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"Timing and patient selection, when and to whom remains the big question!"

Not really, Mark.  The question is whether to give it at all.....and I have to tell you that in my experience the use of RFVIIa, with what we know (little) and when we currently use it, is as helpful as peeing into the ocean hoping to raise the tides.

Just my 2 cents,
Ron


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Mark Forrest
Sent: Thursday, December 23, 2010 4:27 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: MTP

Stuke
We have certainly found that you can give it too late. Our original protocol was basically to consider it after 18 units of blood (not quite sure where the figure came from) but at this late stage it never appeared to work in our hands, so we now at least 'consider it' as soon as we activate our massive transfusion protocol and after TXA.

But we also ensure other necessary  factors are present and that a reasonable degree of homeostasis is present or it definitely won't work. Saying that sometimes we do everything by the book and it still doesn't seem to do much!

You can certainly give it too late but also too early too ( Yoram Kluger trialled it with paramedics in Israel with no improvement). 

Timing and patient selection, when and to whom remains the big question!

Regards
Mark



Sent from my iPhone

On 23 Dec 2010, at 19:39, "Stuke, Lance E." <lstuke at lsuhsc.edu> wrote:

> I've had little success with Factor VIIa, and rarely use it now at Charity, as I don't believe it works. However, I wonder if I've been using it incorrectly. For example - I usually give it as a last-ditch salvage attempt in a trauma patient who is already severely coagulopathic after I've operated on them in a damage-control situation. These patients have usually had several blood volumes replaced and are requiring ongoing blood product replacement. I suspect most of us have used it in a similar fashion.
> 
> What if we gave it in the operating room immediately after getting control of surgical bleeding instead of waiting until the patient is near extremis? Has anybody tried this already?  It may be something to consider in a multi-institutional trial in trauma centers with high rates of operative trauma (Charity, BenTaub, Grady, etc). Perhaps giving it early instead of late in the course of resuscitation will improve its efficacy. I doubt it, and I'm not a fan, but a study like this could put the issue to rest. 
> 
> Stuke
> 
> Lance Stuke, MD, MPH
> Spirit of Charity Trauma Center
> Assistant Professor of Surgery
> LSU Department of Surgery
> New Orleans, LA
> 
> 
> ________________________________
> 
> From: trauma-list-bounces at trauma.org on behalf of Karim Brohi
> Sent: Thu 12/23/2010 1:51 AM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: MTP
> 
> 
> 
> We never really used Factor VIIa routinely in trauma haemorrhage - we
> were part of both the Phase II and Phase III (CONTROL) factor 7 trials
> and it was used occasionally in extremis with variable effect.  It was
> never included in our protocols because we felt we did not know where
> it's place was in the transfusion/coagulopathy armamentarium.
> Unfortunately I think that is still the case.
> 
> Fundamentally the design of CONTROL was flawed and based on limited
> available data.  Many always expected CONTROL to be negative because
> of the low acuity of the target population (changed from the Phase II
> study).  (This is similar to the positive to negative switch in the
> PROWESS to ADDRESS in the activated protein C studies).
> 
> Lack of effect in CONTROL  (above the identified reduction in
> transfusion requirements) does not necessarily mean rFVIIa has no
> effect in trauma patients.  We still don't know A) Which trauma
> patients develop low coagulation factor levels, what induces this and
> when it occurs during haemorrhage and B) which trauma patients respond
> optimally to procoagulant therapy (F7a, PCC, Fibrinogen or FFP), when
> and in what dose.
> 
> So I wouldn't use rVIIa in trauma patients at the moment but I
> wouldn't write it (or its newer analogues) off yet, there's a lot more
> to learn.
> 
> Karim
> 
> On Wed, Dec 22, 2010 at 13:28, Juan Duchesne <jduchesn at tulane.edu> wrote:
>> No. Since we instituted DCR into our MTP back in 06-07, we've used factor 7 rarely ( 2-3 times a year).
>> J
>> 
>> Sent from my iPhone from Spirit of Charity Trauma Center, NOLA
>> 
>> 
>> On Dec 22, 2010, at 1:10, Tchaka Shepherd <tshepherdmd at hotmail.com> wrote:
>> 
>>> 
>>> Has anyone found it advantageous to add factor seven or factor nine to their MTP?
>>> 
>>> 
>>> NOTHING  SPLENDID Has Ever Been Achieved Except By Those Who DARED BELIEVE THAT SOMETHING INSIDE THEM  Was Superior to CIRCUMSTANCE
>>> 
>>> 
>>> 
>>> 
>>> 
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