title: Successful use of recombinant factor VIIa for hemostasis during total knee replacement in a severe hemophiliac with high-titer factor VIII inhibitor.
abstract: A 32-year-old male patient with severe factor VIII (FVIII) deficiency had developed a high-titer FVIII inhibitor at age 13. Recurrent hemarthroses caused bony destruction in both knees, significantly impairing his ability to walk. Knee examination revealed 20 degrees of varus, destruction of the medial joint line, and flexion contracture. Total knee arthroplasty was performed using recombinant factor VIIa (rFVIIa, NovoSeven) for hemostatic control. rFVIIa (85 microg/kg given intravenously over 3-5 minutes) was given just prior to surgery. The dose was repeated every 2 hours during and for the first 48 hours after surgery. When the tourniquet was removed, rFVIIa had not been infused for 1.5 hours, and significant hemorrhage was noted. The hemorrhage responded promptly to rFVIIa infusion. The infusion interval was extended to every 4 hours for an additional 48 hours, and subsequent doses were given every 6 hours until the patient returned to the clinic 2 days postdischarge. Hemoglobin levels dropped from 16.9 gm/dL on admission to 9.1 gm/dL at discharge. After 2 months, the patient returned to work. We recommend that tourniquet release be performed immediately after rFVIIa administration and that aggressive physical therapy be considered in the early postoperative period when rFVIIa infusions are frequent.
authors.affiliation: Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, USA. mcarr@hsc.vcu.edu
authors.forename: Marcus E
authors.initials: ME
authors.lastname: Carr
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Loughran
authors.forename: John A
authors.initials: JA
authors.lastname: Cardea
authors.forename: Wade K
authors.initials: WK
authors.lastname: Smith
authors.forename: Jan G
authors.initials: JG
authors.lastname: Kuhn
authors.forename: Maribeth V
authors.initials: MV
authors.lastname: Dottore
mesh_terms: D000328:Adult; D019645:Arthroplasty, Replacement, Knee; D016063:Blood Loss, Surgical; D004334:Drug Administration Schedule; D005169:Factor VIII / Q000276:immunology*; D015942:Factor VIIa / Q000008:administration & dosage / Q000235:genetics / Q000627:therapeutic use*; D006395:Hemarthrosis / Q000209:etiology / Q000601:surgery*; D006467:Hemophilia A / Q000150:complications* / Q000276:immunology; D006488:Hemostasis, Surgical; D006801:Humans; D007262:Infusions, Intravenous; D007518:Isoantibodies / Q000097:blood*; D008297:Male; D019106:Postoperative Hemorrhage / Q000188:drug therapy; D011292:Premedication; D011993:Recombinant Fusion Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D014111:Tourniquets
chemical_list: D007518:Isoantibodies; D011993:Recombinant Fusion Proteins; D005169:Factor VIII; D015942:Factor VIIa