SESSION TITLE: Critical Care Cases
SESSION TYPE: Case Reports
PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM
INTRODUCTION: The use of recombinant activated Factor VIIa(rFVIIa) was first approved in the United States in 1999 for treating bleeding episodes in patients with congenital and acquired Hemophilia A and B, hemophilia with inhibitors to factor VIII and IX, and surgical prophylaxis. The indications have been limited due to its risk of thrombosis. We are reporting a case of rFVIIa use for life threatening diffuse alveolar hemorrhage.
CASE PRESENTATION: A previously healthy 46 year-old woman from New York was airlifted to our facility from Jamaica for further management of respiratory failure and shock due to an unclear etiology. She developed an episode of febrile illness with diarrhea that was treated with ciprofloxacin. She then progressed to multiorgan failure including respiratory failure that required intubation. On arrival she was in distributive shock requiring multiple vasopressors. On the third day of ICU admission, oxygen saturation suddenly decreased requiring an increase in her FiO2 to 100%. Large amounts of fresh blood was noted in the endotracheal tube. Hemogram showed a hemoglobin decreased from 9.6g/dl to 7.5g/dl. Platelet count was 46,000/µL, INR was 1.3 and a PTT of 38 seconds. Subsequently, she had a pulseless electrical activity cardiac arrest. After 3 cycles of CPR and intravenous epinephrine she had return of spontaneous circulation. An urgent bronchoscopy revealed profuse bleeding from both lungs. Uncontrolled bleeding with unstable hemodynamic status prompted us to administer endobronchialFVIIa. 50µg/kg of rFVIIa (NovoSeven) was dissolved in 50 ml of normal saline administered via bronchoscopy into the right and left main bronchus simultaneously. Bleeding rapidly ceased in 2 hours with improved hemodynamics. PaO2/ FiO2 ratio increased from 43/100 to 82/100. She was transfused 2 units of packed red blood cells, which resulted in an increase in hemoglobin from 7.5g/dL to 11.5g/dL and platelets from 45,000 to 90,000. In twelve hours PaO2/FiO2 ratio was 116/50 with decreased need of norepinephrine from 20mcg/min to 10mcg/min. No pulmonary bleeding or thromboembolic complication was observed after the procedure. Over the next 7 days she was weaned off of the ventilator and successfully extubated.
DISCUSSION: The therapeutic potential of rFVIIa has been evaluated in clinical settings such as active bleeding in trauma, spontaneous intracranial hemorrhage, and liver transplantation. However, these off-label uses have been difficult to translate into clinical recommendations.
CONCLUSIONS: In our patient, uncontrolled alveolar hemorrhage was successfully controlled with no further bleeding or thromboemolic complications after a single dose of endobronchial rFVIIa.
Reference #1: Heslet L, Nielsen JD, Levi M, Sengelov H, Johansson PI. Successful pulmonary administration of activated recombinant factor VII in diffuse alveolar hemorrhage. Crit Care 2006;10:R177.
DISCLOSURE: The following authors have nothing to disclose: Felix Hernandez, Michael Alvarez, Jose Ramirez, Gustavo Ferrer
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