title: Case report: management of life-threatening oropharyngeal bleeding with recombinant factor VIIa.
abstract: OBJECTIVE
  To report the use of recombinant factor VIIa (rFVIIa) for management of profuse oropharyngeal bleeding in a cirrhotic patient that nearly resulted in a 'cannot intubate, cannot ventilate' scenario.
  
  
  METHODS
  A 42-yr-old woman with end-stage liver disease presented for orthotopic liver transplantation. She was dialysis dependent and had marked coagulopathy [international normalized ratio (INR) = 3.1], without evidence of active bleeding. Following uneventful induction of anesthesia, routine airway manipulation for tracheal intubation caused profuse upper airway bleeding making visualization of her airway by direct laryngoscopy impossible. Moreover, several further attempts at tracheal intubation along with the bleeding made manual ventilation progressively more difficult, nearly resulting in a 'cannot intubate, cannot ventilate' scenario. In an attempt to control the bleeding, rFVIIa 4.8 mg iv was administered. Within five minutes, her INR had decreased to 1.1, bleeding was markedly reduced, the vocal cords were successfully visualized using an anterior commissure laryngoscope, and intubation of the trachea was achieved with the use of a gum-elastic bougie. Postintubation examination of the airway showed several abrasions along the right oropharyngeal wall with minimal bleeding. The remainder of surgery and postoperative airway management were uneventful.
  
  
  CONCLUSIONS
  This report demonstrates that in the relatively uncommon setting of upper airway hemorrhage in a patient with pre-existing coagulopathy, rFVIIa can be effective in gaining rapid control of bleeding to facilitate visualization of the vocal cords and securing of the airway.
authors.affiliation: Toronto General Hospital, University Health Network, Department of Anesthesia, Toronto, Ontario, Canada.
authors.forename: Sheila
authors.initials: S
authors.lastname: Riazi
authors.forename: Keyvan
authors.initials: K
authors.lastname: Karkouti
authors.forename: Jane
authors.initials: J
authors.lastname: Heggie
mesh_terms: D000328:Adult; D005167:Factor VII / Q000627:therapeutic use*; D015942:Factor VIIa; D005260:Female; D006470:Hemorrhage / Q000188:drug therapy*; D006801:Humans; D007442:Intubation, Intratracheal; D009960:Oropharynx / Q000503:physiopathology*; D010608:Pharyngeal Diseases / Q000188:drug therapy; D011994:Recombinant Proteins / Q000627:therapeutic use
chemical_list: D011994:Recombinant Proteins; D005167:Factor VII; C103587:recombinant FVIIa; D015942:Factor VIIa