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Sun Jan 18 11:03:44 GMT 2009

Dear List
The issue with Factor VIIa would appear to be not if it should be used but rather when and in what circumstances.

Many units have clearly demonstrated that it is not a 'cure all' for TIC. I have no doubt that the lack of support for VIIa has resulted from it's completely random use by some units in all sorts of differ-net situations. Inevitably in many such cases it failed to help.

The timing of administration would appear to be essential, given too late, after massive transfusion (as many units use as their 'trigger') then it is too late, but Yoram Kluger and the Israeli work has demonstrated that giving it at the roadside produces poor reuslts. There is clearly a critical time for administration, we just don't know when!

Hypothermia is another major issue as so many units have administered VIIa to cold and acidotic patients. The effect of VIIa can be reduced by as much as 90% in hypothermia and they have wasted such a precious agent.

When giving VIIa we also need to support it with other factors or else it simply creates a deficiency of other factors in the cascade. Always organise FFP and platelets to immediately support the use of the agent.

As  we have all described avoiding over-dilution with crystalloid and usin permissive anaemia and early haemostasis remains the priority.

1:1:1 may not be such an ideal concept and we rarely if ever achieve 1:1 blood to FFP as we simply cannot get that amount of FFP. Even the centres in Germany that have adopted this can rarely achieve it. In addition, as Karim suggests, there are many papers that also describe significant side effects from high volume FFP.

The bottom line as others have said, is that there is certainly a place for VIIa but the problem is when. Factor XIII is interesting as Karim has said but I would imagine that the problem will be the same. Many of us hoped that TEG may be the best indicator for timing use of these agents and it may still be the best option, but it is far from totally reliable.

The old line.....'more research is needed' sadly comes to the fore!

Regards
Mark F 
UK

Dr Mark Forrest
Consultant in Anaesthetics & Critical Care
Medical Director of Cheshire Fire & Rescue Service
Medical Director of ATACC

________________________________
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
To: Trauma & <trauma-list at trauma.org>
Sent: Saturday, 17 January, 2009 1:55:40 PM
Subject: RE: Factor VII (7) clinical triggers for use in the trauma OR

The most important move is to quicker application of Factor XIV

Hemostat and ligature 

Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of Karim Brohi
Sent: Sat 1/17/2009 2:55 AM
To: Trauma &amp, Critical Care mailing list
Subject: Re: Factor VII (7) clinical triggers for use in the trauma OR

We have also not given Factor 7 for some time now, and are using a higher
(but not 1:1) plasma dose than previously (give very little crystalloid and
no colloid).  Having said that we never really incorporated it into our
protocols and outside of the CONTROL trial really never gave the drug.  Not
because we don't think it works but because, as Ken says, we simply didn't
know who to give it to, or when.
Which is a shame, because I do believe it has a place somewhere in the
anti-TIC armamentarium.  Moreover, I think it's probably safer (and
definitely less immunogenic) to give a dose of F7a than 10 or 15 units of
FFP.  Whether F7a is equivalent to 10 units of FFP (or 5 or 15) is another
matter.  There's a lot more work to be done, and we need to get a lot better
at identifying the pattern of coagulopathy and directing therapy - probably
with multiple interventions.  It's a shame there'll probably be no further
funded research into Factor 7.  I'm hopeful for Son of factor 7 - not as a
panacea as NovoSeven was promoted - but as a procoagulant drug to be used to
treat TIC).

Also keep an eye out for Factor XIII, which looks like it might be
interesting.

K

2009/1/16 <KMATTOX at aol.com>

> I agree with the group from Charity in New Orleans and Tulane.  If you  do
> not give large volumes of crystalloid, your requirements for rVIIa will
> basically disappear.
>
> k
>
>
>
>
>
>
> In a message dated 1/16/2009 7:45:02 A.M. Central Standard Time,
> Marc_Matthews at medprodoctors.com writes:
>
> Juan,
>
> Thank you. I would like to set up triggers for my  surgeons. I will read
> this
> ASAP.
>
> Thanks,
>
>
> -  MRM
>
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> -----Original  Message-----
> From: trauma-list-bounces at trauma.org  [mailto:
> trauma-list-bounces at trauma.org]
> On Behalf Of Duchesne, Juan C
> Sent: Friday, January 16, 2009 5:25 AM
> To: Trauma &amp; Trauma  &amp
> Subject: RE: Factor VII (7) clinical triggers for use in the  trauma OR
>
> Dear Marc- since the institution of Early Hemostatic  Resuscitation at
> Charity, NO we counted only 2 cases were factor VII was used  over the last
> 2 years,
> for which both patients end up dying. Based on our  experience we decided
> to
> look further into this question. The below reference  may be of help:
> Good Luck
> Juan
>
> Current evidence based guidelines  for factor VIIa use in trauma: the good,
> the bad, and the ugly.
> <
> https://ent.tulane.edu/pubmed/19097529?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel
> .
> Pubmed_RVDocSum>
>
> Duchesne JC, Mathew KA, Marr AB, Pinsky MR, Barbeau JM, McSwain  NE.
>
> Am Surg. 2008 Dec;74(12):1159-65.
>
>
> Juan C. Duchesne MD,  FACS, FCCP
> Director Surgical Hospital Center
> Director Tulane Surgical  Intensive Care Unit AMR Regional Director
> Louisiana
> Emergency Response  Network
>
>
> Division of Trauma and Critical Care Surgery Tulane &  LSU Department of
> Surgery and Anesthesiology 1430 Tulane Ave., SL-22 New  Orleans LA
> 70112-2699 Tel.
> 504-988-5111 Fax.  504-988-3683
>
>
>
>
>
> ________________________________
>
> From:  trauma-list-bounces at trauma.org on behalf of Marc Matthews - MedPro
> MMC
>  X
> Sent: Thu 1/15/2009 9:34 PM
> To: Trauma &amp
> Subject: RE: Factor  VII (7) clinical triggers for use in the trauma OR
>
>
> All,
>
> Does anybody have clinical triggers for the use of  Factor VII (7) in the
> trauma OR? I am looking for any institution that has a  guideline based on
> the
> literature for the triggers that they could share with  me and anyone on
> this
> list server. I am looking to educate and provide  economically sound advice
> on a
> very expensive medication. There have to be  guidelines in trauma centers.
>
> Anyone with a guideline or protocol  regarding this would help as well as
> any
> salient pieces of advice in its use  or non-use.
>
> Thank you,
>
> MRM
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Factor VII (7) clinical triggers for use in the trauma OR