Optimal care of inhibitor patients during surgery

The care of haemophilia patients with high titre inhibitors during surgery has always been a formidable challenge. The introduction of recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) appears to be a major breakthrough for the management of such patients. Administration of rFVIIa as a continuous infusion is a very attractive option and precludes the need for very frequent (2-h) injections due to the very short half-life of the product. Successful major surgery has been performed in patients with high titre inhibitors using continuous infusion of rFVIIa. Several questions remain, however, such as optimal therapeutic level, optimal monitoring, optimal prevention of thrombophlebitis at the injection site and the necessity for antifibrinolytic agents.