Department of Intensive Care Medicine, St George Hospital, Kogarah, Sydney NSW 2217, Australia
* Corresponding author: E-mail grantcprice{at}hotmail.com
Accepted for publication February 25, 2004.
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Abstract |
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Keywords: blood ; coagulation ; recombinant factor VIIa ; complications ; haemorrhage
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Introduction |
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Case report |
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In the intensive care unit, the patient continued to be hypotensive (80/50 mm Hg) and she received 4 u of red blood cells, 6 u of fresh frozen plasma, and 10 u of pooled platelets. She had an increasingly distended abdomen, and became oliguric. We considered a trial of aprotonin but decided against this primarily because of our concerns that there was on-going surgical bleeding and that aprotonin administration can induce hypotension and coagulopathy. Despite being given a further 6 u of red cell concentrate and 4 u of fresh frozen plasma her haemoglobin concentration fell to 5.1 g dl1 and she remained coagulopathic with an INR of 1.6, and platelet count of 38x109. As the patient was still coagulopathic, her surgeons were reluctant to take her back to theatre without more evidence of bleeding: a CT scan of the abdomen confirmed the clinical picture of intra-abdominal haemorrhage.
At laparotomy, performed 12 h after the Caesarian section, 3.5 litre of blood clot and fresh blood were removed although no discrete bleeding point was discovered. Intraoperative correction of her coagulopathy continued with fresh frozen plasma (4 u), cryoprecipitate (10 u), and platelets (10 u). Fluid resuscitation intra-operatively consisted of 1000 ml of Hartmans solution and a further 3 u of red cell concentrate. On return to the ICU she remained haemodynamically stable for around 4 h but her haemoglobin fell from 8.6 to 6.2 g dl1 and she lost 600 ml of blood-stained fluid from her intra-abdominal drains. Subsequently, she again became hypotensive requiring further fluid resuscitation, and became anuric. Further infusion of red blood cells, fresh frozen plasma, cryoprecipitate, and platelets led to pulmonary oedema and the development of hyperkalaemia, requiring the institution of renal replacement therapy.
With a continuing coagulopathy and exclusion of a surgical cause for on-going bleeding, we felt that a trial of recombinant factor VIIa could be of benefit. A single dose of 90 µg kg1 (6 mg) recombinant factor VIIa was administered and a clinical response was apparent within 30 min. The drainage from her abdomen fell to 10 ml over the next 3 h and then stopped. Her haemoglobin concentration and arterial pressure stabilized and began to improve. There was no requirement for further red cell transfusion, but another 10 u of platelets was administered as her platelet count decreased to 30x109. She required a further 6 days of intensive care during which her acute renal failure recovered. In total during her initial 24-h period on intensive care she had received 22 u of red cell concentrate, 18 u of fresh frozen plasma, 40 u of platelets, and 20 u of cryoprecipitate. Her liver transaminases, coagulation profile and platelet count had returned to normal levels by day 10 post-admission. Both mother and baby continued to do well.
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Discussion |
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There have been recent reports in the literature outlining the benefits of recombinant factor VIIa in obstetric disasters.11 Zupanic and colleagues report the successful use of recombinant factor VIIa in massive bleeding post-Casearian section. In this case report the patient developed evidence of HELLP syndrome in association with pre-eclampsia and also developed massive bleeding post-Caesarian section. In common with our case report their patient also responded rapidly to administration of rFVIIa.
It is important to note that the use of recombinant factor VIIa requires attention to replacement of deficient coagulation factors, red cells, fibrinogen, and platelets in addition to more general measures such as avoidance of hypothermia, acidaemia, and ongoing surgical bleeding.12 There is limited experience of the use of rFVIIa in non-haemophiliac bleeding and some caution is advised with its use. Reported adverse events have included myocardial infarction, arterial thrombosis and DIC.13
Recombinant factor VIIa proved to be an effective agent in achieving prompt haemostasis in our patient with on-going bleeding unresponsive to the aggressive replacement of deficient coagulation factors and correction of surgical bleeding. We believe that it may become a useful adjunct in the treatment of difficult postoperative bleeding from acquired coagulopathies. This warrants further study in these situations with large numbers of patients to establish safety and efficacy of this drug in this clinical setting.
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References |
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