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Case report: Management of life-threatening oropharyngeal bleeding with recombinant factor VIIa

[Une présentation de cas : le traitement de graves saignements oropharyngiens avec le facteur VIIa recombinant]

Sheila Riazi, MD^*, Keyvan Karkouti, MD^*, and Jane Heggie, MD^*

^* From the Department of Anesthesia, and the
Department of Health Policy, Management, and Evaluation,University of Toronto, University Health Network, Toronto, Ontario, Canada.

Address correspondence to: Dr. Keyvan Karkouti, Toronto General Hospital, University Health Network, Department of Anesthesia, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada. Phone: 416-340-5164; Fax: 416-340-3698; E-mail: keyvan. karkouti{at}uhn.on.ca

Purpose: To report the use of recombinant factor VIIa (rFVIIa) for management of profuse oropharyngeal bleeding in a cirrhotic patient that nearly resulted in a ‘cannot intubate, cannot ventilate’ scenario.

Clinical features: A 42-yr-old woman with end-stage liver disease presented for orthotopic liver transplantation. She was dialysis dependent and had marked coagulopathy [international normalized ratio (INR) = 3.1], without evidence of active bleeding. Following uneventful induction of anesthesia, routine airway manipulation for tracheal intubation caused profuse upper airway bleeding making visualization of her airway by direct laryngoscopy impossible. Moreover, several further attempts at tracheal intubation along with the bleeding made manual ventilation progressively more difficult, nearly resulting in a ‘cannot intubate, cannot ventilate’ scenario. In an attempt to control the bleeding, rFVIIa 4.8 mg iv was administered. Within five minutes, her INR had decreased to 1.1, bleeding was markedly reduced, the vocal cords were successfully visualized using an anterior commissure laryngoscope, and intubation of the trachea was achieved with the use of a gum-elastic bougie. Postintubation examination of the airway showed several abrasions along the right oropharyngeal wall with minimal bleeding. The remainder of surgery and postoperative airway management were uneventful.

Conclusions: This report demonstrates that in the relatively uncommon setting of upper airway hemorrhage in a patient with pre-existing coagulopathy, rFVIIa can be effective in gaining rapid control of bleeding to facilitate visualization of the vocal cords and securing of the airway.