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J Thorac Cardiovasc Surg 2002;124:852-854
© 2002 The American Association for Thoracic Surgery

Brief Communications

Fatal thrombosis after administration of activated prothrombin complex concentrates in a patient supported by extracorporeal membrane oxygenation who had received activated recombinant factor VII

Jack D. Bui, MD, PhDa, George D. Despotis, MDa,b, Elbert P. Trulock, MDc, G. Alexander Patterson, MDd, Lawrence T. Goodnough, MDa,c St Louis, Mo

From the Departments of Pathology and Immunology,a Anesthesiology,b Internal Medicine,c and Surgery,d Washington University School of Medicine, St Louis, Mo.

Received for publication April 11, 2002. Accepted for publication April 24, 2002. Address for reprints: Lawrence T. Goodnough, MD, Department of Pathology and Immunology, Box 8118, Washington University School of Medicine, 660 S Euclid, St Louis, MO 63110 (E-mail: goodnough@labmed.wustl.edu).

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  		Dr Goodnough

 
Excessive bleeding after cardiac surgery has been attributed to perturbations of the hemostatic system as a result of surgical trauma and the use of cardiopulmonary bypass (CPB). Factor concentrates, such as recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrates (APCCs, Factor Eight Inhibitor Bypass Inhibitor [FEIBA]; Baxter Healthcare Corporation, Deerfield, Ill) have been used with variable success and complications. We describe a case in which a patient supported by extracorporeal membrane oxygenation (ECMO) received two doses of rFVIIa without apparent complication. He then received APCC and subsequently died of massive thrombosis. We discuss the use of factor concentrates in the surgical setting and make recommendations.

Clinical summary

A 56-year-old man underwent retransplantation on November 19, 2000, for bronchiolitis obliterans syndrome that developed after bilateral lung transplantation in 1993 for chronic obstructive pulmonary disease. The patient had normal hepatic and renal function and a normal coagulation profile before surgery. After an uneventful anesthetic induction, CPB was required to maintain acceptable oxygenation during the intraoperative period. There was profuse blood loss during the procedure, which necessitated transfusion of large amounts of blood products (Figure 1). Continued blood loss was observed at the end of the operation, despite discontinuation and reversal of heparin. Attempts to terminate CPB were unsuccessful, and ECMO was instituted without heparin. The patient was transported to the intensive care unit with ECMO support. In the intensive care unit, drainage from the chest tubes exceeded 1 L/h for 2 hours, with no response to continued transfusion of blood components. . . . [Full Text of this Article]




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