Use of recombinant factor VIIa for refractory hemorrhage during extracorporeal membrane oxygenation*

Objective To describe the outcome and treatment of two patients with recombinant factor VIIa (rFVIIa) for severe hemorrhage associated with extracorporeal membrane oxygenation (ECMO). Design Case report. Setting A 38-bed pediatric intensive care unit and 20-bed pediatric cardiac intensive care unit at a tertiary care children's hospital. Patient Two patients with life-threatening hemorrhagic complications associated with ECMO requiring massive transfusion of blood products. Interventions Administration of repeated doses of rFVIIa at 90 microg/kg/dose. Measurement and main results PATIENT 1 was an 11-yr-old male with a dilated cardiomyopathy who had undergone an orthotopic heart transplant treated with venoarterial ECMO postoperatively for right ventricular dysfunction. PATIENT 2 was a 13-yr-old male treated with venoarterial ECMO for cardiopulmonary failure from necrotizing staphylococcal pneumonia. Both patients had severe hemorrhage from the cannulation sites and thoracostomy tubes requiring massive transfusion to maintain intravascular blood volume and replace clotting factors. Both patients were treated with rFVIIa every 2-4 hrs and attained hemostasis. PATIENT 1 was administered three doses and PATIENT 2 was administered ten doses. No evidence of abnormal thrombus formation was noted in their respective ECMO circuits. Conclusions The efficacy of rFVIIa in reducing intractable bleeding postcardiac surgery and in other coagulopathic states is being investigated. Despite theoretical concerns of thrombosis, these cases illustrate that there may be a role for the cautious use of rFVIIa in treating severe and intractable hemorrhage associated with ECMO.