Use of recombinant FVIIa for intraperitoneal coagulopathic bleeding in a septic patient.

Recombinant activated coagulation factor VII (rFVIIa) is a U.S. Food and Drug Administration (FDA)-approved drug for use in hemophiliacs with inhibitors. It has been safely utilized in this population of patients for over 13 years. rFVIIa functions by increasing local thrombin generation at sites where endothelium is damaged, resulting in increased platelet activation and aggregation and enhanced fibrin deposition. Because of its localized action at the site of endothelial damage, it is now being used in treating patients with an acquired coagulopathy. The emergency use of intravenous adjuncts for hemorrhage control, other than standard component therapy, has been largely ignored in the massively bleeding surgical patient. An injectable substance that would enhance normal clotting might reduce deaths from uncontrolled hemorrhage, decrease units transfused along with their complications, and reduce expense. Several drugs (estrogens and anti-fibrinolytic agents) have been utilized to decrease bleeding during elective surgery, but rFVIIa holds more promise. rFVIIa was originally isolated and later produced by recombinant technology to treat hemophilia patients with inhibitors to factors VIII and IX during critical bleeding episodes or major surgery. It also corrects the platelet defects associated with Glanzmanns thrombasthenia, Bernard– Soulier syndrome, uremia, and other severe congenital and acquired thrombocytopathias. Furthermore, it has been shown to rapidly reverse coumadin anticoagulation in healthy volunteers and to correct prothrombin times in cirrhotic patients. The widening clinical indications for rFVIIa are suggested by recent published descriptions of reduced blood loss in many previously normal surgical patients. These include patients undergoing orthotopic liver transplantation, massive gastrointestinal bleeding, exsanguinating trauma, cirrhosis, bone marrow transplant, heart valve replacement, amniotic embolus and disseminated intravascular coagulation (DIC), transabdominal retropubic prostatectomy, and Dengue hemorrhagic fever with DIC. We report here the use of rFVIIa utilized to control diffuse bleeding from the retroperitoneum in a septic patient with DIC from necrotizing pancreatitis.