding episodes from 243 nonhemophilic patients who underwent surgery were analyzed. Effective bleeding control was demonstrated in 153 patients. The overall in-hospital mortality rate was 40%. Multivariate analysis identified 4 independent predictors for effective bleeding control: timing of rFVIIa administration, intraoperative blood loss, postoperative international normalization ratio values, and total units of platelets transfused. A rFVIIa success prediction score was developed.

CONCLUSIONS

The use of this new prediction score may support decision making by identifying patients with a high probability of obtaining effective bleeding control from rFVIIa therapy.