Strategies for Preventing and Treating Uncontrolled Perioperative Bleeding

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Strategies for Preventing and Treating
UncontrolledPerioperative Bleeding

• Richard P. Dutton, MD, MBA
• Associate Professor of Anesthesiology
• R Adams Cowley Shock Trauma Center
• University of Maryland School of Medicine
• Baltimore, Maryland

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Disclosure Information

• Presenting Faculty
• Richard P. Dutton, MD, MBA
• Consultancy fees for Novo Nordisk
  Pharmaceuticals
• Sponsorship
• Jointly sponsored by Postgraduate Institute for
  Medicine, Cardiovascular
• Metabolic Health Foundation, and Educational
  Concepts in Medicine
• Support
• Supported by an educational grant from Novo
  Nordisk Pharmaceuticals

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(No Transcript)
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Strategies for Preventing and Treating
Uncontrolled Perioperative Bleeding

• About This Initiative
• Part of a special project from the
  Cardiovascular Metabolic Health Foundation
• Led by renowned surgeons, anesthesiologists,
  blood banking specialists, and other experts in
  operative hemostasis and transfusion management
• Offers peer-driven programs and activities,
  including live, online teleconferences and
  other education
• Find out more at

www.bloodcmecenter.org
5
Learning Objectives

• Upon completion of this activity, participants
  should be better able to
• Identify specific patient types who may be at
  increased risk for perioperative bleeding and
  complications from acquired coagulopathy
• Specify the importance of the preoperative
  patient evaluation as a tool in determining risk
  for perioperative bleeding
• Explain the essentials of surgical hemostasis and
  current guidelines for achieving balance between
  bleeding and clotting
• Explain the benefits and risks of blood products
  as a therapeutic modality
• Describe the role of available nontransfusional
  treatment modalities for achieving operative
  hemostasis

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Polling Question 1

• Generally, what percentage of surgical
  complications that you encounter relate to
  bleeding or clotting?
• Only a small percentage
• No more than other complications
• More than many other complications
• Most complications relate to bleeding or clotting

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Prevalence of Uncontrolled Bleeding
Surgical Discipline Uncontrolled Bleeding Rate
Cardiovascular 5-7 Post-op1
General 1.9 Laparoscopic cholecystectomy2
Obstetric 3.9 (vaginal) 6.4 (cesarean)3,4
Orthopedic 2-6.3 Hip/knee arthroplasty5-7
Urologic 4-8 TURP8 3.3-9.9 URL9
Trauma 30-4010,11
TURPtransurethral resection of prostate
URLupper retroperitoneal laparoscopy.
1. Despotis GJ, et al. Anesth Analg.
19968213-21 2. Erol DD, et al. The Internet
Journal of Anesthesiology. 200592 3. Combs
CA, et al. Obstet Gynecol. 19917769-76 4.Combs
CA, et al. Obstet Gynecol. 19917777-82 5. Hull
R, et al. N Engl J Med. 19933291370-1376 6.
Leclerc JR, et al. Ann Intern Med.
1996124619-626 7. Strebel N, et al. Arch
Intern Med. 20021621451-1455 8. Daniels PR.
Nat Clin Pract Urol. 20052343-350 9.Rosevear
HM, et al. J Urol. 20061761458-1462 10.
Holcomb JB. Crit Care. 20048(suppl 2)S57-S60
11. Sauaia A, et al. J Trauma. 199538
185-193.
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Practical Applications

• After this presentation, we urge participants to
• Assess and review recent patient cases where
  surgical complications were attributed to
  bleeding or clotting
• Evaluate how real-world scenarios have fit with
  practice guidelines and evidence on bleeding and
  clotting
• Assess recent cases when transfusions may have
  been avoided with alternate approaches
• Determine how best to conduct thorough patient
  histories to gauge perioperative risk for
  bleeding or clotting

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Definition of Hemostasis
Hemostasis The Arrest of Bleeding Stedmans
Medical Dictionary

• Trauma
• Major Surgery
• Hemophilia

• Stroke
• MI
• Thrombosis

Hemostasis Life in the Balance
Lawson JH, et al. Semin Hematol. 200441(suppl
1)55-64.
10
Significant Bleeding

