SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Intravenous recombinant activated Factor VIIa (rFVIIa) is an approved agent for bleeding disorders hemophilia A and B. Intrapulmonary administration of rFVIIa to control alveolar hemorrhage has been published in only a few case reports. Here we are reporting a case of rFVIIa used for life threatening pulmonary hemorrhage in setting of severe septic shock and DIC.
CASE PRESENTATION: A previously healthy 46 year-old female patient was airlifted to our facility for further management of respiratory failure and shock of unclear etiology. On arrival patient was in septic shock requiring multiple vasopressors medications. On 3rd day of ICU admission, patient’s oxygen saturation dropped suddenly requiring FiO2 of 1.0, and large amounts of fresh red blood was coming from the endotracheal tube. Repeat hemoglobin decreased from 9.6 to 7.5 g/dl. Platelet count was 46,000/µL, with INR/PTT of 1.3/38. Subsequently patient had PEA arrest, after 3 cycles of CPR and epinephrine patient regained spontaneous circulation. An urgent bronchoscopy revealed profuse bleeding from both lungs. Uncontrolled bleeding with unstable hemodynamic prompt us to administer rFVIIa. 50µg/Kg rFVIIa (NovoSeven) dissolved in 50 ml of normal saline administered by BAL into right and left main bronchus simultaneously. Pulmonary bleeding rapidly ceased in 2 hours with improved hemodynamic. PaO2/ FiO2 ratio increased from 43 to 82. Patient was transfused 2 units of PRBC’s with increase in Hb from 7.5 to 11.5g/dL. In 12 hours PaO2/FiO2 ratio was 232 with decreased need of norepinephrine from 20 to 10mcg/min. Over next 7 days patient was wean of ventilator and successfully extubated.
DISCUSSION: Diffuse pulmonary hemorrhage could be a life threatening complication of systemic illness such as DIC. Intrapulmonary rFVIIa has been used successfully for diffuse alveolar hemorrhage associated with bone marrow transplant, vasculitis, after clopidgrel use. Proposed Mechanism of action for local mode of Factor VIIa is activation of factor IX and X by alveolar tissue factor (TF)-rFVIIa complexes, leading to generation of thrombin and production of fibrin. In our patient uncontrolled alveolar hemorrhage due to DIC was successfully controlled with no further bleeding or thromboemolic complications after single dose of rFVIIa.
CONCLUSIONS: Intrapulmonary use rFVII should be considered in critically ill patient with uncontrolled diffuse alveolar hemorrhage resulting in life threatening condition.
1) Heslet L et al: Successful pulmonary administration of activated recombinant factor VII in diffuse alveolar hemorrhage. Critical Care 2006
2) Macdonald J A et al: Successful use of recombinant factor VII in massive hemoptysis due to community- acquired pneumonia. Chest 2006.
DISCLOSURE: The following authors have nothing to disclose: Amitesh Agarwal, Ferrer Gustavo
No Product/Research Disclosure InformationCleveland Clinic Florida, Weston, FL