Alternative Factor Prescribing after Low-Dose Recombinant Factor VIIa Protocol in Cardiac Surgery

BackgroundSafety concerns exist with the off-label use of recombinant factor VIIa (rFVIIa, Novoseven RT(R)) for refractory bleeding in cardiac surgery, including increased risk of thromboembolism. A rFVIIa protocol was implemented in December 2015 to standardize rFVIIa for cardiac surgery related hemorrhage. MethodsWe performed a retrospective, observational review of rFVIIa in adult cardiac surgery patients pre-protocol (January 2015 to November 2015) vs. post-protocol (December 2015 to March 2016). Study outcomes were rate of rFVIIa administration, rFVIIa dosing characteristics, length of stay, mortality, readmission rate, need for re-exploration, and rate of 4-factor Prothrombin Complex Concentrates (PCC; Kcentra(R)) administration. ResultsThere was a significant reduction in percentage of cardiac surgery cases receiving rFVIIa pre-vs. post-protocol (14.3 vs. 5.2%, p=0.015). Average total dose per patient decreased between groups (81.4 vs. 56.6 mcg/kg, p=0.059). In-hospital mortality, length of stay, need for re-exploration, readmission rates and 30-day mortality did not differ. Although 4-four-factor PCC significantly increased post-protocol (2.5% vs. 8%, p=0.02), overall use of factor products, rFVIIa or 4-factor PCC, did not change between study periods (16.8% vs. 13%, p=0.416). Mean cost of either rFVIIa or 4-factor PCC pre-protocol was significantly higher than that post-protocol ($8,778 vs. $4,421, p=0.0008). ConclusionsThe use of rFVIIa decreased after implementation of a rFVIIa protocol targeting 30 mcg/kg/dose without compromising morbidity or mortality outcomes. Four-factor PCC use significantly increased during the study, but the overall cost was reduced. Institutions wanting to implement a rFVIIa protocol should take careful measures to concurrently address off-label use of 4-factor PCC.