Journal: Br J Anaesth 99(2):221-225, 2007. 42 References
Reprint: Dept of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, Queensland 4006, Australia (Dr G Pang)
Faculty Disclosure: Abstracted by L. Easley, who has nothing to disclose.
Several reports have suggested a life-saving role of recombinant activated factor VII (rFVIIa) in uncontrollable traumatic hemorrhage in non-hemophiliacs who have failed to respond to conventional therapy. The authors present the first case report of right atrial space-occupying lesion (SOL) consistent with thrombus detected immediately after administration of rFVIIa.
A 33-yr-old male involved in a pedestrian road traffic accident sustained a closed head injury, blunt chest, and abdominal trauma. Emergency laparotomy was performed revealing massive hemoperitoneum, multiple liver lacerations, portal venous injury, partial gallbladder avulsion, and a right perinephric retroperitoneal hematoma. Several attempts to pack the four quadrants of the abdomen proved unsuccessful because of continued bleeding. Hemorrhage continued despite aggressive attempts to correct coagulation with available fresh frozen plasma, cryoprecipitate, platelets, boluses and an infusion of calcium gluconate and calcium chloride, active warming, sodium bicarbonate, and hyperventilation.
In consultation with the surgeons and a hematologist, the decision to administer rFVIIa 100 mcg/kg was made. After 3 hr of continuous transesophageal echocardiography (TEE) monitoring, and within 2 min after the second 4.8 mg rFVIIa bolus, the TEE revealed the right atrium filling with echogenic material, partially occluding the right ventricular inflow. Hemodynamics did not appear to deteriorate further, and there was no difference noted in the rate of bleeding. Fragments were seen to embolize from the space-occupying lesion, until the lesion was dispersed over the next 5 minutes. Hemostasis could not be achieved, despite 66 units of packed red cells and 21 liters of crystalloid, and cardiovascular instability and bleeding continued. The patient died shortly after in the ICU.
rFVIIa is a synthetic activated clotting factor that enhances localized clot formation at the site of endothelial tissue factor (TF) exposure via both TF and non-TF (platelet)-dependent pathways. Therapeutic doses of factor VIIa produce plasma levels 1000 times that of normal. In conditions where there are high levels of TF expression, the thrombogenic potential of rFVIIa may be increased. Appropriate timing of rFVIIa administration is not known. rFVIIa was administered only after all surgical avenues were exhausted.
Despite the many case reports of rFVIIa efficacy, this case demonstrates that rFVIIa is not a panacea for intractable hemorrhage. Little information exists to indicate which patients may benefit from rFVIIa administration and in which patients its use will be futile. Previous case reports of thromboembolism associated with rFVIIa use were in patients with high thromboembolic risk where it was difficult directly to implicate rFVIIa as a causative agent. rFVIIa may be useful in life-threatening hemorrhage; however, this case report suggests a potential for thrombosis when used in states associated with high TF concentrations and platelet activation. Further studies are required to define the safety profile of this agent in massive hemorrhage. |
