Slappendel R, Huvers FC, Benraad B, Novakova I, Van Hellemondt GG:, Use of recombinant factor VIIa (NovoSeven®) to reduce postoperative bleeding after total hip arthroplasty in a patient with cirrhosis and thrombocytopenia. Anesthesiology 2002;96:1525-1527.
Recombinant blood coagulation factor VIIa (rFVIIa, NovoSeven®) has been used to treat severe bleeding in patients with complex underlying hemostatic disorders. The authors describe the use of rFVIIa for treating a patient with cirrhosis and hypersplenism requiring total hip arthroplasty (THA). The patient was a 59-yr-old woman with a prior hip fracture treated in 1998 using reposition osteosynthesis. During the removal of the osteosynthesis material in 1999, the patient had a severe postoperative bleed, and the patient developed pseudoarthrosis requiring the surgery. The patient was refused THA in another hospital because of the bleeding incident in 1999 and existing thrombocytopenia. The patient had developed alcoholic liver cirrhosis, portal hypertension, and hypersplenism. The patient was 162 cm, 60 kg, with no icterus, no palmar erythema, no spider nevi, and no hepatosplenomegaly. Laboratory investigation showed an increased prothrombin time (PT), a slightly increased bleeding time, and thrombocytopenia (67,000).
Spinal anesthesia was administered, and a cemented total hip prosthesis was placed. The duration of surgery was 80 min, with a perioperative blood loss of 1,890 ml. The blood was collected and treated (filtration and washing) by a cell saver device. After processing the collected blood, 560 ml (hemoglobin 20.16 g/dl) was infused into the patient. Postoperatively, the cell saver was used. During the first 6 h after surgery, the total blood loss was 1,850 ml, and 560 ml of processed red cells was reinfused to the patient. Platelet count further decreased from 55,000 to 44,000, and the PT increased to 20 s. rFVIIa 100 mcg/Kg was administered intravenously. After rFVIIa administration, the total amount of blood lost via the drain was 670 ml during the subsequent 11 h. Postoperative bleeding completely ceased 18 h postoperatively, requiring no further intervention.
The authors suggest that administering rFVIIa to patients with liver cirrhosis, thrombocytopenia, or reduced platelet function may result in additional thrombin generation on the phospholipid surface of activated thrombocytes. Since thrombin generation is one of the most powerful existing activators of platelets, the additional rFVIIa-induced thrombin generation might compensate for the reduced amount of platelets available and the associated decreased thrombin generation. Furthermore, a bolus injection of rFVIIa generates a local burst of thrombin, which subsequently results in the activation of thrombin-activatable fibrinolysis inhibitor (TAFI). TAFI is activated by high concentrations of thrombin. Activated TAFI down-regulates fibrinolysis by cleaving C-terminal lysine and arginine residues from partially degraded fibrin These lysine and arginine residues are essential cofactors in tissue-type plasminogen activator (t-PA) mediated fibrinolysis. The authors suggest although rFVIIa is not antigenic and does not carry the potential for transmission of disease, the current cost of rFVIIa, in a dose of 100 mcg/kg, is approximately 3,000–3,800 ($2,668–$3,430) per patient. The risks of allogenic blood transfusions are associated with incremental hospital costs. In a recently published study these additional costs were estimated to be $1,000–$1,500 per unit of blood transfused.