Authors: Thomas C Tsai James H Rosing Jeffrey A Norton
Publish Date: 2010/06/02
Volume: 14, Issue: 8, Pages: 1311-1318
Abstract
Hemorrhage is a significant complication after major gastrointestinal and abdominal surgery Clinically significant bleeding can lead to shock transfusion of blood products and reoperation Recent reports suggest that activated rfVIIa may be effective in correcting coagulopathy and decreasing the need for reoperationThis study was a retrospective review over a 4year period of 17 consecutive bleeding postoperative patients who received rfVIIa to control hemorrhage and avoid reoperation Outcome measures were blood and clotting factor transfusions deaths thromboembolic complications and number of reoperations for bleedingSeventeen patients with postoperative hemorrhage following major abdominal gastrointestinal surgery nine pancreas four sarcoma two gastric one carcinoid and one fistula were treated with rfVIIa In these 17 patients rfVIIa was administered for 18 episodes of bleeding dose 24009600 mcg 2981008 mcg/kg Transfusion requirement of pRBC and FFP were each significantly less than prerfVIIa Out of the 18 episodes bleeding was controlled in 17 94 without surgery and only one patient returned to the operating room for hemorrhage There were no deaths and two thrombotic complications Coagulopathy was corrected by rfVIIa from 137 to 096 p 00001Activated factor VII rfVIIa plays a key role in hemostasis by activating the extrinsic pathway of coagulation Factor VIIa initiates coagulation by interacting with exposed tissue factor in turn activating factor X to produce thrombin1 Thrombin then causes a conformational change of circulating platelets and the activated surface of platelets further activates the coagulation cascade to produce stable fibrin clots2 Injured subendothelial cells express tissue factor Activation of factor VII by exposed tissue factor occurs at sites of local tissue injury and endothelial damage making factor VII an attractive therapeutic agent for active hemorrhage following surgical injuryIn 1999 the US Food and Drug administration approved the use of recombinant rfVIIa for the treatment of the inherited bleeding disorders hemophilia A and B as well as inhibitors to factor VIII or IX Because rfVIIa targets areas of active bleeding it has been used to treat nonhemophiliac cases of coagulopathy or refractory hemorrhage in trauma neurosurgery cardiac surgery and liver transplantation34 In randomized placebocontrolled trials among trauma patients rfVIIa was shown to significantly decrease units of red blood cells RBC transfused56 Multiple case reports and case series have since suggested the effectiveness of rfVIIa in treating hemorrhage during surgery7 8 9 10Although these studies have shown significant reductions in bleeding there are no studies clearly evaluating the role of rfVIIa in preventing reoperations for hemorrhage following major abdominal gastrointestinal surgical procedures Although sepsis and anastamotic leaks are the most common indications for reoperation following gastrointestinal surgery bleeding accounts for as much as185 of urgent abdominal reexplorations1112 Because these reoperations represent additional trauma to the patient and family and may result in increased morbidity and mortality surgeons are faced with the dilemma of continuing potentially futile resuscitation with blood products or performing a potentially harmful repeat operation In general in these situations reoperation has been recommended However we hypothesized that rfVIIa would control bleeding by correcting dilutional coagulopathy after surgery without significant complications To evaluate the role of rfVIIa in preventing reoperations for hemorrhage following major abdominal and gastrointestinal surgery we performed a retrospective chart review of 17 consecutive patients treated by a single surgeon with rfVIIa to avoid reoperation
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