Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA.
Ann Pharmacother. 2011 Nov;45(11):e60. doi: 10.1345/aph.1Q305. Epub 2011 Oct 25.
To evaluate the use of recombinant activated factor VII (rFVIIa) in a patient with fulminant hepatic failure (FHF) requiring placement of an intracranial pressure monitor.
A 21-year-old female with no significant medical history was admitted to an outside hospital with elevated results of liver function tests. Subsequently, the patient was diagnosed with autoimmune hepatitis. Systemic corticosteroids were started, but her condition continued to decompensate. She was transferred to our tertiary care facility 5 days after initial presentation. The liver function test results remained elevated (eg, total bilirubin 27 mg/dL), and international normalized ratio (INR) was 3.57. The medical team decided to place an intracranial pressure monitor, with the neurosurgery team's goal being an INR less than 1.5 before placement of the monitor. After multiple units of fresh frozen plasma (FFP) failed to lower the patient's INR, rFVIIa 40 μg/kg was administered. A rapid decrease of the INR allowed the neurosurgery team to perform the procedure without complications.
The use of rFVIIa allowed for decrease of this patient's INR after multiple units of FFP had failed to correct it. The utility of INR as a marker of coagulopathy in fulminant hepatic failure has been debated, but it is currently used as the standard laboratory test prior to invasive procedures, as in the case presented here.
The use of rFVIIa for rapid decrease of INR in a patient with FHF prior to an invasive procedure was safe and efficacious. When considering the use of rFVIIa, clinicians should be aware of the risk of thrombosis. In our experience, and in the limited literature on the matter, rFVIIa 40 μg/kg appears to be an appropriate dose for decrease of the INR. Further studies are needed to confirm this finding.
评估在需要放置颅内压监测器的暴发性肝衰竭（FHF）患者中使用重组活化因子 VII（rFVIIa）的效果。
一名 21 岁女性，无明显病史，因肝功能检查结果升高而被收入外院。随后，该患者被诊断为自身免疫性肝炎。给予全身皮质类固醇治疗，但病情持续恶化。在初始表现后 5 天，她被转至我们的三级护理机构。肝功能检查结果仍居高不下（例如，总胆红素 27mg/dL），国际标准化比值（INR）为 3.57。医疗团队决定放置颅内压监测器，神经外科团队的目标是在放置监测器前 INR 小于 1.5。尽管输注了多单位新鲜冷冻血浆（FFP），但仍未能降低患者的 INR，随后给予 rFVIIa 40μg/kg。INR 迅速下降，使神经外科团队能够在没有并发症的情况下进行该操作。
在多次输注 FFP 未能纠正 INR 后，rFVIIa 的使用使该患者的 INR 降低。INR 作为暴发性肝衰竭凝血功能障碍的标志物的效用存在争议，但目前在侵入性操作前仍被用作标准实验室检查，如本例所示。
在侵入性操作前，rFVIIa 可安全有效地用于快速降低 FHF 患者的 INR。在考虑使用 rFVIIa 时，临床医生应注意血栓形成的风险。根据我们的经验和有限的文献资料，rFVIIa 40μg/kg 似乎是降低 INR 的合适剂量。需要进一步的研究来证实这一发现。
