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Adequacy of hemostatic resuscitation improves therapeutic efficacy of recombinant activated factor VII and reduces reexploration rate for bleeding in postoperative cardiac surgery patients with refractory hemorrhage


1 Department of Pharmacy, Froedtert and the Medical College of Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
2 Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
3 Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee; Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, Wisconsin, USA
4 Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin; The Blood Center of Wisconsin, Blood Research Institute, Milwaukee, Wisconsin, USA
5 Department of Anesthesiology, Medical College of Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
6 Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA

Correspondence Address:
Justin N Tawil
Department of Anesthesiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, Wisconsin 53226
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_108_18

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Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 388-393

 

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Background: Excessive bleeding and surgical reexploration are common complications that increase the risk of multi-organ failure and prolonged hospitalization after cardiac surgery. Off-label use of recombinant activated factor VII (rFVIIa) is a recommended treatment for refractory bleeding. Objective: The objective of the study is to determine if the adequacy of hemostatic resuscitation enhances the efficacy of rFVIIa. Methods: This retrospective, observational, cohort study included patients who received rFVIIa for refractory postoperative bleeding after cardiac surgery. Patients were divided into two groups based on the presence or absence of adequate coagulation resuscitation before rFVIIa administration, defined as international ratio (INR) ≤1.5, platelet count ≥100 K/mL, and fibrinogen ≥200 mg/dL. The failure of rFVIIa treatment was defined as surgical reexploration within 24 h, thoracostomy drainage >400 mL/h within 6 h or transfusion of additional blood products or another rFVIIa dose within 6 h after initial rFVIIa dose. Results: Of the 3833 patients, screened who underwent cardiothoracic surgery procedures, 58 patients received rFVIIa for refractory postoperative bleeding. Successful hemostasis with rFVIIa was more likely in patients who were adequately resuscitated compared with those who were not (20 [71.4%] vs. 10 [33.3%], respectively; P = 0.0046). Multiple logistic regression analysis indicated that patients who were adequately resuscitated before rFVIIa were less likely to fail treatment (odds ratio, 0.16; 95% confidence interval [0.04–0.62]; P = 0.007). Conclusions: The therapeutic efficacy of rFVIIa is dependent on the adequacy of hemostatic resuscitation; restoration of normal serum fibrinogen, INR, and platelet counts >100 K/mL may provide an adequate substrate for rFVIIa to be effective in managing refractory postoperative cardiac surgical bleeding.






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1 Department of Pharmacy, Froedtert and the Medical College of Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
2 Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
3 Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee; Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, Wisconsin, USA
4 Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin; The Blood Center of Wisconsin, Blood Research Institute, Milwaukee, Wisconsin, USA
5 Department of Anesthesiology, Medical College of Wisconsin; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
6 Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA

Correspondence Address:
Justin N Tawil
Department of Anesthesiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, Wisconsin 53226
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_108_18

Rights and Permissions

Background: Excessive bleeding and surgical reexploration are common complications that increase the risk of multi-organ failure and prolonged hospitalization after cardiac surgery. Off-label use of recombinant activated factor VII (rFVIIa) is a recommended treatment for refractory bleeding. Objective: The objective of the study is to determine if the adequacy of hemostatic resuscitation enhances the efficacy of rFVIIa. Methods: This retrospective, observational, cohort study included patients who received rFVIIa for refractory postoperative bleeding after cardiac surgery. Patients were divided into two groups based on the presence or absence of adequate coagulation resuscitation before rFVIIa administration, defined as international ratio (INR) ≤1.5, platelet count ≥100 K/mL, and fibrinogen ≥200 mg/dL. The failure of rFVIIa treatment was defined as surgical reexploration within 24 h, thoracostomy drainage >400 mL/h within 6 h or transfusion of additional blood products or another rFVIIa dose within 6 h after initial rFVIIa dose. Results: Of the 3833 patients, screened who underwent cardiothoracic surgery procedures, 58 patients received rFVIIa for refractory postoperative bleeding. Successful hemostasis with rFVIIa was more likely in patients who were adequately resuscitated compared with those who were not (20 [71.4%] vs. 10 [33.3%], respectively; P = 0.0046). Multiple logistic regression analysis indicated that patients who were adequately resuscitated before rFVIIa were less likely to fail treatment (odds ratio, 0.16; 95% confidence interval [0.04–0.62]; P = 0.007). Conclusions: The therapeutic efficacy of rFVIIa is dependent on the adequacy of hemostatic resuscitation; restoration of normal serum fibrinogen, INR, and platelet counts >100 K/mL may provide an adequate substrate for rFVIIa to be effective in managing refractory postoperative cardiac surgical bleeding.






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