• gt2 L within the first 24 post-op hours1
• Surgical or vascular component corrected by
  surgical intervention or embolization2
• Coagulopathic component more difficult to
  control due to several interrelated mechanisms2,3
• Consumption of coagulation factors and platelets
• Dilution of coagulation factors
• Metabolic disorders (eg, hypothermia, acidosis)
• Inflammation due to tissue injury

1. Despotis GJ, et al. Ann Thorac Surg. 200070(2
suppl)S20-S32 2.
Vincent J-L, et al. Crit Care. 2006101-12 3.
Brohi K, et al. Ann Surg. 2007245812-818.
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Reasons for Uncontrolled Bleeding

• Patient-related
• Advanced age
• Small body size
• Gender
• Pre-op anemia (low red blood cell
  volume)
• Antiplatelet or antithrombotic drugs
• Comorbidities
• Congestive heart failure
• Hypertension
• Chronic obstructive pulmonary disease
• Peripheral vascular disease
• Diabetes mellitus
• Renal insufficiency

• Procedure-related
• Prolonged operation
• Coronary artery bypass graft
• Emergency/trauma
• Surgical-site bleeding
• Surgical skill

Ferraris VA, et al. Ann Thorac Surg.
200783S27-S86.
12
Can We Predict Who Will Bleed?
There Is a Difference Between Who Is At Risk and
Who Will Bleed

• Who is likely to bleed or clot too much?
• How do we optimize the patients physiology?
• Which topical agents are effective?
• Which biologic/pharmacologic agents are
  effective?

Adapted from Lawson JH, et al. Semin Hematol.
200441(suppl 1)55-64.
13
Patients at Risk for Surgical Bleeding

• Certain patients are at higher risk for surgical
  bleeding,
• including
• Patients taking the following1
• Long-acting anticoagulant therapy
• Clopidogrel
• Patients undergoing the following1
• Repeat surgical procedures
• Oncologic surgery
• Aortic surgery
• Cardiac surgery
• Neurologic procedures or neurosurgery
• Dialysis patients2
• Trauma patients2

1. Ferraris VA, et al. Ann Thorac Surg.
200783S27S86 2. Disorders of hemostasis. In
Fauci AS, et al, eds. Harrisons Internal
Medicine. New York, NY McGraw-Hill 2007.
Available at http//www.accessmedicine.com/resour
ceToc.aspx?resourceID4.
Accessed January 28, 2008.
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Conditions Associated With Coagulopathy

• Hemophilia
• Platelet disorders
• Liver disease
• Uremia
• Disseminated intravascular coagulation (DIC)
• Dilutional coagulopathy
• Anticoagulant treatment
• Tissue injury

Ferraris VA, et al. Ann Thorac Surg.
200783S27S86 Disorders of hemostasis. In
Fauci AS, et al, eds. Harrisons Internal
Medicine. New York, NY McGraw-Hill 2007.
Available at http//www. accessmedicine.com/resou
rceToc.aspx?resourceID4. Accessed January 28,
2008.
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Thienopyridines (eg, clopidogrel) and
Postoperative Bleeding

• Evidence is more compelling than for aspirin1
• 11 studies of clopidogrel and CABG
• All studies show increased bleeding when
  clopidogrel given within 5 days of CABG some
  with increased mortality
• ACC/AHA and STS/SCA guidelines recommend stopping
  clopidogrel for 5 days before surgery (if
  possible)1,2

CABGcoronary artery bypass graft.
1. Ferraris VA, et al. Ann Thorac Surg.
2005791454-1461

2. Braunwald E, et al. J Am
Coll Cardiol. 2002401366-1374.
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The Preoperative Patient Evaluation

• Labs for hemostatic abnormalities1
• Complete blood count (CBC)
• Platelet count
• Clot-based assays
• ? Activated clotting time (ACT)
• ? Activated partial thromboplastin time
  (aPTT)
• ? Fibrinogen
• ? Prothrombin time (PT)
• ? Thrombin time (TT)
• Clinical patient history2
• Multiple miscarriages?
• Bleeding from minor procedures?
• Easy bruising?
• Complications with previous surgeries?
• Family members had difficult surgeries?

