Hemostatic Management: Drugs

Abstract

INTRODUCTION:

Studies are inconclusive regarding clinical outcomes after administration of recombinant activated coagulation factor VII (rFVIIa) during severe haemorrhage. The circumstances encountered during desperate haemorrhage make it difficult to include the most critically ill patients that could possibly benefit the most from such treatment into randomized controlled trials. We report our experience with rFVIIa as last-resort treatment of desperate haemorrhage when all standard treatment has failed.

Abstract

PURPOSE:

A retrospective review of consecutive adult patients undergoing scoliosis correction surgery was performed to compare the effects of aprotinin and tranexamic acid in blood conservation and to define a comprehensive blood conservation strategy for such surgery.

METHODS:

Summary Bishop and colleagues review a series of patients who received rVIIa as a rescue therapy for uncontrolled, non-surgical, post-operative hemorrhage following cardiac surgery. Over a 23 month period 1,393 cardiac surgeries were performed at their institution. 12 patients received rVIIa following 13 operations. Demographic and procedural data were collected as well as hematological data and blood product usage pre- and post-rVIIa infusion.

This study, raising serious safety concerns about aprotinin, has generated considerable discussion including an accompanying editorial and comment in the same issue (N Engl J Med. 2006 Jan 26;354(4):329-31. N Engl J Med.

Summary [In this prospective study the authors evaluate the cost-effectiveness of routine use of intraoperative blood salvage (IBS) in adult liver transplantation. It is helpful in view of previous studies concluding that routine IBS is not cost-effective in liver transplantation or that it is only cost-effective when transfusion requirements are considerable. The authors also highlight its importance given the reported 340% increase in the cost of allogeneic blood products in the United Kingdom over the period of their study, and ongoing safety concerns with donor blood.

Summary Bishop and colleagues review a series of patients who received rVIIa as a rescue therapy for uncontrolled, non-surgical, post-operative hemorrhage following cardiac surgery. Over a 23 month period 1,393 cardiac surgeries were performed at their institution. 12 patients received rVIIa following 13 operations. Demographic and procedural data were collected as well as hematological data and blood product usage pre- and post-rVIIa infusion.

There is little in the literature on the use of recombinant activated factor VII (rFVIIa) in neurosurgery. Hartmann and colleagues present two case reports of its use in uncontrollable microvascular bleeding in pediatric brain tumor surgery. Both patients (9-year-old and 14-year-old girls) had normal preoperative laboratory values for aPTT, PT, fibrinogen, antithrombin and platelet count. Massive intraoperative bleeding (total blood loss of 25 L and 5 L respectively) resulted in multiple blood product transfusions (RBCs, FFP and platelets).

Summary Ickx and colleagues conducted this prospective randomized trial to compare aprotinin and tranexamic acid as prophylactic antifibrinolytics in patients undergoing liver transplantation. Primary outcome measures were perioperative blood loss, transfusion requirements and calculated hemoglobin (Hb) loss. 51 cirrhotic transplant patients were randomly assigned to one of two groups; one to receive aprotinin (AP group) and the other tranexamic acid (TA group). The two agents were administered from the anhepatic phase until 2 hours after graft reperfusion.

Summary To the authors’ knowledge this is the largest retrospective study to date reviewing the use of epsilon aminocaproic acid (EACA) in hematology patients with thrombocytopenic hemorrhage. Although there have been no randomized controlled trials evaluating EACA’s use in thrombocytopenic hemorrhage, a number of small case reports and series have indicated a role for it in this setting. In this current report, 77 patients in the Cleveland Clinic Foundation database met their study criteria.