Novoseven use in a non-cardiac pediatric ECMO patient with uncontrolled bleeding

Despite the presence of normal coagulation values, refractory bleeding during extracorporeal membrane oxygenation (ECMO) is encountered. Occasionally, hemostasis is not achieved through traditional techniques including surgical exploration, anti-fibrinolytics, increasing fibrinogen level, increasing platelet counts, and decreasing activated clotting time (ACT). We report the case of an infant on veno-arterial ECMO for respiratory syncytial virus with severe bleeding and the use of recombinant activated factor VII (rFVIIa; NovoSeven; Novo Nordisk, Copenhagen, Denmark). This was a retrospective review of the patient's medical records, laboratory values, and chest radiographs. rFVIIa was given to this patient on two separate occasions for bleeding unresponsive to traditional bleeding management. On both occasions, the patient's blood loss returned to zero within 20 minutes of administration and remained there for a minimum of 4 days. Continued bleeding on ECMO unresponsive to current medical management may be an indication for rFVIIa. However, rFVIIa should not be administered without first considering the ECMO circuits conditions to include presence of clot, and documentation of circuit pressures, which, after rFVIIa, may be the first indication of intraoxygenator clot formation. Additionally, rFVIIa should not be a first-line treatment until continued studies allow for approved use in this patient population.