1. Riley RS, et al. Laboratory Evaluation of
Hemostasis. Richmond, VA Virginia Commonwealth
University. Available at www.pathology.vcu.edu/cl
inical/coag/Lab20Hemostasis.pdf. Accessed March
4, 2008 2. Lawson JH. PPT presentation
available at www.bloodcmecenter.org. Accessed
March 4, 2008.
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Preparatory Measures for the Management
of Perioperative Bleeding

• Availability of anesthesia/support
• Topical hemostatic agents
• Systemic therapies
• Antifibrinolytic agents
• Cryoprecipitate
• Fresh frozen plasma (FFP)
• Platelets
• Recombinant factor VIIa (rVIIa)

Lawson JH. PPT presentation available at
www.bloodcmecenter.org. Accessed March 4, 2008.
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Question and Answer Session
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Patient Profile Claire W.

• Dx Hepatocellular adenoma
• Hx 34-year-old Caucasian female nulliparous
• 54, 110 lb pain in right upper quadrant
• Physical exam findings
• Palpable tender mass in
• right hypochondrium
• Jaundice
• Labs
• AST/ALT (mildly elevated)
• AFP (within reference range)
• Normal HbA1c (5)
• Normal fasting blood glucose level
  
• (100 mg/dL)
• Prolonged aPTT and PT
• Imaging studies
• Ultrasonography reveals hypoechoic lesion, well
  circumscribed,
• ?15 cm, located predominantly in
  right lobe of liver
• Liver resection surgery scheduled in 2 days

ASTaspartate aminotransferase ALTalanine
aminotransferase AFPserum
alpha-fetoprotein HbA1cglycosylated hemoglobin.
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Patient Profile Claire W. (cont)

• Surgical history
• ? Flexor tendon repair (uneventful surgery)
• ? Laparoscopic appendectomy (intraoperative
  bleeding
• complications encountered cautery used
  to resolve)
• Patient concerned about family history of
  surgical complications
• no further details available
• Medications
• ? Ethinyl estradiol and norethindrone
  combination oral
• contraceptive pill discontinued 3 months
  ago after 7 years
• of use wants to become pregnant
• Comorbidities
• ? None

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Polling Question 2

• Given this patients medical history and lab
  results, how concerned are you regarding her risk
  of bleeding?
• I am not concerned she is less likely to bleed
  than most patients
• I am not unduly concerned she runs the normal
  risk of bleeding
• I am somewhat concerned and would prepare for
  potential bleeding complications
• I am gravely concerned she runs a great risk of
  bleeding

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The Model of Hemostasis Is Evolving
II
X
VIII/vWF
VIIa
TF
Xa
IIa
Va
VIIIa
TF-Bearing Cell
TF
V
Va
VIIa
IX
Platelet
II
IXa
X
IIa
Xa
VIIIa
IXa
Va
Activated Platelet
VIIa
IXa
Va
IIa
Xa
VIIIa
II
IX
X
TFtissue factor vWFvon Willebrand factor.
Hoffman M, et al. Blood Coag Fibrinol.
19989(suppl 1)S61-S65.
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Normal Hemostasis Is a Balance

• Trauma
• Major Surgery
• Hemophilia

• Stroke
• MI
• Thrombosis

• Blood coagulation
• Anticoagulation
• Fibrinolysis
• Antifibrinolysis
• Vascular tone and blood flow
• Endothelial cells and platelets

Adapted from Lawson JH, et al. Semin Hematol.
200441(suppl 1)55-64.
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Keeping On Center Moving Toward
Normal Hemostasis
Topical Hemostatics Purified Factors, FFP, Cryo,
PLTs
Aminocaproic acid, Tranexamic acid, Aprotinin
Procoagulant Activity
Antifibrinolytic Activity
Normal Hemostasis
Bleeding
Clotting
Anticoagulant Activity
Fibrinolytic Activity
Heparin, Warfarin LMWH, Argatroban
t-PA, SK, UPA
FFPfresh frozen plasma Cryocryoprecipitate
PLTsplatelets SKstreptokinase
UPAurinary-type plasminogen activator
LMWHlow-molecular-weight heparin.
Adapted from Lawson JH, et al. Semin Hematol.
200441(suppl)55-64.
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Achieving Optimal Operative Hemostasis
Thrombosis
Clotting
Physiology and Good Surgery
Bleeding
Topical Hemostatic Agents
Hemorrhage
Systemic Biologic Therapies
Adapted from Lawson JH, et al. Semin Hematol.
200441(suppl)55-64.
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Hemostasis Practical Application Points

• Many surgical complications, regardless of
  surgery type, can be attributed to issues of
  bleeding or clotting
• It is important to determine which patients are
  at greatest risk for acquired coagulopathy as a
  result of uncontrolled bleeding
• Achieving optimal hemostasis involves a balancing
  act, whereby patients must be kept from bleeding
  or clotting to death through transfusional and
  nontransfusional therapies

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Patient Case Claire W.

