Open Access Research Article Khalil et al., J Anesthe Clinic Res 2013, 4:5 DOI: 10.4172/2155-6148.1000319 Volume 4 • Issue 5 • 1000319 J Anesth Clin Res ISSN:2155-6148 JACR an open access journal Keywords: Recombinant factor VII; Liver transplant; Coagulopathy; Blood transfusion Introduction Recipients undergoing liver transplantation require varying amounts of blood products due to the haemostatic changes relating to severity of the end stage hepatic dysfunction, portal hypertension and collateral circulation [1]. Te procedure still carries a risk of excessive blood loss that is associated with a higher risk of morbidity and mortality [2-4]. Activated recombinant factor VII (rFVIIa) was initially introduced to treat hemophilic patients, but during the last years, it had been proposed for a large number of of-label treatments [5]. Prophylactic intraoperative correction of coagulopathy in patients with end stage liver disease undergoing liver transplantation with rFVIIa was investigated previously by several studies but frequently at higher doses and with diferent outcomes [6-8]. Te impact of a prophylactic intravenous administration of rFVIIa at a low dose (40 µ/Kg), prior to the surgical incision and during adult living donor liver transplantation will be the focus of this current study. Tis involves studying the efect on coagulation parameters and blood products transfusion requirements (BT), together with reporting any adverse events observed during the study period with particular focus on vascular thrombosis. Patients and Methods Afer ethical committee approval (MD 15 -2008, Chair of committee Prof Magdy Kamal) at the Liver Institute, Menoufya University, Egypt and written informed consent, 50 adult patients scheduled for living donor liver transplantation were included in the study. Te study included 50 patients divided into 2 equal groups of recipients for living donor liver transplantation operated upon by the same surgical team. Exclusion criteria; age <18 years, renal impairment, hypertension, history of genetic coagulation disorder and massive surgical bleeding due to accidental vascular injury Patients were divided into two equal groups : control group (C Group) (25 patients) as a placebo and treatment group (R Group) (25 patients) which received an intravenous infusion of rFVIIa (rFVIIa, Novoseven, NovoNordisk A/S, Bagsvaerd, Denmark) 20 µ/kg, 30 min prior to the induction of anesthesia followed one hour latter by another dose to cover the dissection phase. Anesthesia was induced with Propofol 2 mg kg -1 , Rocuronium 0.9 mg kg -1 was given to facilitate rapid sequence orotracheal intubation with a cufed tube. Anesthesia was maintained with Desfurane in oxygen and air mixture (FiO 2 =0.4)), Rocuronium and Fentanyl to keeping the Spectral Entropy (GE Healthcare, Helsinki, Finland) value between 40 and 60. Head and extremity wraps, and warmer systems in the form *Corresponding author: Dr. N Fayed, Anesthesia Department, Menoufya University, Egypt, Fax: +204822217 29; E-mail: drnirmeena@yahoo.com Received April 05, 2013; Accepted May 28, 2013; Published May 30, 2013 Citation: Khalil M, Fayed N, Abdullah M, Refaat E, Suliman H, et al. (2013) Preoperative Low Dose Recombinant Activated Factor VII Effect during Liver Transplantation. J Anesthe Clinic Res 4: 319. doi:10.4172/2155-6148.1000319 Copyright: © 2013 Khalil M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Preoperative Low Dose Recombinant Activated Factor VII Effect during Liver Transplantation Khalil M 1 , Fayed N 1 *, Abdullah M 1 , Refaat E 1 , Suliman H 2 , Yassen K 1 , Ibrahim T 2 , Tanaka K 3 , and Abdallah A 4 1 Anaesthesia Department, Menoufya University, Egypt 2 Surgery Department, Menoufya University, Egypt 3 Surgery Department, Koyoto University, Japan 4 Community Medicine Department, Liver Institute, Menoufya University, Egypt Abstract Background: End stage liver disease patients are prone to coagulopathy and frequently require blood transfusion during transplantation. Methods: Prospective study (2008-2011) to investigate the effect of prophylactic intravenous administration of low dose recombinant activated factor VII (rFVIIa) (20 µ/kg) 30 min prior to surgery and repeated one hour later on Standard Coagulation Tests (SCTs), Rotational Thromboelastomery (ROTEM) and Blood Transfusion (BT) requirements during Living Donor Liver Transplantation (LDLT). SCT include Prothrombin Time (PT), International Normalized Ratio (INR) of prothrombin time, Activated Partial Thromboplastin Time (aPPT), fbrinogen and platelets blood levels. ROTEM include EXTEM and INTEM representing coagulation extrinsic and intrinsic pathways respectively, and FIBTEM for fbrinogen activity. Blood transfusion was guided by ROTEM parameters. Control group(C), n=25 and rFVII group, n=25, Results: Both groups preoperative MELD scores, ROTEM and SCTs were comparable (P>0.05). After initial dose to end of dissection, a reduction in INR and aPTTin rFVII group versus control were observed, associated with a reduction in clotting time (CT) and increased alpha angle in ROTEM (P<0.05) with no hypercoagulability or thromboembolic fndings. Mean BT reduced signifcantly in rFVII group (p<0.05). 4% of controls received no BT versus 36% in rFVII group (P<0.05). Duration of dissection, hemoglobin (HB) at induction were comparable (p>0.05). BT correlated positively with dissection time (r=0.7, p<0.01), but weakly with preoperative HB (r=-0.3, p<0.05). Conclusion: Low dose rFVII monitored by ROTEM improved coagulation and reduced BT requirements with no evidence of thromboembolic events. Dissection time was another important contributing factor. J o u r n a l o f A n e s t h e s i a & C l i n i c a l R e s e a r c h ISSN: 2155-6148 Journal of Anesthesia & Clinical Research