Recombinant factor VIIa for the correction of coagulopathy before emergent craniotomy in blunt trauma patients.
BACKGROUND
Recombinant activated factor VII (rFVIIa) has been associated with decreased blood transfusion requirements in trauma patients. Clinical use has recently been extended to the treatment of coagulopathic patients with traumatic brain injury, and results have been encouraging. However, the cost and possible thromboembolic complications of rFVIIa have been considered barriers to its widespread use. We hypothesize that rFVIIa would provide an effective and cost efficient means of correcting coagulopathy in patients with traumatic brain injury undergoing emergent craniotomy.


METHODS
We performed a 2-year (2005-2006) retrospective study of adult blunt trauma patients with traumatic brain injury who presented coagulopathic (international normalized ratio [INR] >1.3) and required emergent craniotomy. We compared patients who did (rFVIIa group) and did not (no-rFVIIa group) receive rFVIIa to correct coagulopathy before craniotomy.


RESULTS
There were 14 rFVIIa patients and 14 no-rFVIIa patients. The rFVIIa patients were older (59 years vs. 41 years, p = 0.04), but there was no difference in male gender (79% vs. 79%, p = 0.68), injury severity score (29 vs. 29, p = 1.0), or Glasgow Coma Scale score (10 vs. 7, p = 0.67). Although there was no difference in admission INR (2.6 vs. 1.9, p = 0.10), the rFVIIa group was more often taking preinjury coumadin (57% vs. 14%, p = 0.05). The rFVIIa group had a preoperative INR (1.2 +/- 0.4 vs. 1.4 +/- 0.2, p = 0.05), but there was no difference in the time from admission to craniotomy (135 minutes vs. 182 minutes, p = 0.51). The rFVIIa group received fewer units of packed red blood cells (PRBCs) and plasma during the perioperative period. In addition, the rVIIa group consumed fewer costs of PRBC ($756 per patient vs. $2,916 per patient, p < 0.001) and plasma ($369 per patient vs. $927 per patient, p = 0.001). The rFVIIa group still consumed fewer total costs of transfused blood products when cost of rFVIIa was included ($2,557 per patient vs. $4,110 per patient, p = 0.04). There were no thromboembolic complications in either group.


CONCLUSIONS
rFVIIa provides a cost-efficient option to effectively correct coagulopathy in patients with traumatic brain injury undergoing emergent craniotomy. In addition, the use of rFVIIa is associated with decreased transfusion of PRBC and plasma and decreased transfusion-related hospital costs in this population.
Department of Surgery, University of Texas Southwestern Medical School - Austin, University Medical Center Brackenridge - Trauma Services, Austin, Texas 78701, USA. cvrbrown@seton.org
Carlos V R
CV
Brown
Kelli H
KH
Foulkrod
Daniel
D
Lopez
John
J
Stokes
Jesus
J
Villareal
Katie
K
Foarde
Eardie
E
Curry
Ben
B
Coopwood
D000328:Adult; D000368:Aged; D001778:Blood Coagulation Disorders / Q000188:drug therapy*; D001930:Brain Injuries / Q000601:surgery*; D003399:Craniotomy; D004632:Emergency Medical Services; D015942:Factor VIIa / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D012189:Retrospective Studies; D014949:Wounds, Nonpenetrating
D011994:Recombinant Proteins; C103587:recombinant FVIIa; D015942:Factor VIIa