• Liver resection surgery commences as planned
• 2 hours into procedure, surgeon notices that
  sponges are not clotting
• Excessive bleeding visible in surgical field
• Cauterization attempts fail
• Indeterminate origin of bleeding
• Hematocrit (HCT) 15, hemoglobin (Hb) 5 g/dL,
  platelets 120,000, fibrinogen lt100 mg/dL

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Question and Answer Session
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Polling Question 3

• At this juncture in the procedure, what would
  your recommendation be, given that the source of
  this patients bleeding is unclear?
• I would attempt to stop the bleeding using
  mechanical means
• I would transfuse using blood products
• I would utilize a nontransfusional method

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Blood Products in the Treatment of Hemorrhage
Decision Made to Transfuse in This Case

• 80 million units donated worldwide on an
  annual basis1
• According to recent estimates, 14.2 million units
  transfused annually in the United States2
• A blood transfusion is the most intimate possible
  contact with a stranger

1. World Health Organization. Available at
www.who.int/bloodsafety/en/Blood_Transfusion_Safet
y/pdf

2. Whitaker BI, et al. 2005 Nationwide
Blood Collection and Utilization Survey.
Bethesda, MD US Department of Health and Human
Services 2005.
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Blood Transfusion An Overview

• Benefits
• Blood volume replacement
• Transport of O2 and CO2
• Coagulation

• Potential Risks
• Transfusion-associated circulatory overload
  (TACO)
• Transfusion-related acute lung injury (TRALI)
• Disease transmission (especially platelets)
• HIV
• Hepatitis B
• Hepatitis C
• Transfusion-related immunomodulation (TRIM)
• Transfusion errors

Evidence Not enough data about benefits
Adapted from Ferraris VA, et al. Ann Thorac Surg.
200783S27-S86.
32
Blood Transfusion ASA Guidelines

• Red blood cell transfusion
• Rarely indicated with Hb gt10 g/dL
• Almost always indicated with Hb lt6 g/dL
• With intermediate Hb concentrations (6-10 g/dL),
  base decision on patients risk for complications
  of inadequate oxygenation

ASAAmerican Society of Anesthesiologists.
Stehling LC, et al. Anesthesiology.
199684732-747.
33
Blood Transfusion STS/SCA Guidelines

• Transfuse patients on CPB with Hb 6 g/dL
• Transfusion justified when Hb 7 g/dL in patients
  older than 65 years and patients with chronic
  CVD or respiratory disease
• Benefit unclear for stable patients with Hb
  between 7 and 10 g/dL
• Transfusion recommended for patients with acute
  blood loss gt1500 mL or gt30 of blood volume
• Evidence of rapid blood loss without immediate
  control warrants transfusion
• Issue of triggershave come a long way since
  10/30 rule, but still a long way to go

CPBcardiopulmonary bypass CVDcardiovascular
disease.
Adapted from Ferraris VA, et al. Ann Thorac Surg.
200783S27-S86.
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Risks of Blood Transfusion

• TACO
• Common reaction from rapid or massive transfusion
  of blood1
• Usually occurs within several hours after start
  of transfusion
• Manifested in signs and symptoms that include
• Dyspnea
• Orthopnea
• Peripheral edema
• Rapid increase in BP
• Incidence difficult to determine due to
  underreporting2
• Patients at risk include3,4
• Infants and elderly gt60/years
• Those with chronic anemia
• Those with cardiac/pulmonary/renal failure

1. Popovsky MA. Transfusion Clin Biol. 2001
8272-277 2. American Association of Blood
Banks. Technical Manual. 1999577-600 3. Gresens
CJ, et al. New York, NY Marcel Dekker, Inc
200171-86 4. Popovsky MA. Transfus Clin Biol.
20018272-277.
35
Risks of Blood Transfusion (cont)

• TRALI
• Rare and life-threatening complication
• Associated with transfusion of blood components
  containing RBCs, platelets, granulocytes, and
  cryoprecipitates1
• Usually occurs within 1-2 hours after start of
  transfusion2
• Characterized by acute respiratory distress2
• Symptoms include2
• Severe bilateral pulmonary edema
• Cyanosis
• Severe hypoxemia
• Tachycardia
• Hypotension
• Fever
• Incidence varies considerably from 1/5000 to
  16/10,0001
• Fatality rate ranges from 5 to 142

