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Managing Acute Bleeding

One of the priveleges I enjoy because I am married to an SBB (Margaret Giddens Fritsma MA MT (ASCP) SBB) is attending the Alabama State Association of Blood Banks semiannual dinner meeting. Last evening Marla Troughton, MD, associate director of the UAB transfusion service spoke on emerging infectious diseases that affect donor blood screening, and Derek Langner, MT (ASCP), manager of the Jackson Hospital, Montgomery, transfusion service shared a statistical comparison of automated antibody identification systems. Of course, these topics were outside my hemostasis comfort zone, but you can always get a blood banker to discuss coagulation component therapy.

I had the opportunity to speak with Mr. Jose DeJesus, MS MT (ASCP), transfusion service manager for DCH Medical Center, Tuscaloosa, about the management of acute bleeding. Neither Jose nor I are physicians, but all transufsion service managers attempt to enforce component therapy guidelines, particularly when supporting a surgeon is faced with a bleeding patient.

Jose expressed concern about the tendency to overuse activated factor VII (VIIa, NovoSeven) to control bleeding, bypassing conventional therapy. He likes to monitor NovoSeven usage because of  its cost and because of recent studies that implicate it in thrombotic episodes.

Before I get into our discussion, let me refer you to some authoritative bleeding patient management text on page 29 in Marques MB, Fritsma GA. Quick Guide to Coagulation Testing. AACC Press, 2006. (Please forgive the self-promotion).

At Jose’s facility, the rule of thumb is to recommend a unit of frozen plasma for every two units of red cells in managing acute bleeding with a suspected coagulopathy. By the way, we’ve moved from fresh frozen to 24-hour plasma (FP24) in most circumstances. Plasma is often used in conjunction with platelet concentrate, or the concentrate may be used as a follow-up.

Jose recommends cryoprecipitate as a next step for fibrinogen replacement, and finally NovoSeven. NovoSeven was originally developed for use in people with hemophilia who have developed an anti-factor VIII inhibitor, as NovoSeven bypasses the need for factor VIII in coagulation. However, the product is now used regularly and successfully to control bleeding. The dosage may be reduced to 1/3 the dosage for inhibitor management.
I’m curious if others are managing acute bleeds this way, and how much NovoSeven you are using. Geo

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