Free
Correspondence  |   April 2003
Use of Recombinant Activated Factor VII in Patients with Severe Coagulopathy and Bleeding: In Reply:
Author Affiliations & Notes
  • Erik Svartholm, M.D., Ph.D.
    *
  • *Jànkàping Hospital, Jànkàping, Sweden.
Article Information
Correspondence
Correspondence   |   April 2003
Use of Recombinant Activated Factor VII in Patients with Severe Coagulopathy and Bleeding: In Reply:
Anesthesiology 4 2003, Vol.98, 1027. doi:
Anesthesiology 4 2003, Vol.98, 1027. doi:
In Reply:—
We are grateful for the interesting responses to our article concerning the use of recombinant activated factor VII (rFVIIa). 1 Drs. Ho, Dion, and Karmakar discuss the place of rFVIIa in refractory bleeding and wish to caution against “premature” use of this drug or any new technology. We fully agree that all other conventional techniques or pharmaceutical agents have to be used primarily. This was also stated in the last few sentences of our report. However, we do not agree that further supplementation with only fresh frozen plasma would have saved our patient.
First, there was no tendency of hemostasis during or shortly after the fresh frozen plasma infusion. Second, there was abrupt stabilization already after administration of the first dose of rFVIIa. This indicates that the amounts of other coagulation factors were enough to stop the bleeding after rFVIIa had initiated the first step, although Ho et al.  are correct that the amount of fresh frozen plasma given to our patient could have been increased. It has been shown that pharmacologic doses of rFVIIa enhance thrombin generation on already activated platelet surfaces on which negatively charged phospholipids are being exposed. 2 
Furthermore, a full thrombin burst is known to be necessary for a stable fibrin hemostatic plug to be formed. By enhancement of thrombin generation, the formation of a tight fibrin structure is ensured. In situations with increased fibrinolytic activity, which often is seen in extensive tissue damage, it may be helpful to make sure that a tight fibrin plug, resistant against premature lysis, is being formed. In fact, preliminary data from the use of rFVIIa in trauma patients do suggest a beneficial effect on profuse, extensive bleeding. 3 
A wide range of therapeutic modalities is therefore necessary for critically ill bleeding patients, but, again, newly developed therapeutic modalities must be critically evaluated before use in clinical situations.
References
Svartholm E, Annerhagen V, Lanne T: Treatment of bleeding in severe necrotizing pancreatitis with recombinant factor VIIa. A nesthesiology 2002; 96: 1528Svartholm, E Annerhagen, V Lanne, T
Monroe D, Hoffmann M, Oliver J, Roberts H: Platelet activity of high-dose factor VIIa is independent of tissue factor. Br J Haematol 1997; 99: 542–7Monroe, D Hoffmann, M Oliver, J Roberts, H
Martinowitz U, Kenet G, Segal E, Luboshitz J, Lubetsky A, Ingerslev J, Lynn M: Recombinant activated factor VII for adjunctive hemorrhage control in trauma. J Trauma 2001; 51: 431–8Martinowitz, U Kenet, G Segal, E Luboshitz, J Lubetsky, A Ingerslev, J Lynn, M