1. Kopko PM, et al. Transfusion.
2001411244-1248 2. Popovsky MA. Transfus Clin
Biol. 20018272-277.
36
Risks of Blood Transfusion (cont)

• Infectious diseases
• HIV
• Hepatitis B
• Hepatitis C
• Bacterial infection
• Immunologic reactions
• Febrile nonhemolytic transfusion reactions
• Anaphylactic transfusion reactions
• Complications resulting from misidentification or
  clerical error

Ferraris VA, et al. Ann Thorac Surg.
200783S27-S86.
37
How to Reduce Transfusions

• Immediate measures
• Employ multidisciplinary, multimodal
  treatment approach
• The lead clinician should provide proactive
  management
• Minimize iatrogenic blood loss, including
  phlebotomies
• Additional measures
• Modify routine practices if necessary
• Employ a restrictive transfusion strategy
• Reassess preoperative/postoperative use of
  anticoagulant and antiplatelet agents
• Establish in advance a management plan for rapid
  control of hemorrhage and transfusion

Shander A, et al. Curr Opin Hematol.
200613462-470.
38
Transfusion Practical Application Points

• Although transfusion is an important treatment
  modality for achieving operative hemostasis, data
  demonstrate that it also carries risks
• The threshold for initiating transfusions may be
  too low
• Are we transfusing more than we need to because
  triggers are not high enough?

39
Considering Alternatives to Blood Transfusion

• Is transfusion always appropriate?
• What are the other treatment options?

40
Prohemostatic Agents

• Antifibrinolytics
• Lysine analogs
• Aprotinin
• Topical hemostatics
• Protamine
• Desmopressin (DDAVP)
• Recombinant factor VIIa (rVIIa)
• Factor VIII inhibitor bypassing activity (FEIBA)/
  prothrombin complex concentrate (PCC)
  

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Antifibrinolytics

• As implied by the name, these agents enhance
  hemostasis when fibrinolysis contributes
  to bleeding
• Lysine analogs
• e-Aminocaproic acid (EACA)
• Tranexamic acid (TXA)
• Aprotinin Approved by FDA to reduce blood loss
  and transfusion in CABG but marketing suspended
  11/5/07

42
Lysine Analogs EACA and TA

• Trial data have limitations
• Often only small numbers of
• patients studied
• Variable design
• ?Treatment criteria
• ?Factor reduction
• Most data are for TA, not EACA
• TA doses range from 2 g to 25 g
• Most EACA/TA studies in lower-risk patients
• EACA removed from many European markets
• ?Safety data

Levy JH. Am J Health-Syst Pharm. 200562(suppl
4)S15-S19 Mangano DT, et al. N Engl J Med.
2006354353-365 Mannucci PM, et al. N Engl J
Med. 20073562301-2311.
43
Aprotinin Meta-analyses of Safety and Efficacy
in CABG

• Quantitative overview of clinical outcomes of
  aprotinin in CABG

• MEDLINE, EMBASE, PHARMLINE (1988 to 2001), and
  reference lists of CABG studies
• Random allocation of treatment
• Placebo control
• Enrollment of only CABG patients
• Noncombined use with another experimental
  medication or device
• Prophylactic and continuous intraoperative use
• Data from 35 CABG trials (N3879)

Mortality
MI
Renal failure
Stroke
Atrial fibrillation
Blood transfusion
0.1
1
10
RR
Sedrakyan J, et al. J Thorac Cardiovasc Surg.
2004128442-448. With permission from Elsevier.
MImyocardial infarction RRrelative risk.
44
Topical Hemostatic Agents

• Identified by FDA as a device intended to
  produce hemostasis by accelerating the clotting
  process of blood1
• Used to augment hemostasis in surgery/trauma
• Available in a variety of forms (solutions, gels,
  granules, sprays) and used in conjunction
  with collagen, gelatin, cellulose matrices
• Local thrombin and fibrinogen levels determine
  the rate of clot formation at wound site
• Classification
• Tissue/fibrin sealants (contain thrombin, fibrin,
  etc)
• Absorbable hemostatic agents (contain matrices)
• Combination products (contain both groups above)
• Efficacy Few RCTs1
• Safety Associated with numerous adverse events2

1. Lawson JH, et al. Available at www.
Fda.gov/ohrms/dockets/dockets/06n0362/06N-0362_ECI
-Attach-1.pdf. Accessed February 20, 2008 2.
Gabay M. Am J Health-Syst Pharm.
2006631244-1253.
45
Protamine

• Basic polypeptide isolated from salmon sperm
• 70 arginine
• Reverses unfractionated heparin, not LMWH
• Heparin rebound may occur
• Causes adverse drug reactions
• No alternatives available

LMWHlow-molecular-weight heparin.
Levy JH, et al. Anesth Analg. 198665739-742
Levy JH, et al. J Thorac Cardiovasc Surg.
198998200-204 Ferraris VA, et al. Ann Thorac
Surg. 200783S27S86.
46
Desmopressin

• Originally developed and licensed for the
  treatment of inherited defects of
  hemostasis1,2
• Several reviews suggest its effect is too small
  to influence the need for transfusion and
  reoperation1,2
• Most evidence of efficacy is in mild hemophilia A
  and von Willebrands disease1,2
• Not indicated for use in cardiac surgery
  patients1,2
• Meta-analysis in cardiac patients 2-fold
  increase in MI, a small decrease in perioperative
  blood loss, and no added benefits on clinical
  outcomes

1. Mannucci PM, et al. N Engl J Med.
20073562301-2311 2. Levy JH. Am J Health-Syst
Pharm. 2005 62(suppl 4)S15-S19.
47
Recombinant Factor VIIa

• Potent biologic prohemostatic agent
• Promotes hemostasis by activating the
  coagulation cascade
• Approved for use in complicated coagulation
  disorders
• Hemophilia A or B
• Patients with inhibitors to factors VIII or IX
• Generates prohemostatic response in patients
  treated with new-generation anticoagulation
  agents
• Safety
• Thromboembolic events
• More randomized controlled trials needed

Kempton CL, et al. Cardiovasc Hematol Agents Med
Chem. 20064319-334 OConnell KA, et al. JAMA.
2006295293-298.
48
Off-label Uses of rVIIa

• Increasingly being considered for
• Reversal of oral anticoagulation
• Reversal of heparin, lepirudin, and fondaparinux
• Thrombocytopenia and thrombocytopathy
• Bleeding with impaired liver function
• Gastrointestinal bleeding
• Trauma
• Surgery Non-trauma?related (hepatic resection,
  prostatectomy, cardiac, spinal)
• Off-label uses are primarily based on case
  reports
• Ongoing trials in cardiac surgery, trauma and
  burns, postpartum hemorrhage, etc

Kempton CL, et al. Cardiovasc Hematol Agents Med
Chem. 20064319-334.
49
Prohemostatic Agents
Practical Application Points

• Lysine analogs have variable effects on reducing
  bleeding no safety data exist
• Aprotinin reduces bleeding and transfusions
  November 2007 Marketing suspended
  in United States1
• Topical hemostatics are useful as adjunctive
  therapy numerous adverse events have occurred
  with their use
• Protamine does not reverse low-molecular-
  weight heparin
• DDAVP has minimal effects on bleeding
• rVIIa is increasingly used off-label to control
  perioperative bleeding/achieve operative
  hemostasis global RCTs in progress

According to a May 14, 2008, FDA news release,
aprotinin stock is being removed from the US
market, with access limited to on-label
investigational uses with IRB approval. 1. US
Food and Drug Administration. Available at
http//www.fda.gov/bbs/topics/NEWS/2008/NEW01834.h
tml. Accessed June 6, 2008.
50
Polling Question 4

• If transfusion proved ineffective in Claire W.s
  clinical situation, how comfortable would you be
  using the prohemostatic biologic/pharmacologic
  agents to achieve optimal hemostasis?
• I would feel very comfortable using any of the
  prohemostatic agents
• I would use the available prohemostatic agents as
  indicated
• I would have reservations about using some of the
  available prohemostatic agents

51
Final Thoughts

• This presentation has demonstrated the following
• The preoperative patient evaluation is an
  important tool in determining risk for
  perioperative bleeding
• Transfusion is only one treatment option for
  achieving operative hemostasis
• Alternative hemostatic agents are available to
  balance bleeding and clotting

52
Question and Answer Session
53

• For more CE/CME educational programs on the
  subject of operative hemostasis and transfusion
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